Benin
Enabling factors affecting
the performance of skilled birth attendants
A wide
variety of factors might affect the performance
of skilled birth attendants, including provider
competence and motivation, various patient
characteristics, hospital leadership and supervision,
availability
of equipment, drugs and supplies, policies, time
of day and week, and support team. This study
examined the relationships between such factors and
performance
during labor, delivery and immediate postpartum
maternal
and newborn care. Data were obtained from 5 referral
hospitals, 12 smaller hospitals, and 4 health
centers in four countries (Benin, Ecuador, Jamaica,
Rwanda).
Performance was defined as compliance according
to international standards and measured by
direct observation
of all births and retrospective record review
of obstetric emergencies. The enabling factors were
measured by a variety of instruments, measurements
of the competency of birth attendants obtained
from a related study.
Measuring competency of skilled birth attendants
This study developed instruments for measuring
knowledge and skills of birth attendants.
It was tested in
four countries: Benin, Ecuador, Jamaica and
Rwanda. The instruments measured competency during
labor,
delivery, postpartum maternal care, and postpartum
newborn care. Knowledge was measured with
a 55-item test derived from several well-known
sources,
such as the WHO IMPAC guidelines. The skills
test
included
two partograph exercises and six skill stations
using mannekins and attended by expert clinicians.
Locally
appropriate standards were added to the tests
in each country.
Download report:
Comparison of Two Methods for Determining
Provider Attendance during Normal Labor and Delivery:
Benin, Ecuador, Jamaica, and Rwanda
Measuring in-facility delays during emergency obstetric
care
This study developed and tested a method for measuring
delays in the treatment of selected obstetrical
emergencies within facilities in four countries:
Benin, Ecuador,
Jamaica, and Rwanda. Emergencies addressed included
eclampsia/pre-eclampsia, sepsis, obstructed labor,
postpartum hemorrhage, and post-abortion complications.
The method included observing patient flow in the
obstetrical ward and/or the emergency room, and
record review of obstretrical emergencies. Patient
flow
data were obtained on 856 maternal cases, and 329
records of obstetrical cases were reviewed by a
physician. The study found that patient flow observation
is
feasible and necessary to measure delays in initial
evaluation. Record reviews by physicians also yielded
usable information on delays in obstetrical emergencies.
Download report:
Safe
Motherhood StudiesResults from Benin:
Competency of Skilled Birth Attendants, The Enabling
Environment for Skilled Attendance at Delivery,
In-Hospital Delays in Obstetric Care (Documenting
the Third Delay)
Chile
Evaluation of the Chile national quality assurance
program
The Chile National Quality Assurance (QA) Program
began in 1991, and working through a QA Unit in
the Ministry of Health, developed standards,
training
modules, and communication strategies, eventually
achieving country-wide coverage. This evaluation
was undertaken in 1999 by a team of three senior
staff from QAP and the director of the national
program to develop and apply an evaluation methodology
that
would document the QA programs structure and
management and its technical and support functions.
The methodology included: (1) developing a logical
framework of technical areas, (2) identifying questions
for each technical area, and indicators, data sources,
and data collection methods for each question, (3)
setting the timing for data collection (before or
during the evaluation team visit), and (4) analysis
and write-up of the findings. The evaluation revealed
a very successful program with many innovative characteristics.
About 12,000 health professionals had been trained
in QA methods, representing 25 % of the health workforce.
The Chilean QA program is closely linked to primary
care and public health, with QA more prevalent in
health centers than larger facilities. Incentives
have been in the form of professional awards and
public acknowledgement. The team concluded that strong
dedication to QA by health professionals throughout
the country has developed close bonds at the local
level that have been crucial to QAs success
there.
Download report:
Evaluation of the Chile National Quality Assurance
Program
Ecuador
Enabling factors affecting the performance of skilled
birth attendants
A wide variety of factors might affect the
performance of skilled birth attendants, including
provider
competence and motivation, various patient
characteristics, hospital leadership and supervision,
availability
of equipment, drugs and supplies, policies, time
of day and week, and support team. This study
examined the relationships between such factors
and performance
during labor, delivery and immediate postpartum
maternal
and newborn care. Data were obtained from 5 referral
hospitals, 12 smaller hospitals, and 4 health
centers in four countries (Benin, Ecuador,
Jamaica, Rwanda).
