Did a quality improvement intervention improve quality of maternal health care? Implementation evaluation from a cluster-randomized controlled study.

Elysia Larson,Godfrey M Mbaruku,Jessica Cohen,Margaret E Kruk

doi:10.1093/intqhc/mzz126

Abstract

ObjectiveTo test the success of a maternal healthcare quality improvement intervention in actually improving quality.DesignCluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls.SettingFour districts in rural Tanzania.ParticipantsHealth facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline).InterventionsIn-service training, mentorship and supportive supervision and infrastructure support.Main outcome measuresWe measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis.ResultsQuality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0–75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators.ConclusionsA multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.

Highlights

Recent trends in increased use of facilities for childbirth have not always been accompanied by declines in maternal and newborn mortality [2, 3], which remain unacceptably high [4, 5]
A Tanzanian study found that in rural public primary care clinics, only 69% of providers reported implementing any oxytocic, an intervention that should occur for every delivery [11]
Despite indications of quality constraints, a substantial proportion of facility deliveries occur in primary care clinics in Tanzania [12]

Summary

Introduction

Recent trends in increased use of facilities for childbirth have not always been accompanied by declines in maternal and newborn mortality [2, 3], which remain unacceptably high [4, 5]. The World Health Organization recommends that most deliveries occur in primary care facilities. This recommendation is based on the expectation that primary care facilities are equipped to conduct normal deliveries and can provide timely referral for complications [6, 7]. The quality of maternal and newborn care at primary care facilities is often low [8,9,10]. A Tanzanian study found that in rural public primary care clinics, only 69% of providers reported implementing any oxytocic, an intervention that should occur for every delivery [11]. Despite indications of quality constraints, a substantial proportion of facility deliveries occur in primary care clinics in Tanzania [12]

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Results

Conclusion