Danika Barry

Improving Maternal and Newborn Health Care Delivery in Rural Amhara and Oromiya Regions of Ethiopia Through the Maternal and Newborn Health in Ethiopia Partnership

Introduction In Ethiopia, rural residence and limited access to skilled providers and health services pose challenges for maternal and newborn survival. The Maternal Health in Ethiopia Partnership (MaNHEP) developed a community-based model of maternal and newborn health focusing on birth and the early postnatal period and positioned it for scale-up. MaNHEPs 3-pronged intervention included community- and facility-based community maternal and newborn health training, continuous quality improvement, and behavior change communications. Methods Evaluation included baseline and endline surveys conducted with random samples of health extension workers, community health development agents, traditional birth attendants (TBAs), and women who gave birth the year prior to the survey; pretraining, posttraining, and postintervention clinical skills assessments conducted with health extension workers, community health development agents, and traditional birth attendants; endline surveys conducted with quality improvement teams; and a perinatal verbal autopsy study. Results There were significant improvements in the completeness of maternal and newborn health care provided by the team of health extension workers, community health development agents, and TBAs in their demonstrated capacity and confidence to provide care and a sense of being part of a maternal and newborn health care team. There were also significant improvements in womens awareness of and trust in the ability of these team members to provide maternal and newborn health care, in the completeness of care that women received, and in the use of skilled providers and health extension workers for antenatal and postnatal care. In addition, a shift occurred toward the use of providers with a higher level of skills for birth care. Successful local solutions for pregnancy identification, antenatal care registration, labor-birth notification, and postnatal follow-up were adopted across 51 project communities. The number of days between perinatal deaths increased over the duration of the project. Discussion MaNHEP was associated with more, and more complete, coverage of maternal and newborn health care and improved perinatal outcomes. The model is adaptable and potentially scalable, as indicated by the pilot test of its integration into the Ethiopian Ministry of Healths newly revised Primary Health Care Unit and Health Extension Program structures.

The Effect of Community Maternal and Newborn Health Family Meetings on Type of Birth Attendant and Completeness of Maternal and Newborn Care Received During Birth and the Early Postnatal Period in Rural Ethiopia

INTRODUCTION Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. METHODS Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. RESULTS A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). DISCUSSION MaNHEPs family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.

Improving coverage of postnatal care in rural Ethiopia using a community-based, collaborative quality improvement approach.

INTRODUCTION Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. METHODS Baseline and endline surveys, monthly quality improvement data, and MaNHEPs CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. RESULTS The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P < .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P < .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension workers mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI, 2.67-8.86; P < .001). DISCUSSION The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.

Knowledge and Skills Retention Among Frontline Health Workers: Community Maternal and Newborn Health Training in Rural Ethiopia

INTRODUCTION We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.

Community-Based ART Programs: Sustaining Adherence and Follow-up

The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.

An Evaluation of Equitable Access to a Community-Based Maternal and Newborn Health Program in Rural Ethiopia

INTRODUCTION The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) aimed to promote equitable access to safe childbirth and postnatal care through a community-based educational intervention. This study evaluates the extent to which MaNHEP reached women who are socially and materially disadvantaged and, thus, at high risk for inadequate access to care. METHODS The data used in this analysis are from MaNHEPs cross-sectional 2010 baseline and 2012 endline surveys of women who gave birth in the prior year. A logistic regression model was fit to examine the effects of sociodemographic characteristics on participation in the MaNHEP program. Descriptive statistics of select characteristics by birth and postnatal care provider were also calculated to explore trends in services use. RESULTS Using data from the endline survey (N = 1019), the regression model showed that age, parity, education, and geographic residence were not significantly associated with MaNHEP exposure. However, women who were materially disadvantaged were still less likely to have participated in the program than their better-off counterparts. From the baseline survey (N = 1027) to the endline survey, womens use of skilled and semiskilled providers for birth care and postnatal care increased substantially, while use of untrained providers or no provider decreased. These shifts were greater for women with less personal wealth than for women with more personal wealth. DISCUSSION MaNHEP appears to have succeeded in meeting its equity goals to a degree. However, this study also supports the intractable relationship between wealth inequality and access to maternal and newborn health services. Strategies targeting the poor in diverse contexts may eventually prove consistently effective in equitable services delivery. Until that time, a critical step that all maternal and newborn health programs can take is to monitor and evaluate to what extent they are reaching disadvantaged groups within the populations they serve.