Performance was defined as compliance according
to international standards and measured by
direct observation
of all births and retrospective record review
of obstetric emergencies. The enabling factors
were
measured by a variety of instruments, measurements
of the competency of birth attendants obtained
from a related study.
Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge
and skills of birth attendants. It was tested in
four countries: Benin, Ecuador, Jamaica and Rwanda.
The instruments measured competency during labor,
delivery, postpartum maternal care, and postpartum
newborn care. Knowledge was measured with a 55-item
test derived from several well-known sources, such
as the WHO IMPAC guidelines. The skills test included
two partograph exercises and six skill stations using
mannekins and attended by expert clinicians. Locally
appropriate standards were added to the tests in
each country.
Measuring in-facility delays during emergency obstetric
care
This study developed and tested a method for
measuring delays in the treatment of selected
obstetrical emergencies
within facilities in four countries: Benin, Ecuador,
Jamaica, and Rwanda. Emergencies addressed included
eclampsia/pre-eclampsia, sepsis, obstructed labor,
postpartum hemorrhage, and post-abortion complications.
The method included observing patient flow in
the obstetrical ward and/or the emergency room,
and record
review of obstretrical emergencies. Patient flow
data were obtained on 856 maternal cases, and
329 records of obstetrical cases were reviewed
by a physician.
The study found that patient flow observation
is feasible and necessary to measure delays in
initial
evaluation. Record reviews by physicians also
yielded usable information on delays in obstetrical
emergencies.
Measuring the cost of inefficiency in hospital labs
in Ecuador
This study developed a method for identifying inefficiencies
in hospital laboratories and measuring their cost,
and tested it in three hospitals in Ecuador. Seven
types of inefficiency are included: (1) ordering
unneeded tests, (2) test results never picked up,
(3) inefficient use of lab resources, (4) low productivity
of laboratory staff, (5) expiration of lab reagents,
(6) lack of quality and cost control practices, and
(7) inefficient procurement of lab reagents and other
resources. Theft and long-term costs of poor quality
were not addressed. It was necessary for the hospitals
to develop explicit standards before the cost of
unneeded tests could be measured. Data collection
methods included review of existing lab records,
financial records, hospital utilization records,
and a sample of medical records; observation of high
frequency tracer tests to estimate time used; and
key informant interviews. The study found that staff
time was the largest cost factor and that under-utilization
of staff is a potentially large component of inefficiency.
Expired reagents were a significant contributor to
inefficiency in all three hospitals. High costs of
resources due to poor procurement practices were
a major source of inefficiency in at least one hospital.
Unneeded tests comprised about 7% of all costs due
to inefficiency, while three types of inefficiency
were not important (tests not picked up, inefficient
use of lab resources, lack of practices).
Redesign of obstetric records
This study redesigned the obstetric patient record
process in four Ecuadorian hospitals using
a standard QA redesign approach. As part of this
process, eight
key indicators of patient record quality were
defined: (1) complete set of forms, (2) correct
chart headers,
(3) complete discharge form, (4) complete delivery
record, (5) signed patient consent and release
forms, (6) identification on admit and discharge
forms,
(7) legible, (8) coherent and consistent. A
random
sample of about 200 records from each hospital
(about 100 before the redesign and 100 after)
were audited.
The percentage of indicators meeting the standard
in the sample improved significantly in all
four hospitals. Overall, quality increased by
an average
of 27 percentage points, from 41% compliant
with quality standards before redesign to 69%
compliant
afterwards. The biggest gains were in legibility,
coherency and consistency, complete set of
forms, discharge form, and delivery record. Further
work is required to assess whether the increase
in quality
reduced medical errors, and whether the records
are now of sufficient quality to use as a data
source
for monitoring quality assurance activities.
Download report:
Redesigning
Hospital Documentation Systems to Improve the
Quality of Obstetric Patient Records in Ecuador
Jamaica
Enabling factors affecting the performance of skilled
birth attendants
A wide variety of factors might affect the performance
of skilled birth attendants, including provider competence
and motivation, various patient characteristics,
hospital leadership and supervision, availability
of equipment, drugs and supplies, policies, time
of day and week, and support team. This study examined
the relationships between such factors and performance
during labor, delivery and immediate postpartum maternal
and newborn care. Data were obtained from 5 referral
hospitals, 12 smaller hospitals, and 4 health centers
in four countries (Benin, Ecuador, Jamaica, Rwanda).
