Facility level factors that determine consistent delivery of essential newborn care at health centers in Ethiopia

BMC Pregnancy and Childbirth, Volume 22, No. 1, Year 2022

Interprétation

Background: Essential newborn care (ENC) is a package of interventions which should be provided for every newborn baby regardless of body size or place of delivery immediately after birth and should be continued for at least the seven days that follows. Even though Ethiopia has endorsed the implementation of ENC, as other many counties, it has been challenged. This study was conducted to measure the level of essential newborn care practice and identify health facility level attributes for consistent delivery of ENC services by health care providers. Methods: This study employed a retrospective cross-sectional study design in 425 facilities. Descriptive statistics were formulated and presented in tables. Binary logistic regression was employed to assess the statistical association between the outcome variable and the independent variables. All variables with p < 0.2 in the bivariate analysis were identified as candidate variables. Then, multiple logistic regression analysis was performed using candidate variables to determine statistically significant predictors of the consistent delivery of ENC by adjusting for possible confounders. Results: A total of 273, (64.2%), of facilities demonstrated consistent delivery of ENC. Five factors—availability of essential obstetrics drugs in delivery rooms, high community score card (CSC) performances, availability of maternity waiting homes, consistent partograph use, and availability of women-friendly delivery services were included in the model. The strongest predictor of consistent delivery of essential newborn care (CD-ENC) was consistent partograph use, recording an odds ratio of 2.66 (AOR = 2.66, 95%CI: 1.71, 4.13). Similarly, providing women-friendly services was strongly associated with increased likelihood of exhibiting CD-ENC. Furthermore, facilities with essential obstetric drugs had 1.88 (AOR = 1.88, 95%CI: 1.15, 3.08) times higher odds of exhibiting consistent delivery of ENC. Conclusion: The delivery of essential newborn care depends on both health provider and facility manager actions and availability of platforms to streamline relationships between the clients and health facility management. The study area covers 1,880 health centers in the 396 intervention districts of the USAID Transform: Primary Health Care project [15]. The study employed a retrospective cross-sectional study design and used program monitoring data collected from October to December 2019. During this period, a total of 425 visits were made to health centers selected using simple random sampling method. The study analyzed the 425 supportive supervision visits data made to the health centers during the three-month period. Three types of data collection procedure are used during an on-site technical assistance visit. The first inquiries about health worker knowledge on the practices of essential newborn care services using a close-ended individual interview questions, the second is a simple observation of the availability of equipment and other relevant materials for care in the facility physical setting and the third involves a retrospective review of patient medical records by extracting last three months recorded data. The data collection is supported by an online electronic system [15]. For this study, data collected using the three procedures were used for analysis. The dependent variable of the study is consistent delivery of ENC by health care providers. Using data pulled from the medical records, the facilities practicing all the ENC components to all cases were labeled as “yes” and those that do not practice all, labeled as a “no”. The independent variable for this study includes other facility and input level variables (Table (Table1).1). They were included in the study to identify facility level attributes for observed differences between facilities in the consistent delivery of ENC. The variables based on findings from other studies [1, 5, 16] and program implementation experience are described in the table below (Table (Table11). Variables included in the analysis •Distance between facility and woreda capital (KM) •Access to roads •Availability of trained providers •Availability of technical staff as per the standard •Consistent partograph use •Availability of water •Availability of electricity •Presence of all the required laboratory investigations for antennal care •Availability of maternity waiting homes •Basic emergency obstetrics and newborn care (BEmONC) signal functions •Separate delivery rooms •Availability of essential obstetric drugs in delivery rooms (vitamin K, Tetracycline eye ointment and other obstetric drugs) •Availability of newborn corners •Established case review/audit system for maternal and newborn deaths •High caseload facility •Community scorecard performance •Availability of women-friendly delivery services A central goal of the project and the objective for its support to health workers and the health system. Essential newborn care is the care provided to the neonate after birth within the delivery room by skilled personnel which includes vitamin k provision, eye care, cord care, initiating exclusive breastfeeding, and thermal care. And, it is considered as consistent delivery when all the care