Publications

    Catherine Arsenault, Min Kyung Kim, Amit Aryal, Adama Faye, Jean Paul Joseph, Munir Kassa, Tizta Tilahun Degfie, Talhiya Yahya, and Margaret E Kruk. 2020. “Hospital-provision of essential primary care in 56 countries: determinants and quality.” Bull World Health Organ, 98, 11, Pp. 735-746D.Abstract
    Objective: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. Methods: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. Findings: On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. Conclusion: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.
    Manisha H Yapa, Jan-Walter De Neve, Terusha Chetty, Carina Herbst, Frank A Post, Awachana Jiamsakul, Pascal Geldsetzer, Guy Harling, Wendy Dhlomo-Mphatswe, Mosa Moshabela, Philippa Matthews, Osondu Ogbuoji, Frank Tanser, Dickman Gareta, Kobus Herbst, Deenan Pillay, Sally Wyke, and Till Bärnighausen. 2020. “The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial.” PLoS Med, 17, 10, Pp. e1003150.Abstract
    BACKGROUND: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa. METHODS AND FINDINGS: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention. CONCLUSIONS: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov under registration number NCT02626351.
    Atkure Defar, Theodros Getachew, Girum Taye, Tefera Tadele, Misrak Getnet, Tigist Shumet, Gebeyaw Molla, Geremew Gonfa, Habtamu Teklie, Ambaye Tadesse, and Abebe Bekele. 2020. “Quality antenatal care services delivery at health facilities of Ethiopia, assessment of the structure/input of care setting.” BMC Health Serv Res, 20, 1, Pp. 485.Abstract
    BACKGROUND: According to the Donabedian model, the assessment for the quality of care includes three dimensions. These are structure, process, and outcome. Therefore, the present study aimed at assessing the structural quality of Antenatal care (ANC) service provision in Ethiopian health facilities. METHODS: Data were obtained from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. The SARA was a cross-sectional facility-based assessment conducted to capture health facility service availability and readiness in Ethiopia. A total of 764 health facilities were sampled in the 9 regions and 2 city administrations of the country. The availability of equipment, supplies, medicine, health worker's training and availability of guidelines were assessed. Data were collected from October-December 2017. We run a multiple linear regression model to identify predictors of health facility readiness for Antenatal care service. The level of significance was determined at a p-value < 0.05. RESULT: Among the selected health facilities, 80.5% of them offered Antenatal care service. However, the availability of specific services was very low. The availability of tetanus toxoid vaccination, folic acid, iron supplementation, and monitoring of hypertension disorder was, 67.7, 65.6, 68.6, and 75.1%, respectively. The overall mean availability among the ten tracer items that are necessary to provide quality Antenatal care services was 50%. In the multiple linear regression model, health centers, health posts and clinics scored lower Antenatal care service readiness compared to hospitals. The overall readiness index score was lower for private health facilities (β = - 0.047, 95% CI: (- 0.1, - 0.004). The readiness score had no association with the facility settings (Urban/Rural) (p-value > 0.05). Facilities in six regions except Dire Dawa had (β = 0.067, 95% CI: (0.004, 0.129) lower readiness score than facilities in Tigray region (p-value < 0.015). CONCLUSION: This analysis provides evidence of the gaps in structural readiness of health facilities to provide quality Antenatal care services. Key and essential supplies for quality Antenatal care service provision were missed in many of the health facilities. Guaranteeing properly equipped and staffed facilities shall be a target to improve the quality of Antenatal care services provision.
    Mike English, David Gathara, Jacinta Nzinga, Pratap Kumar, Fred Were, Osman Warfa, Edna Tallam-Kimaiyo, Mary Nandili, Alfred Obengo, Nancy Abuya, Debra Jackson, Sharon Brownie, Sassy Molyneux, Caroline Olivia Holmes Jones, Georgina AV Murphy, and Jacob McKnight. 2020. “Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya.” BMJ Glob Health, 5, 1, Pp. e001937.Abstract
    There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.
    Sanam Roder-DeWan, Kojo Nimako, Nana AY Twum-Danso, Archana Amatya, Ana Langer, and Margaret Kruk. 2020. “Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.” BMJ Glob Health, 5, 10.Abstract
    Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.
    Della Berhanu, Yemisrach Behailu Okwaraji, Atkure Defar, Abebe Bekele, Ephrem Tekle Lemango, Araya Abrha Medhanyie, Muluemebet Abera Wordofa, Mezgebu Yitayal, Fitsum W/Gebriel, Alem Desta, Fisseha Ashebir Gebregizabher, Dawit Wolde Daka, Alemayehu Hunduma, Habtamu Beyene, Tigist Getahun, Theodros Getachew, Amare Tariku Woldemariam, Desta Wolassa, Lars Åke Persson, and Joanna Schellenberg. 2020. “Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia.” BMJ Open, 10, 9, Pp. e040868.Abstract
    INTRODUCTION: Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses. METHODS: We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS: There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION: We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER: ISRCTN12040912.
