The MNH Quality Improvement Collaborative Context: IHI has partnered with the FMoH to reduce maternal and neonatal deaths by 30% through the introduction of district-wide quality improvement (QI) collaboratives. Program design details are published elsewhere (31). In brief the approach brings together facility teams from all facilities in the district for a 12- to 15-month period for a district- level improvement collaborative work. Target indicators representing key evidence-processes of MNH were selected by national and regional MNH leadership based on country wide priorities and available data and included two RMC focused measures related to birth companionship and privacy. The QI program commenced in April 2016 with a facility leadership training in quality improvement to build leadership buy-in, followed by a baseline assessment of key MNH service inputs, processes, and outcomes using data from the previous 12 months (July 2015 to June 2016) to determine areas for improvement focus. During the first learning session (LS), in November 2016, QI teams from all facilities in the woreda were convened, trained in QI methods, and presented with the baseline assessment findings. QI teams were then supported to design QI projects to fill identified gaps in the baseline assessment. These teams pursued a collective aim of improving MNH by using the Model for Improvement where they generated and tested change ideas using multiple Plan-Do-Study-Act (PDSA) cycles in their local facilities during the time between LSs (action period) (32). Intensive QI coaching and MNH clinical mentorship occurred during each action period (Figure 1). When training gaps were found during the baseline assessment, HCPs 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 Senior Project Officers (SPOs) while the BEmONC training was provided by Ethiopian Midwives Association in collaboration with IHI.
In close consultation with the regional health bureaus, three districts were targeted as prototype districts[1] by the project in Tigray, Oromia and Southern Nations, Nationalities, and People’s (SNNP) Regions (Table 1).
RMC Intervention
Design of the RMC videos: We conducted a focus group discussion (FGD) with IHI SPOs who had first-hand experiences as health care workers in rural settings. Focus group participants drew upon their experiences supporting and listening to pregnant women during community engagement activities, as clinical mentors and care providers having witnessed the disrespect and abuse that mothers face first-hand. In the FGD, we explored the current state of RMC-related issues in the program-supported districts. These findings were consolidated and key themes were identified. Three testimonial scripts were written to capture these key themes; these 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. Volunteer actresses were then trained to perform the scripts in video testimonials to protect patient confidentiality.
Delivery of the RMC Training Module: The videos were shown to participants during the second LS. Participants of this LS in the three districts are described in Table 2. The LS was attended by multidisciplinary health professionals, including 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 a skills-building session on empathic communication and relationship development with patients (Annex 2). Following the LS, participants returned to their QI teams to develop change ideas or local solutions to enhance RMC in their facilities using multiple PDSA cycles. The importance of testing changes to enhance RMC was reinforced by facility coaches during action period coaching visits. Coaching visits also helped to collect data and assure the data quality. A minimum of three coaching visits happened per facility in each action period.
Data Collection: The measures targeted for improvement through this intervention were privacy maintained and birth companion offered during labor and delivery (L&D), as these were the only data readily available from the programmatic database. Monthly programmatic data indicating the percentage of sampled deliveries with privacy maintained and with birth companion offered were collected from the facilities in these three districts (17 health centers and three primary hospitals) from November 2016 until January 2019 for a total of 27 months. Data were sampled from 30 births in the previous month that had been monitored using the FMoH-adopted Safe Childbirth Checklist (SCC). A systematic sampling technique was used for facilities that have higher number of deliveries (Annex 3- SCC). For facilities with lower birth rates (30 or less), all the SCCs filled-in during the past month were reviewed. The IHI SPOs collected the data and entered it 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 these two measures to assess the effectiveness 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 (32). Those with higher degrees of success and 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 occurred), 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 the change ideas implemented in the facilities that successfully enhanced the experience of care for mothers as results.
[1] The prototype districts included two additional districts from each of Amhara and 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.