packages are delivered to the newborn. The data collectors randomly pick five cards from the months prior to the data collection date and check for what is recorded on the patient card. After review of each card, the data collectors then mark if ENC is practiced or not. The case is marked as ‘yes’ when all the five components of the package, (vitamin K, TTC eye ointment, chlorohexidine for cord care, early initiation of breastfeeding and thermal care) are recorded as having been provided. The facility having two or more providers trained on either BEmONC or ENC within the last three years. The facility having 25 or more technical staff that provide services. The technical staff are health professionals that are assessing and managing medical treatments, providing ongoing care, and providing services to help with diagnosis and treatment. The facility offering delivery services for more than 500 births per year. A continuous variable—the community analyzes facility services and score them based on their personal perceptions of the services. As per the Ethiopian standard operating procedure, selected community representatives rate each facility’s performance based on the selected six indicators (1) compassionate, respectful and caring health workforce; (2) availability of services, biomedical equipment and pharmaceutical supplies; (3) patient waiting time; (4) health facility infrastructure; (5) ambulance service and management; and (6) clean and safe health facility (CASH). A composite ratio scale of the six indicators was used for analysis. A facility is labeled as having newborn corners when it has all the required equipment and materials in the labor and delivery rooms. The equipment and materials are: Ambu bag, suction machine, radiant warmer/heat source, oxygen source, fixed length board, resuscitator, weight scale, thermometer, stethoscope, mucus extractor, towel, cord care equipment, tube for feeding, sterile gloves, TTC eye ointment, vitamin K, CHX, syringe, feeding cup, ampicillin, and gentamicin. A facility which exhibits correct use of partographs in the reviewed patient cards. The facility having tests for Rh blood group, hemoglobin, venereal disease research laboratory (VDRL)/RPR (rapid plasma reagin), urinalysis, provider initiated testing and counseling (PITC) for HIV, and hepatitis B surface antigen (HBsAg). Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low and middle-income countries to reduce maternal and newborn mortality. A set of seven key obstetric services, or “signal functions,” has been identified as critical to BEmONC. BEmONC is recorded as “Yes” if all the seven signal functions, 1) Administration of parenteral antibiotics, 2) Administration of parenteral anticonvulsants, 3) Administration of parenteral uterotonics, 4) Removal of retained products (manual vacuum aspiration), 5) Assisted vaginal delivery, 6) Manual removal of the placenta, and 7) Resuscitation of the newborn are provided are available and recorded as “No” If any of the signal functions are missing. Data were managed using a web-based system, DHIS2 [17], and then exported to SPSS version 25 for statistical analysis. Descriptive statistics were formulated and presented in tables. Binary logistic regression was employed to assess the statistical association between the outcome variable and the independent variables. First, the assumptions including multicollinearity among the independent variables and linearity of independent variables for binary logistic regression model were checked and then bivariate analysis was used to identify candidate variables for multiple logistic regression analysis. All variables with p < 0.2 in the bivariate analysis were identified as candidate variables. Then, multiple logistic regression analysis was performed using candidate variables to determine statistically significant predictors of the consistent delivery of ENC by adjusting for possible confounders. In addition, a variable that was significant from a program implementation point of view was included in the final model even if the bivariate inclusion criteria were not met. Finally, variables with a p value less than 0.05 from the logistic regression were declared as statistically significant. Adjusted odds ratio with 95% CI was estimated to identify predictors for consistent delivery of ENC. Multicollinearity between the study variables was diagnosed using a variance inflation factor (VIF), an eigenvalue, and a condition index. Large, greater than 5, VIF values indicate a high degree of collinearity or multicollinearity among the independent variables [18]. Linearity of the continuous variables, distance between facility and woreda capital (KM) and community score card, with respect to the logit of the dependent variables were assessed via the Box-Tidwell (1962) procedure. The goodness-of-fit of the model was also checked using the Hosmer–Lemeshow test. The study used project data that has been collected as part of follow-up monitoring visits to health centers. The results of the study did not distinguish the name of the district and other specific site identifiers. Therefore, JSI research and Training Institute, Inc’s Institutional Review Board (IRB) has determined that this activity is exempt from human subjects’ oversight (IRB #20-17E). As part of the activity facility entry and document review permissions were sought from the health center management and staff.