Performance was defined as compliance according to
international standards and measured by direct observation
of all births and retrospective record review of
obstetric emergencies. The enabling factors were
measured by a variety of instruments, measurements
of the competency of birth attendants obtained from
a related study.
Follow-up of HIV+ mother and child pairs in Jamaica
This study examined the practices of women in Jamaica
who had been found HIV-positive during antenatal
visits and who had participated in a pilot program
to prevent mother-to-child transmission of HIV/AIDS.
The study measured the womens knowledge,
attitudes, and practices relating to the prevention
of transmission, stigma, and related issues; tested
infants of consenting mothers for HIV status; and
observed providers in selected clinics to identify
program areas needing improvement. Although the
small sample size did not show any statistical
difference in disease transmission for women who
did or did not take nevirapine, the study did find
that women who did not breast feed were less likely
to transmit the virus to their infants
(p< 0.001).
Download report
The Impact of a Programme to Prevent Mother-to-Child
Transmission of HIV: Disease Transmission and
Health-Seeking Behaviour among HIV-Positive Mother-Child
Pairs
in Jamaica
Measuring competency
of skilled birth attendants
This study developed instruments for measuring
knowledge and skills of birth attendants. It
was tested in
four countries: Benin, Ecuador, Jamaica and
Rwanda. The instruments measured competency during
labor,
delivery, postpartum maternal care, and postpartum
newborn care. Knowledge was measured with a
55-item test derived from several well-known
sources,
such as the WHO IMPAC guidelines. The skills
test included
two partograph exercises and six skill stations
using mannekins and attended by expert clinicians.
Locally
appropriate standards were added to the tests
in each country.
Measuring in-facility delays during emergency obstetric
care
This study developed and tested a method for
measuring delays in the treatment of selected
obstetrical
emergencies within facilities in four countries:
Benin, Ecuador,
Jamaica, and Rwanda. Emergencies addressed
included eclampsia/pre-eclampsia, sepsis, obstructed
labor,
postpartum hemorrhage, and post-abortion complications.
The method included observing patient flow
in the obstetrical ward and/or the emergency
room,
and
record review of obstretrical emergencies.
Patient flow
data were obtained on 856 maternal cases, and
329 records of obstetrical cases were reviewed
by a
physician. The study found that patient flow
observation is
feasible and necessary to measure delays in
initial evaluation. Record reviews by physicians
also
yielded usable information on delays in obstetrical
emergencies.
Download report
Safe
Motherhood StudiesResults from Jamaica:
Competency of Skilled Birth Attendants; The Enabling
Environment for Skilled Attendance at Delivery; In-Hospital
Delays in Obstetric Care (Documenting the Third Delay)
Indonesia
Improving family planning counseling with
self-assessment and peer review in Indonesia
The quality of client-provider communication during a counseling
session was measured by the number of facilitative communications
and number
of informative communications by the provider during the session.
Three interventions were tested: a one week training for the providers
in
inter-personal communication, a low cost self-assessment protocol,
and weekly peer review meetings. The self-assessment and peer review
aimed primarily at reinforcing facilitative communication. A sample
of 203 family planning counselors was randomly assigned to one of
three groups. Group 1 received the training only; group 2 received
the training
and implemented the self-assessment for 16 weeks following the training;
and group 3 received the training and implemented both the self-assessment
and peer review for 16 weeks. Approximately two counseling sessions
per counselor were audio-taped and analyzed at three different times:
just before the training, just after the training, and 16 weeks after
the training. The average number of facilitative and informative
communications increased by 2-3 times between the first two measurements
for all three
groups, indicating that the training had a strong short-term impact.
However, after 16 weeks, the training-only group lost about half
of its gain in both facilitative and informative communication,
while
the other two groups maintained their gain in facilitative communication
although they lost about half the gain in informative communication.
These results suggest that self-assessment and peer review interventions
are effective strategies for reinforcing training in facilitative
communication.
