Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania.

Elysia Larson,Margaret E Kruk,Sebastien Haneuse,Redempta Mbatia,Anna D Gage,Godfrey M Mbaruku

doi:10.1111/tmi.13220

Abstract

ObjectivesReduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub‐optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth.MethodsIn this cluster‐randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in‐service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference‐in‐differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation.ResultsThe intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup.ConclusionsWe attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.

Highlights

After two decades of global policy and action focused on increasing the proportion of births occurring in health facilities, many populations have seen a shift in delivery location to health facilities [1, 2]
The MNH+ health system quality improvement intervention resulted in a modest increase in overall facility utilisation
The increased relative risk of 10% corresponds to an absolute increase in utilisation of 6.7 percentage points

Summary

Introduction

After two decades of global policy and action focused on increasing the proportion of births occurring in health facilities, many populations have seen a shift in delivery location to health facilities [1, 2]. Gaps in facility utilisation for childbirth persist in many regions, throughout sub-Saharan Africa (SSA) [1]. High quality facility-based care, with good access to emergency obstetric care, has the potential to reduce preventable maternal and newborn mortality and morbidity [3, 4]. Maternal characteristics, such as education, socio-economic status, and parity, are often cited as reasons for incomplete facility utilisation [5]. Many efforts to increase facility utilisation for childbirth have focused on the demand side; for example, providing travel vouchers, fee exemption, community education and text message reminders [6–8]. While some demand-side interventions have been successful in increasing facility utilisation, recent evidence suggests that quality plays an important role in motivating (when quality is strong) or dissuading (when quality is weak) utilisation [9, 10]

Methods

Results

Conclusion