Intervention in mothers and newborns to reduce maternal and perinatal mortality in three provinces in South Africa using a quality improvement approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation.

Abstract

The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels through universal coverage of sustainable quality health systems and clinical care. Our evaluation aims to determine the effect of various exposures, including COVID-19 and a system-level, complex, patient-centred quality improvement (QI) intervention (Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected facilities in South Africa. The objectives are to determine whether Mphatlalatsane reduces institutional maternal mortality ratio (iMMR), neonatal mortality rate and stillbirth rate (Objective 1); improves patients' experiences (Objective 2) and quality of care (Objective 3). Objective 4 assesses the contextual and implementation process factors, including COVID-19, that shape Mphatlalatsane and uptake variation. This study is an implementation science type 2 hybrid effectiveness, controlled-before-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For Objective 1, intervention and control facility-level data from the District Health Information System is compared for changes in institutional maternal and neonatal mortality and stillbirth rate and associations with QI, the COVID-19 pandemic and with both. This first analysis will consider data from 18 facilities, regardless of their allocation to intervention or comparison catchment areas to obtain a general idea of the effect of COVID-19. For Objectives 2-3, data collectors' abstract data from maternal and neonatal records, interview participants and conduct neonatal facility assessments. For Objective 4, interviews, programme documentation, surveys, and observations are used to assess how contextual factors at macro-, meso-, and micro-levels, explain variation in intervention uptake and outcome. The intervention dose is measured at micro-level only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. In preliminary analysis, across three provinces there was an increase in maternal and neonatal deaths during COVID-19 while stillbirths remained unchanged. Maternal satisfaction with quality of care was above 95%., COVID-19 severely disrupted the functioning of the QI teams. However, the QI teams regained their pre-COVID-19 momentum adapting the QI model, with advisors providing mentoring and support. Variation in adoption at meso-level was related to stable and motivated leadership (particularly at facility level), lack of integration into routine processes and buy-in from senior district managers who were affected by competing priorities. Referral and specialist outreach systems, staff availability and development and service delivery infrastructures also varied, plausible factors in variable outcomes. Few evaluations rigorously evaluated the effect of health systems interventions on improving health services and outcomes. Results will inform upscaling successful intervention components, and strategies to mitigate the effect of COVID-19 or similar emerging epidemics on maternal and neonatal mortality. DERR1-10.2196/42041.