    Theodros Getachew, Solomon Mekonnen Abebe, Mezgebu Yitayal, Lars Åke Persson, and Della Berhanu. 2020. “Assessing the quality of care in sick child services at health facilities in Ethiopia.” BMC Health Serv Res, 20, 1, Pp. 574.Abstract
    BACKGROUND: Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia. METHODS: Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction. RESULT: Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients' satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction. CONCLUSION: The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client's satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.
    Azmach Hadush, Ftalew Dagnaw, Theodros Getachew, Patricia E Bailey, Ruth Lawley, and Ana Lorena Ruano. 2020. “Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system.” BMC Pregnancy Childbirth, 20, 1, Pp. 206.Abstract
    BACKGROUND: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.
    Jacquie Narotso Oliwa, Jacinta Nzinga, Enos Masini, Michaël Boele van Hensbroek, Caroline Jones, Mike English, and Anja Van't Hoog. 2020. “Improving case detection of tuberculosis in hospitalised Kenyan children-employing the behaviour change wheel to aid intervention design and implementation.” Implement Sci, 15, 1, Pp. 102.Abstract
    BACKGROUND: The true burden of tuberculosis in children remains unknown, but approximately 65% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert® machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel. METHODS: We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented? RESULTS: The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification. CONCLUSION: The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.
    Laura Ferguson, Rifat Hasan, Chantelle Boudreaux, Hannah Thomas, Mariama Jallow, Günther Fink, and Günther Fink. 2020. “Results-based financing to increase uptake of skilled delivery services in The Gambia: using the 'three delays' model to interpret midline evaluation findings.” BMC Pregnancy Childbirth, 20, 1, Pp. 712.Abstract
    BACKGROUND: Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays. METHODS: A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed. RESULTS: No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p < 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p < 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p < 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p < 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility. CONCLUSIONS: Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms.
    An Thi Binh Nguyen, Ngan Thi Kim Nguyen, Phuc Huu Phan, Peter van Eeuwijk, and Günther Fink. 2020. “Parental satisfaction with quality of neonatal care in different level hospitals: evidence from Vietnam.” BMC Health Serv Res, 20, 1, Pp. 238.Abstract
    BACKGROUND: Most health systems provide the most specialized, and presumably also the highest quality of care at a central level. This study assessed parental satisfaction and its determinants in the context of neonatal care in a provincial as well as a national hospital of Vietnam. METHODS: In this cross-sectional quantitative study, parents of 340 preterm infants admitted to neonatal care units of a national and a provincial hospital in 2018 were interviewed using structured questionnaires. Unadjusted and adjusted linear regression models were used to assess the relationship between parental satisfaction and hospital rank. RESULTS: The mean parental satisfaction score was 3.74 at the provincial, and 3.56 at the national hospital. These satisfaction differences persisted when parent and child characteristics were adjusted for in multivariate analysis. Longer length of stay and worsening infant health status were associated with parents reporting lower levels of satisfaction with the quality of care being provided at the healthcare facility. CONCLUSIONS: This study suggests that parents of preterm infants admitted in a provincial hospital were more satisfied with the quality of care received than those in a specialized national hospital. Length of stay and infant health status were the two most important determinants of level of parental satisfaction.
    Rachel R Yorlets, Katherine R Iverson, Hannah H Leslie, Anna Davies Gage, Sanam Roder-DeWan, Humphreys Nsona, and Mark G Shrime. 2019. “Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi.” BMJ Glob Health, 4, 2, Pp. e000930.Abstract
    Introduction: In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility. Methods: A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion. Results: Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women. Conclusion: For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.
    Teketo Kassaw Tegegne, Catherine Chojenta, Theodros Getachew, Roger Smith, and Deborah Loxton. 2019. “Antenatal care use in Ethiopia: a spatial and multilevel analysis.” BMC Pregnancy Childbirth, 19, 1, Pp. 399.Abstract
    BACKGROUND: Accessibility and utilization of antenatal care (ANC) service varies depending on different geographical locations, sociodemographic characteristics, political and other factors. A geographically linked data analysis using population and health facility data is valuable to map ANC use, and identify inequalities in service access and provision. Thus, this study aimed to assess the spatial patterns of ANC use, and to identify associated factors among pregnant women in Ethiopia. METHOD: A secondary data analysis of the 2016 Ethiopia Demographic and Health Survey linked with the 2014 Ethiopian Service Provision Assessment was conducted. A multilevel analysis was carried out using the SAS GLIMMIX procedure. Furthermore, hot spot analysis and spatial regressions were carried out to identify the hot spot areas of and factors associated with the spatial variations in ANC use using ArcGIS and R softwares. RESULTS: A one-unit increase in the mean score of ANC service availability in a typical region was associated with a five-fold increase in the odds of having more ANC visits. Moreover, every one-kilometre increase in distance to the nearest ANC facility in a typical region was negatively associated with having at least four ANC visits. Twenty-five percent of the variability in having at least four ANC visits was accounted for by region of living. The spatial analysis found that the Southern Nations, Nationalities and Peoples region had high clusters of at least four ANC visits. Furthermore, the coefficients of having the first ANC visit during the first trimester were estimated to have spatial variations in the use of at least four ANC visits. CONCLUSION: There were significant variations in the use of ANC services across the different regions of Ethiopia. Region of living and distance were key drivers of ANC use underscoring the need for increased ANC availability, particularly in the cold spot regions.
