Abstract
BackgroundQuality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services.MethodsCollaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors.ResultsThe intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25–28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6–9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2–60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0–28%).ConclusionsThe systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points.Trial registrationPan African Clinical Trials Registry: PACTR201311000681314
Highlights
Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited
The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes
Of the eight learning sessions planned during the 24 implementation months, seven and five health facility sessions and six and five community sessions were held in Tanzania and Uganda, respectively
Summary
Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. Implementation levels of essential evidence-based interventions for maternal and newborn health vary within and between countries [4] with major quality gaps. In Tanzania and Uganda, essential interventions such as the active management of the third stage of labour or measuring blood pressure during antenatal care should be implemented according to national guidelines, but actual coverage remains limited for several reasons including low availability of essential items in facilities [5,6,7,8], weak governance and substandard health care worker practices [9]. A total of 409 and 291 last event interviews were done with health workers in Tanzania and Uganda
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