The MNH Quality Improvement Collaborative Context: IHI has partnered with the FMoH to reduce maternal and neonatal deaths by 30% through a district-wide quality improvement (QI) collaborative, being integrated into the existing health system. This approach brings together facility teams from the district for a 12 to 15-month period for a woreda level improvement collaborative work. This work commenced with a training in quality improvement followed by a baseline assessment of key maternal newborn health service inputs, processes, and outcomes to determine areas for improvement focus. During the first learning session (LS), QI teams from all facilities in the woreda were convened and were presented with the baseline findings. They were then supported to design QI projects to fill in identified gaps in the baseline. These teams pursued a collective aim of improving MNH by using the Model for Improvement where they tested different change ideas using Plan-Do-Study-Act cycles (PDSA) in their local facilities during the action period. Intensive coaching and clinical mentorship focused on QI approach and MNH clinical skills happened in between the LSs (action period) (Figure 1). When training gaps were found during the baseline assessment, providers received basic emergency obstetric and newborn care (BEmONC) training which included RMC orientation.
In this endeavor, IHI provided the QI training, the baseline assessment tool and supported facilities in conducting the baseline assessment. The coaching visits to the facility team were done by IHI SPOs while the BEmONC training is provided by Ethiopian Midwives Association in collaboration with IHI.
In close consultation with the regional health bureaus, three districts in Tigray - Tanqua Abergele (TA), Oromia - Limu Bilbilu/Bekoji (LB) and Southern Nations, Nationalists, and People’s (SNNP) - Duguna Fango (DF) were targeted as prototype districts by the project as of October 2016 (Table 1). The prototype districts included additionally Woreta/Fogera in Amhara and Amibara in Afar which were engaged at a later time by the project (April 2017 and January 2019 respectively). These two districts were excluded from this analysis as the implementation time difference makes comparison difficult.
Design of the RMC videos: We conducted a focus group discussion (FGD) with IHI staff team members who had first-hand experiences as health care workers in rural settings and as coaches, to explore the current state of RMC-related issues in the program-supported districts. These findings were consolidated and key themes were identified. Three stories were written to capture these key themes. The testimonial scripts depicted a mother with normal delivery, another one with referral and emergency care and an adolescent pregnant woman who experienced preterm labor (Annex 1). The scripts were three to four minutes long and translated into Amharic. Student-actresses were then trained to perform the scripts to protect patient confidentiality in creating the video testimonials.
Delivery of the RMC Training Module: The videos were shown to participants during the second LS and facilitated by IHI Senior Project Officers (SPOs). Participants of this LS in the three districts are depicted in Table 2. Learning session participants were multidisciplinary, and included facility leadership, MNH clinical providers, data managers, and health extension workers.
The three videos were followed by participatory reflection and discussion. Participants were asked to reflect on the videos using questions depicted in Annex 2.
After the discussion, there was a short presentation on the prevalence of mistreatment in Ethiopia and skills to improve empathic communication and relationships with patients (Annex 2). Following the LS, teams returned to their QI projects to develop change ideas or local solutions to enhance RMC in their facility. Skills were reinforced by facility coaches between LSs. This includes supporting staff to ensure privacy of mothers by using screens and encouraging them to allow birth companion. Coaching visits also helped to collect data and assure the data quality. A minimum of three coaching visits happened between two LSs per facility.
Data Collection: Monthly programmatic data indicating the percentage of sampled deliveries with privacy maintained and with birth companion offered were collected from November 2016 until January 2019 for a total of 27 months, from the facilities in these three districts (17 health centers and three primary hospitals). Data were collected from 30 maternal medical records of the FMoH adopted safe child birth checklist on mothers who gave birth in the previous month, using a systematic sampling technique for facilities that have higher number of deliveries (Annex 3). For facilities with lower birth rates (30 or less), all the safe childbirth checklists filled-in during the past month were reviewed. Data were collected by IHI SPOs and entered into the program database as part of their routine work. Even though the RMC training addressed all the seven categories of mistreatment, the programmatic database measured only the sampled births with privacy and those with birth companion. Hence, in this study we used the two categories to assess the results of the training module.
Change ideas tested at facilities were extracted from routine QI coach programmatic documentation and were evaluated based on quantitative criteria for “success” based on run chart rules (30). Those with higher degrees of success were then reviewed and those with an RMC focus were extracted for this analysis.
Data Analysis: We conducted an interrupted time series and regression analysis using STATA version 13 to analyze the effectiveness of the intervention. In the regression analysis, we analyzed the short-term effect of the intervention which measures the first 10 to 11 months following the training (February/March to December 2017 during which direct project support was going on), while the long-term effect measures the impact of the intervention after the direct support ended. We used the Bowser and Hill mistreatment categories to label a ‘change idea’ as having a component that aims to enhance RMC. We presented sample change ideas implemented in the targeted facilities in ensuring privacy and allowing birth companion.