How do we learn about improving health care: a call for a new epistemological paradigm

Purpose The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions. Questions We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.) Next steps Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement.

Appropriateness and timeliness of care-seeking for complications of pregnancy and childbirth in rural Ethiopia: a case study of the Maternal and Newborn Health in Ethiopia Partnership.

BackgroundIn 2014, USAID and University Research Co., LLC, initiated a new project under the broader Translating Research into Action portfolio of projects. This new project was entitled Systematic Documentation of Illness Recognition and Appropriate Care Seeking for Maternal and Newborn Complications. This project used a common protocol involving descriptive mixed-methods case studies of community projects in six low- and middle-income countries, including Ethiopia. In this paper, we present the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) case study.MethodsMethods included secondary analysis of data from MaNHEP’s 2010 baseline and 2012 end line surveys, health program inventory and facility mapping to contextualize care-seeking, and illness narratives to identify factors influencing illness recognition and care-seeking. Analyses used descriptive statistics, bivariate tests, multivariate logistic regression, and thematic content analysis.ResultsMaternal illness awareness increased between 2010 and 2012 for major obstetric complications. In 2012, 45% of women who experienced a major complication sought biomedical care. Factors associated with care-seeking were MaNHEP CMNH Family Meetings, health facility birth, birth with a skilled provider, or health extension worker. Between 2012 and 2014, the Ministry of Health introduced nationwide initiatives including performance review, ambulance service, increased posting of midwives, pregnant women’s conferences, user-friendly services, and maternal death surveillance. By 2014, most facilities were able to provide emergency obstetric and newborn care. Yet in 2014, biomedical care-seeking for perceived maternal illness occurred more often compared with care-seeking for newborn illness—a difference notable in cases in which the mother or newborn died. Most families sought care within 1 day of illness recognition. Facilitating factors were health extension worker advice and ability to refer upward, and health facility proximity; impeding factors were time of day, weather, road conditions, distance, poor cell phone connectivity (to call for an ambulance), lack of transportation or money for transport, perceived spiritual or physical vulnerability of the mother and newborn and associated culturally determined postnatal restrictions on the mother or newborn’s movement outside of the home, and preference for traditional care. Some families sought care despite disrespectful, poor quality care.ConclusionsImprovements in illness recognition and care-seeking observed during MaNHEP have been reinforced since that time and appear to be successful. There is still need for a concerted effort focusing on reducing identified barriers, improve quality of care and provider counseling, and contextualize messaging behavior change communications and provider counseling.

A framework for learning about improvement: embedded implementation and evaluation design to optimize learning

Abstract Improving health care involves many actors, often working in complex adaptive systems. Interventions tend to be multi-factorial, implementation activities diverse, and contexts dynamic and complicated. This makes improvement initiatives challenging to describe and evaluate as matching evaluation and program designs can be difficult, requiring collaboration, trust and transparency. Collaboration is required to address important epidemiological principles of bias and confounding. If this does not take place, results may lack credibility because the association between interventions implemented and outcomes achieved is obscure and attribution uncertain. Moreover, lack of clarity about what was implemented, how it was implemented, and the context in which it was implemented often lead to disappointment or outright failure of spread and scale-up efforts. The input of skilled evaluators into the design and conduct of improvement initiatives can be helpful in mitigating these potential problems. While evaluation must be rigorous, if it is too rigid necessary adaptation and learning may be compromised. This article provides a framework and guidance on how improvers and evaluators can work together to design, implement and learn about improvement interventions more effectively.