    Vanessa Brizuela, Hannah H Leslie, Jigyasa Sharma, Ana Langer, and Özge Tunçalp. 2019. “Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools.” Lancet Glob Health, 7, 5, Pp. e624-e632.Abstract
    BACKGROUND: Ensuring quality of care during pregnancy and childbirth is crucial to improving health outcomes and reducing preventable mortality and morbidity among women and their newborns. In this pursuit, WHO developed a framework and standards, defining 31 quality statements and 352 quality measures to assess and improve quality of maternal and newborn care in health-care facilities. We aimed to assess the capacity of globally used, large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework. METHODS: We identified assessment tools through a purposive sample that met the following inclusion criteria: multicountry, facility-level, major focus on maternal and newborn health, data on input and process indicators, used between 2007 and 2017, and currently in use. We matched questions in the tools with 274 quality measures associated with inputs and processes within the WHO standards. We excluded quality measures relating to outcomes because these are not routinely measured by many assessment tools. We used descriptive statistics to calculate how many quality measures could be assessed using each of the tools under review. Each tool was assigned a 1 for fulfilling a quality measure based on the presence of any or all components as indicated in the standards. FINDINGS: Five surveys met our inclusion criteria: the Service Provision Assessment (SPA), developed for the Demographic and Health Surveys programme; the Service Availability and Readiness Assessment, developed by WHO; the Needs Assessment of Emergency Obstetric and Newborn Care developed by the Averting Maternal Death and Disability programme at Columbia University; and the World Bank's Service Delivery Indicator (SDI) and Impact Evaluation Toolkit for Results Based Financing in Health. The proportion of quality measures covered ranged from 62% for the SPA to 12% for the SDI. Although the broadest tool addressed parts of each of the 31 quality statements, 68 (25%) of 274 input and process quality measures were not measured at all. Measures of health information systems and patient experience of care were least likely to be included. INTERPRETATION: Existing facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research. FUNDING: None.
    Jigyasa Sharma, Hannah H Leslie, Mathilda Regan, Devaki Nambiar, and Margaret E Kruk. 2018. “Can India's primary care facilities deliver? A cross-sectional assessment of the Indian public health system's capacity for basic delivery and newborn services.” BMJ Open, 8, 6, Pp. e020532.Abstract
    OBJECTIVES: To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states. DESIGN: Cross-sectional study. SETTING: Data from the nationally representative 2012-2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India. PARTICIPANTS: 8536 PHCs and 4810 CHCs. OUTCOME MEASURES: We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location. RESULTS: About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise. CONCLUSIONS: Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.
    Margaret E Kruk, Anna D Gage, Godfrey M Mbaruku, and Hannah H Leslie. 2018. “Content of Care in 15,000 Sick Child Consultations in Nine Lower-Income Countries.” Health Serv Res, 53, 4, Pp. 2084-2098.Abstract
    OBJECTIVE: Describe content of clinical care for sick children in low-resource settings. DATA SOURCES: Nationally representative health facility surveys in Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda from 2007 to 2015. STUDY DESIGN: Clinical visits by sick children under 5 years were observed and caregivers interviewed. We describe duration and content of the care in the visit and estimate associations between increased content and caregiver knowledge and satisfaction. PRINCIPAL FINDINGS: The median duration of 15,444 observations was 8 minutes; providers performed 8.4 of a maximum 24 clinical actions per visit. Content of care was minimally greater for severely ill children. Each additional clinical action was associated with 2 percent higher caregiver knowledge. CONCLUSIONS: Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.
    Choolwe Jacobs, Charles Michelo, and Mosa Moshabela. 2018. “Implementation of a community-based intervention in the most rural and remote districts of Zambia: a process evaluation of safe motherhood action groups.” Implement Sci, 13, 1, Pp. 74.Abstract
    BACKGROUND: A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved. METHODS: A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done. RESULTS: We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women's education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention. CONCLUSION: We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.
    Choolwe Jacobs, Charles Michelo, Mumbi Chola, Nicholas Oliphant, Hikabasa Halwiindi, Sitali Maswenyeho, Kumar Sridutt Baboo, and Mosa Moshabela. 2018. “Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia.” PLoS One, 13, 1, Pp. e0190145.Abstract
    BACKGROUND: A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia's poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas. METHODOLOGY: Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0-5 months of age using a 'before-and-after' evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention. RESULTS: Mothers' mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95% CI 1.38-1.99) and SBA (aOR 1.72; 95% CI 1.38-1.99) were at least 60% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95% CI 1.62-2.79) and a SMAG (aOR 4.87; 95% CI 3.14-7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95% CI, 1.20-2.19) and receiving ANC from a skilled provider (aOR 4.01; 95% CI, 2.88-5.75) were significant predictors for SBA at delivery and PNC. CONCLUSIONS: Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.

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