Résumé de l’IA

Study Justification:

The study aimed to measure the level of essential newborn care (ENC) practice and identify health facility level attributes for consistent delivery of ENC services in Ethiopia. This is important because although Ethiopia has endorsed the implementation of ENC, there have been challenges in consistently delivering these services. By understanding the factors that determine consistent delivery of ENC, policymakers and health care providers can take targeted actions to improve newborn care and reduce infant mortality rates.

Study Highlights:

– The study found that 64.2% of facilities demonstrated consistent delivery of ENC.
– Five factors were identified as predictors of consistent delivery of ENC: availability of essential obstetrics drugs in delivery rooms, high community score card performances, availability of maternity waiting homes, consistent partograph use, and availability of women-friendly delivery services.
– The strongest predictor of consistent delivery of ENC was consistent partograph use.
– Providing women-friendly services and having essential obstetric drugs in delivery rooms were also strongly associated with increased likelihood of consistent delivery of ENC.

Study Recommendations:

Based on the study findings, the following recommendations can be made:

1. Ensure the availability of essential obstetric drugs in delivery rooms to support consistent delivery of ENC.
2. Strengthen community score card performances to improve the quality of newborn care.
3. Increase the availability of maternity waiting homes to facilitate access to timely and appropriate care.
4. Promote consistent use of partographs to monitor and manage labor effectively.
5. Improve the availability of women-friendly delivery services to enhance the overall experience of mothers during childbirth.

Key Role Players:

To address the recommendations, the following key role players are needed:

1. Health facility managers: They play a crucial role in ensuring the availability of essential obstetric drugs, implementing community score card programs, and improving the quality of delivery services.
2. Health care providers: They need to be trained on the consistent use of partographs and providing women-friendly delivery services.
3. Community representatives: They can contribute to improving the quality of care by actively participating in community score card assessments and advocating for better services.
4. Program managers: They can provide guidance, resources, and support to health facilities in implementing the recommended interventions.

Cost Items for Planning Recommendations:

While the actual cost will vary depending on the specific context, the following cost items should be considered in planning the recommendations:

1. Procurement and supply of essential obstetric drugs for delivery rooms.
2. Training programs for health care providers on partograph use and women-friendly delivery services.
3. Construction or improvement of maternity waiting homes.
4. Community engagement activities for implementing and monitoring the community score card program.
5. Monitoring and evaluation activities to assess the impact of the interventions and make necessary adjustments.
Please note that the provided cost items are general and should be further assessed and tailored to the specific needs and resources of the health system.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study employed a retrospective cross-sectional study design with a large sample size of 425 facilities. Descriptive statistics and logistic regression analysis were used to assess the association between variables. However, the abstract does not provide information on the representativeness of the sample or the generalizability of the findings. To improve the strength of the evidence, future studies could consider using a prospective design and include a more diverse sample of health centers.

