quality(of(antenatal(and(childbirth(care(in(selected(rural

Quality of Antenatal and Childbirth Care in Selected Rural Primary Healthcare Facili:es in Burkina Faso, Ghana and

Tanzania: an Interven:on Study Els Duysburgh, MD, MPH October 2015

Clinical decision support system

(eCDSS)

Performance based

incen9ves

QUALMAT project

Bridging the Gap Knowing what to do

Doing what you know

Improved quality of antenatal and childbirth care

Improved mother and newborn health 2

Objec9ve •  Document changes in the quality of rou9ne antenatal and childbirth care –  interven9on and non-‐interven9on – before and aKer interven9on implementa9on

3

Study SeMng (1)

Source: MMR: Kassebaum N, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, Lancet 2014 – NMR: Wang H, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, Lancet 2014

Nouna Health District

Boucle du Mouhoun Region

Solenzo Health District

Kassena-Nankana District Builsa District

Upper East Region

Burkina Faso MMR: 310.5 NMR: 28.7

Ghana MMR: 293.4 NMR: 27.8

Tanzania MMR: 389.6 NMR: 23.8

Lindi Region

Lindi Rural District

Mtwara Rural District Mtwara Region

4

Study SeMng (2) •  Rural primary health care facili9es –  outside district capital -‐ no more than 2 hours drive from district hospital

–  electricity present or installable –  admission facili9es available

•  Staff: health professionals with 1-‐3 years of training -‐ no medical doctors

•  Emergency transport available upon request or not available

5

Interven9on performance based incen9ves

•  Burkina Faso –  financial and non-‐financial incen9ves –  individual and health facility team awards (financial incen9ves only at facility level)

•  Ghana and Tanzania –  non-‐financial incen9ves –  individual and health facility team awards

•  Implemented for 36 (Burkina Faso), 15 (Ghana), and 17 (Tanzania) months before the post-‐interven9on assessment

6

Interven9on computer-‐assisted clinical decision support system

(eCDSS) •  Checklists: guiding of rou9ne ac9ons

–  Checkboxes –  Proposed ac9ons

•  Electronic tracking of childbirth and immediate postpartum ac9vi9es –  Electronic partograph

•  Detec9on of situa9ons of concern –  Algorithms with warnings and proposed ac9ons 7

Methodology Quality Assessment •  Availability of material and human resources –  Health facility survey

•  Actual care given –  Direct observa9on study –  Review of pa9ent records and rou9nely collected data

•  Women’s experience of care –  Sa9sfac9on survey (exit interviews)

Compiling Quality Scores •  Health facility survey and direct observa9on study

–  Commodity available or ac9vity observed=1 / not available or observed=0

–  Variables grouped –  Mean score for each variable, each group and total score

•  Sa9sfac9on survey –  5-‐point Likert scale –  Factor analysis => variables grouped –  Mean score for each variable, each group and total score

13

Assessment of Quality Changes •  Same quality assessment tools used – 2010 and 2013/14 – All interven9on and non-‐interven9on facili9es

•  Wilcoxon–Mann–Whitney test and Wilcoxon signed-‐rank test used for assessing sta9s9cally significant differences in quality of care

14

Main Findings •  Cri9cal gaps

–  Counselling and health educa9on –  Laboratory inves9ga9ons –  Examina9on and monitoring of mother and newborn during

childbirth –  Partographs not (correctly) used –  Equipment to provide assisted vaginal deliveries absent in almost

all surveyed facili9es •  Post-‐interven9on quality of care does not show a clear

difference to pre-‐interven9on quality and quality at the non-‐interven9on facili9es

15

Quality of Rou9ne ANC Care

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14

Nouna Solenzo

Qua

lity Score (m

in:0.00 -‐ m

ax:

1.00)

ANC health facility survey ANC observa9on study ANC pa9ent record review

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14

Kassena-‐Nankana Builsa

Qua

lity Score (m

in:0.00 -‐ m

ax:

1.00)

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14

Lindi Rural Mtwara Rural Qua

lity Score (m

in:0.00 -‐ m

ax:

1.00)

Burkina Faso

Ghana Tanzania

16

Quality of Rou9ne ANC Care Sa#sfac#on Survey

-‐2.00 -‐1.50 -‐1.00 -‐0.50 0.00 0.50 1.00 1.50 2.00

2010 2013/14 2010 2013/14

Lindi Rural Mtwara Rural Qua

lity Score (m

in:-‐2

.00 -‐ m

ax:

2.00)

Lindi Rural 2010

Lindi Rural 2013/14 Mtwara Rural 2010 Mtwara Rural 2013/14

-‐2.00 -‐1.50 -‐1.00 -‐0.50 0.00 0.50 1.00 1.50 2.00

2010 2013/14 2010 2013/14


Qua

lity Score (m

in:-‐2

.00 -‐

max:2.00)