Download report:
Improving Provider-Client Communication: Reinforcing IPC/C Training
in Indonesia with Self-Assessment and Peer Review
Client communication behaviors with healthcare
providers
This study used the data obtained in the Indonesia counseling, self-assessment,
and peer review study to analyze what causes clients to participate
actively during family planning counseling. Culturally acceptable ways
for Indonesian clients to participate in consultations include asking
questions, requesting clarification, stating opinions, and expressing
concerns. Based on a multi-variate analysis of 1,200 counseling sessions,
factors significantly associated with client active communication were,
in order of importance: providers information giving, providers facilitative
communication, providers expressing negative emotion, client educational
level, and province. The studys findings reinforce the importance
of achieving good provider counseling performance.
Download report:
Client Communication Behaviors with Healthcare Providers in Indonesia
Kenya
QA teams and IMCI
compliance in Kenya
This study tested whether facility-based
QA teams, trained and coached to develop
and implement solutions
to IMCI problems, could improve IMCI case management
after one year. The study looked at 21 QA teams
that implemented a variety of improvements:
procure more
IMCI drugs, clocking-in register, on-the-job
IMCI training, patient IMCI education,
workload sharing
by staff, reduce waiting time, and monthly
meetings. Approximately 70 providers were
observed attending
about 10 IMCI cases each before the team interventions,
and again after the interventions, in the 21
facilities with QA teams and in 14 facilities
without QA teams.
Case management was scored against a set of
indicators for IMCI assessment, classification,
treatment,
and counseling, and change in performance
was analyzed
for the 59 providers observed both before and
after. Quality of case management improved
by 57 percentage
points in the facilities with QA teams, compared
to only 14 percentage point improvement in
the control facilities.
Download report:
Using
Problem-Solving Teams to Improve Compliance
with IMCI Guidelines in Kenya
Vendor-to-vendor education to improve malaria treatment
by private drug outlets
Although many patients obtain anti-malarial drugs
from small private drug outlets in Kenya, earlier
studies indicated that 87% of shopkeepers had never
received training in appropriate use of anti-malarial
drugs and that 60% gave instructions or dosages to
customers. This study tested whether a low-cost education
strategy in one district of Kenya would increase
private drug outlet knowledge of and compliance with
national malaria guidelines. Local wholesalers (mobile
vendors and counter attendants at wholesale outlets)
were given a one-day training in malaria drug standards
and equipped with customized job aids (posters) to
give to the retail drug outlets that were their customers.
Mystery shoppers visited 101 intervention outlets
that received the job aids from wholesalers and 151
control outlets that did not receive the job aids,
asking for treatment for their child under two distinct
scenarios that required decision-making by the shopkeeper.
In response, the mystery shoppers were sold over
70 different anti-malarials (only 5 are government
approved), and over 30 anti-pyretics. In the intervention
outlets, the shoppers came away with an approved
anti-malarial and were told the correct dosage 17%
(27/157) of the time compared to 1.5% (3/202) in
the control outlets. In the intervention outlets,
35% of shopkeepers answered all 10 knowledge questions
correctly compared to only 4% in the controls. The
intervention cost was about $17 per outlet reached,
or about $0.10 per additional case correctly treated.
Download report:
Vendor to Vendor Education to Improve Malaria Treatment
by Drug Outlets in Kenya
Neighbor-to-neighbor education to improve malaria
treatment by private drug outlets
This study tested interventions to increase the compliance
of private drug outlets in selling anti-malarial
drugs for children beyond what was achieved in the
Vendor-to-Vendor study summarized above. The intervention
tested was a public education campaign that included
recruiting and training one advocate in each village
who spread information and brochures via a reach-one-teach-five
diffusion strategy and a radio campaign. An evaluation
of a sample of households seeking to purchase anti-malarials
for a child from private drug outlets found that
57 percent of households exposed to the education
campaign obtained acceptable medicines and doses,
compared to only 31 percent of households not exposed.
Another interesting finding was the messiness of
the marketplace for anti-malarials. Over 100 different
substances were offered for sale by the drug outlets
studied, only a few of which were appropriate. Many
inappropriate substances mimicked the packaging of
approved drugs, thus increasing confusion and inappropriate
treatment.
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