Abstrait

The study area covers 1,880 health centers in the 396 intervention districts of the USAID Transform: Primary Health Care project [15]. The study employed a retrospective cross-sectional study design and used program monitoring data collected from October to December 2019. During this period, a total of 425 visits were made to health centers selected using simple random sampling method. The study analyzed the 425 supportive supervision visits data made to the health centers during the three-month period. Three types of data collection procedure are used during an on-site technical assistance visit. The first inquiries about health worker knowledge on the practices of essential newborn care services using a close-ended individual interview questions, the second is a simple observation of the availability of equipment and other relevant materials for care in the facility physical setting and the third involves a retrospective review of patient medical records by extracting last three months recorded data. The data collection is supported by an online electronic system [15]. For this study, data collected using the three procedures were used for analysis. The dependent variable of the study is consistent delivery of ENC by health care providers. Using data pulled from the medical records, the facilities practicing all the ENC components to all cases were labeled as “yes” and those that do not practice all, labeled as a “no”. The independent variable for this study includes other facility and input level variables (Table (Table1).1). They were included in the study to identify facility level attributes for observed differences between facilities in the consistent delivery of ENC. The variables based on findings from other studies [1, 5, 16] and program implementation experience are described in the table below (Table (Table11). Variables included in the analysis •Distance between facility and woreda capital (KM) •Access to roads •Availability of trained providers •Availability of technical staff as per the standard •Consistent partograph use •Availability of water •Availability of electricity •Presence of all the required laboratory investigations for antennal care •Availability of maternity waiting homes •Basic emergency obstetrics and newborn care (BEmONC) signal functions •Separate delivery rooms •Availability of essential obstetric drugs in delivery rooms (vitamin K, Tetracycline eye ointment and other obstetric drugs) •Availability of newborn corners •Established case review/audit system for maternal and newborn deaths •High caseload facility •Community scorecard performance •Availability of women-friendly delivery services A central goal of the project and the objective for its support to health workers and the health system. Essential newborn care is the care provided to the neonate after birth within the delivery room by skilled personnel which includes vitamin k provision, eye care, cord care, initiating exclusive breastfeeding, and thermal care. And, it is considered as consistent delivery when all the care packages are delivered to the newborn. The data collectors randomly pick five cards from the months prior to the data collection date and check for what is recorded on the patient card. After review of each card, the data collectors then mark if ENC is practiced or not. The case is marked as ‘yes’ when all the five components of the package, (vitamin K, TTC eye ointment, chlorohexidine for cord care, early initiation of breastfeeding and thermal care) are recorded as having been provided. The facility having two or more providers trained on either BEmONC or ENC within the last three years. The facility having 25 or more technical staff that provide services. The technical staff are health professionals that are assessing and managing medical treatments, providing ongoing care, and providing services to help with diagnosis and treatment. The facility offering delivery services for more than 500 births per year. A continuous variable—the community analyzes facility services and score them based on their personal perceptions of the services. As per the Ethiopian standard operating procedure, selected community representatives rate each facility’s performance based on the selected six indicators (1) compassionate, respectful and caring health workforce; (2) availability of services, biomedical equipment and pharmaceutical supplies; (3) patient waiting time; (4) health facility infrastructure; (5) ambulance service and management; and (6) clean and safe health facility (CASH). A composite ratio scale of the six indicators was used for analysis. A facility is labeled as having newborn corners when it has all the required equipment and materials in the labor and delivery rooms. The equipment and materials are: Ambu bag, suction machine, radiant warmer/heat source, oxygen source, fixed length board, resuscitator, weight scale, thermometer, stethoscope, mucus extractor, towel, cord care equipment, tube for feeding, sterile gloves, TTC eye ointment, vitamin K, CHX, syringe, feeding cup, ampicillin, and gentamicin. A facility which exhibits correct use of partographs in the reviewed patient cards. The facility having tests for Rh blood group, hemoglobin, venereal disease research laboratory (VDRL)/RPR (rapid plasma reagin), urinalysis, provider initiated testing and counseling (PITC) for HIV, and hepatitis B surface antigen (HBsAg). Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low and middle-income countries to reduce maternal and newborn mortality. A set of seven key obstetric services, or “signal functions,” has been identified as critical to BEmONC. BEmONC is recorded as “Yes” if all the seven signal functions, 1) Administration of parenteral antibiotics, 2) Administration of parenteral anticonvulsants, 3) Administration of parenteral uterotonics, 4) Removal of retained products (manual vacuum aspiration), 5) Assisted vaginal delivery, 6) Manual removal of the placenta, and 7) Resuscitation of the newborn are provided are available and recorded as “No” If any of the signal functions are missing. Data were managed using a web-based system, DHIS2 [17], and then exported to SPSS version 25 for statistical analysis. Descriptive statistics were formulated and presented in tables. Binary logistic regression was employed to assess the statistical association between the outcome variable and the independent variables. First, the assumptions including multicollinearity among the independent variables and linearity of independent variables for binary logistic regression model were checked and then bivariate analysis was used to identify candidate variables for multiple logistic regression analysis. All variables with p < 0.2 in the bivariate analysis were identified as candidate variables. Then, multiple logistic regression analysis was performed using candidate variables to determine statistically significant predictors of the consistent delivery of ENC by adjusting for possible confounders. In addition, a variable that was significant from a program implementation point of view was included in the final model even if the bivariate inclusion criteria were not met. Finally, variables with a p value less than 0.05 from the logistic regression were declared as statistically significant. Adjusted odds ratio with 95% CI was estimated to identify predictors for consistent delivery of ENC. Multicollinearity between the study variables was diagnosed using a variance inflation factor (VIF), an eigenvalue, and a condition index. Large, greater than 5, VIF values indicate a high degree of collinearity or multicollinearity among the independent variables [18]. Linearity of the continuous variables, distance between facility and woreda capital (KM) and community score card, with respect to the logit of the dependent variables were assessed via the Box-Tidwell (1962) procedure. The goodness-of-fit of the model was also checked using the Hosmer–Lemeshow test. The study used project data that has been collected as part of follow-up monitoring visits to health centers. The results of the study did not distinguish the name of the district and other specific site identifiers. Therefore, JSI research and Training Institute, Inc’s Institutional Review Board (IRB) has determined that this activity is exempt from human subjects’ oversight (IRB #20-17E). As part of the activity facility entry and document review permissions were sought from the health center management and staff.

