See the published version of this article at BMC Pregnancy and Childbirth.
This is a preprint, a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
A practice improvement package at scale to improve management of birth asphyxia in Rwanda: A before-after mixed methods evaluation
RACHEL FAVERO
JHPIEGO
Corresponding Author
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Pregnancy and Childbirth.
Background: Helping Babies Breathe (HBB) is a competency-based educational method for an evidence-based protocol to manage birth asphyxia in low resource settings. HBB has been shown to improve health worker skills and neonatal outcomes, but studies have documented problems with skills retention and little evidence of effectiveness at large scale in routine practice. This study examined the effect of complementing provider training with clinical mentorship and quality improvement as outlined in the second edition HBB materials. This “system-oriented” approach was implemented in all public health facilities (n=172) in ten districts in Rwanda from 2015 to 2018.
Methods: A before-after mixed methods study assessed changes in provider skills and neonatal outcomes related to birth asphyxia. Mentee knowledge and skills were assessed with HBB objective structured clinical exam (OSCE) B pre and post training and during mentorship visits up to one year afterward. The study team extracted health outcome data across the entirety of intervention districts and conducted interviews to gather perspectives of providers and managers on the approach.
Results: Nearly forty percent (n= 772) of health workers in maternity units directly received mentorship. Of the mentees who received two or more visits (n=456), sixty percent demonstrated competence (received > 80% score on OSCE B) on the first mentorship visit, and 100% by the sixth. In a subset of 220 health workers followed for an average of five months after demonstrating competence, 98% maintained or improved their score. Three of the tracked neonatal health outcomes improved across the ten districts and the fourth just missed statistical significance: neonatal admissions due to asphyxia (37% reduction); fresh stillbirths (27% reduction); neonatal deaths due to asphyxia (13% reduction); and death within 30 minutes of birth (19% reduction, p=0.06). Health workers expressed satisfaction with the clinical mentorship approach, noting improvements in confidence, patient flow within the maternity, and data use for decision-making.
Conclusions: Framing management of birth asphyxia within a larger quality improvement approach appears to contribute to success at scale. Clinical mentorship emerged as a critical element. The specific effect of individual components of the approach on provider skills and health outcomes requires further investigation.
Keywords
newborn resuscitation, helping babies breathe, scale up, quality improvement, Rwanda, supervision
Figure 1
Figure 2
Figure 3
Figure 4
This is a list of supplementary files associated with this preprint. Click to download.
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 3
Posted 15 Aug, 2020
Published
On 06 Oct, 2020
No community comments so far
Submission checks complete
On 13 Aug, 2020
Editorial decision: Accept
On 13 Aug, 2020
No comments provided
Editorial decision: Minor revision
On 20 Jul, 2020
Review #1 received
Received 15 Apr, 2020
Reviewer #1 agreed
On 03 Apr, 2020
Editor assigned
On 31 Mar, 2020
Reviewers invited
Invitations sent on 31 Mar, 2020
Submission checks complete
On 30 Mar, 2020
Editor invited
On 30 Mar, 2020
No comments provided
Editorial decision: Major revision
On 20 Feb, 2020
Review #2 received
Received 19 Feb, 2020
Reviewer #2 agreed
On 05 Feb, 2020
Review #1 received
Received 30 Jan, 2020
Reviewer #1 agreed
On 22 Jan, 2020
Reviewers invited
Invitations sent on 13 Jan, 2020
Editor assigned
On 10 Jan, 2020
Submission checks complete
On 23 Dec, 2019
Editor invited
On 23 Dec, 2019
First submitted
On 19 Nov, 2019
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Learn more about our company.
This preprint is under consideration at BMC Pregnancy and Childbirth. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
A practice improvement package at scale to improve management of birth asphyxia in Rwanda: A before-after mixed methods evaluation
RACHEL FAVERO
JHPIEGO
Corresponding Author
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 3
Posted 15 Aug, 2020
Published
On 06 Oct, 2020
No community comments so far
Submission checks complete
On 13 Aug, 2020
Editorial decision: Accept
On 13 Aug, 2020
No comments provided
Editorial decision: Minor revision
On 20 Jul, 2020
Review #1 received
Received 15 Apr, 2020
Reviewer #1 agreed
On 03 Apr, 2020
Editor assigned
On 31 Mar, 2020
Reviewers invited
Invitations sent on 31 Mar, 2020
Submission checks complete
On 30 Mar, 2020
Editor invited
On 30 Mar, 2020
No comments provided
Editorial decision: Major revision
On 20 Feb, 2020
Review #2 received
Received 19 Feb, 2020
Reviewer #2 agreed
On 05 Feb, 2020
Review #1 received
Received 30 Jan, 2020
Reviewer #1 agreed
On 22 Jan, 2020
Reviewers invited
Invitations sent on 13 Jan, 2020
Editor assigned
On 10 Jan, 2020
Submission checks complete
On 23 Dec, 2019
Editor invited
On 23 Dec, 2019
First submitted
On 19 Nov, 2019
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Pregnancy and Childbirth.
Background: Helping Babies Breathe (HBB) is a competency-based educational method for an evidence-based protocol to manage birth asphyxia in low resource settings. HBB has been shown to improve health worker skills and neonatal outcomes, but studies have documented problems with skills retention and little evidence of effectiveness at large scale in routine practice. This study examined the effect of complementing provider training with clinical mentorship and quality improvement as outlined in the second edition HBB materials. This “system-oriented” approach was implemented in all public health facilities (n=172) in ten districts in Rwanda from 2015 to 2018.
Methods: A before-after mixed methods study assessed changes in provider skills and neonatal outcomes related to birth asphyxia. Mentee knowledge and skills were assessed with HBB objective structured clinical exam (OSCE) B pre and post training and during mentorship visits up to one year afterward. The study team extracted health outcome data across the entirety of intervention districts and conducted interviews to gather perspectives of providers and managers on the approach.
Results: Nearly forty percent (n= 772) of health workers in maternity units directly received mentorship. Of the mentees who received two or more visits (n=456), sixty percent demonstrated competence (received > 80% score on OSCE B) on the first mentorship visit, and 100% by the sixth. In a subset of 220 health workers followed for an average of five months after demonstrating competence, 98% maintained or improved their score. Three of the tracked neonatal health outcomes improved across the ten districts and the fourth just missed statistical significance: neonatal admissions due to asphyxia (37% reduction); fresh stillbirths (27% reduction); neonatal deaths due to asphyxia (13% reduction); and death within 30 minutes of birth (19% reduction, p=0.06). Health workers expressed satisfaction with the clinical mentorship approach, noting improvements in confidence, patient flow within the maternity, and data use for decision-making.
Conclusions: Framing management of birth asphyxia within a larger quality improvement approach appears to contribute to success at scale. Clinical mentorship emerged as a critical element. The specific effect of individual components of the approach on provider skills and health outcomes requires further investigation.
Figure 1
Figure 2
Figure 3
Figure 4