Kassena-‐Nankana 2010 Kassena-‐Nankana 2013/14 Builsa 2010

Builsa 2013/14

-‐2.00 -‐1.50 -‐1.00 -‐0.50 0.00 0.50 1.00 1.50 2.00

2010 2013/14 2010 2013/14

Nouna Solenzo

Qua

lity Score (m

in:-‐2

.00 -‐

max:2.00)

Nouna 2010

Nouna 2013/14

Solenzo 2010

Solenzo 2013/14

Burkina Faso

Tanzania Ghana

17

Quality of Rou9ne Childbirth Care

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14

Nouna Solenzo

Qua

lity Score (m

in:0.00 -‐ m

ax:

1.00)

Childbirth health facility survey Childbirth observa9on study

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14


Qua

lity score (m

in:0.00 -‐ m

ax:

1.00)

0.00

0.20

0.40

0.60

0.80

1.00

2010 2013/14 2010 2013/14

Lindi Rural Mtwara Rural

Qua

lity Score (m

in:0.00 -‐ m

ax:

1.00)

Burkina Faso

Ghana Tanzania

18

-‐2.00 -‐1.50 -‐1.00 -‐0.50 0.00 0.50 1.00 1.50 2.00

2010 2013/14 2010 2013/14

Lindi Rural Mtwara Rural

Qua

lity Score (m

in:-‐2

.00 -‐ m

ax:

2.00)

Lindi Rural 2010

Lindi Rural 2013/14

Mtwara Rural 2010

Mtwara Rural 2013/14

19

Quality of Rou9ne Childbirth Care Sa#sfac#on Survey

-‐2.00

-‐1.50

-‐1.00

-‐0.50

0.00

0.50

1.00

1.50

2.00

2010 2013/14 2010 2013/14

Nouna Solenzo

Qua

lity Score (m

in:-‐2

.00 -‐ m

ax:

2.00) Nouna 2010

Nouna 2013/14 Solenzo 2010 Solenzo 2013/14

-‐2.00 -‐1.50 -‐1.00 -‐0.50 0.00 0.50 1.00 1.50 2.00

2010 2013/14 2010 2013/14


Qua

lity Score (m

in:-‐2

.00 -‐

max:2.00)

Kassena-‐Nankana 2010 Kassena-‐Nankana 2013/14 Builsa 2010

Builsa 2013/14

Burkina Faso

Ghana Tanzania

Conclusion •  Quality assessment results quite similar at the three study

sites •  QUALMAT interven9on did not improve the quality of ANC

and childbirth care -‐ no trend in change of quality iden9fied •  Urgent ac9on to improve quality of ANC and childbirth

needed •  Suppor9ve environment addressing know-‐do gap needed

–  context specific interven9ons –  genuine involvement of all stakeholders

•  Computers can be successfully introduced in rural PHC facili9es in resource-‐constrained seMngs

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References •  Blank A, Prytherch H, Kaltschmidt J et al. (2013) ‘"Quality of prenatal and maternal care: bridging

the know-‐do gap" (QUALMAT study): an electronic clinical decision support system for rural Sub-‐Saharan Africa’. BMC Med Inform Decis Mak 13: 44.

•  Duysburgh E, Zhang WH, Yé M, Williams A, Massawe S, Sié A, Williams J, Mpembeni R, Loukanova S & Temmerman M (2013) ‘Quality of antenatal and childbirth care in selected rural health facili9es in Burkina Faso, Ghana and Tanzania: similar finding’. Tropical medicine & interna9onal health: TM & IH, 18, 534-‐547.

•  Duysburgh E, Williams A, Williams J, Loukanova S & Temmerman M (2014) ‘Quality of antenatal and childbirth care in northern Ghana’. BJOG, 121 Suppl 4, 117-‐126.

•  Duysburgh E, Temmerman M, Yé M, Williams A, Massawe S, Williams J, Mpembeni R, Loukanova S, Haefeli WE & Blank A ‘Quality of antenatal and childbirth care in selected rural health facili9es in Burkina Faso, Ghana and Tanzania: an interven9on study’ accepted for publica9on at Tropical medicine & interna9onal health.

•  Sukums F, Mensah N, Mpembeni R et al. (2015) ‘Promising adop9on of an electronic clinical decision support system for antenatal and intrapartum care in rural primary healthcare facili9es in sub-‐Saharan Africa: The QUALMAT experience’. Int J Med Inform.

•  Yé M, Aninanya GA, Sie A et al. (2014) ‘Establishing sustainable performance-‐based incen9ve schemes: views of rural health workers from qualita9ve research in three sub-‐Saharan African countries’. Rural Remote Health, 14, 2681. 25

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Thank you

quality(of(antenatal(and(childbirth(care(in(selected(rural

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