Matériaux

N/A

Innovations

Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health by allowing pregnant women in remote areas to consult with healthcare providers through video calls or phone calls. This can help address the issue of limited access to healthcare facilities.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources related to maternal health can empower pregnant women to take control of their own health. These apps can provide guidance on prenatal care, nutrition, and exercise, as well as reminders for appointments and medication.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services and education in underserved areas can help bridge the gap in access to healthcare. These workers can conduct home visits, provide prenatal care, and educate women on safe delivery practices.

4. Maternity waiting homes: Establishing maternity waiting homes near healthcare facilities can provide a safe and comfortable place for pregnant women to stay as they approach their due dates. This can ensure that women have timely access to skilled birth attendants and emergency obstetric care.

5. Strengthening supply chains: Ensuring the availability of essential obstetric drugs and equipment in healthcare facilities is crucial for providing quality maternal health services. Implementing innovative supply chain management systems can help track and manage inventory, reducing stockouts and improving access to necessary supplies.

6. Quality improvement initiatives: Implementing quality improvement initiatives at healthcare facilities can help improve the consistency and effectiveness of essential newborn care. This can involve regular training and supervision of healthcare providers, as well as the use of standardized protocols and checklists.

7. Public-private partnerships: Collaborating with private sector organizations can help leverage their resources and expertise to improve access to maternal health services. This can involve partnerships with private hospitals, pharmaceutical companies, or technology companies to expand service delivery and improve healthcare infrastructure.

It’s important to note that the specific recommendations for improving access to maternal health will depend on the context and specific challenges faced in Ethiopia.

AI Innovations Description

Based on the study titled “Facility level factors that determine consistent delivery of essential newborn care at health centers in Ethiopia,” the following recommendations can be developed into an innovation to improve access to maternal health:

1. Promote consistent use of partographs: Implementing a system that ensures healthcare providers consistently use partographs during delivery can significantly improve the delivery of essential newborn care. This can be achieved through training programs, reminders, and monitoring systems.

2. Improve availability of essential obstetric drugs: Ensuring that delivery rooms have a consistent supply of essential obstetric drugs, such as vitamin K and Tetracycline eye ointment, can enhance the delivery of essential newborn care. This can be achieved through effective supply chain management and regular monitoring of drug availability.

3. Establish maternity waiting homes: Maternity waiting homes provide a safe and comfortable environment for pregnant women to stay near health facilities before giving birth. By establishing and promoting the use of maternity waiting homes, access to timely and quality maternal health services can be improved.

4. Enhance community scorecard performance: Engaging the community in assessing and rating facility performance can help identify areas for improvement and ensure accountability. Strengthening community scorecard systems and involving community representatives in monitoring and evaluation processes can contribute to better access to maternal health services.

5. Provide women-friendly delivery services: Creating a supportive and respectful environment for women during childbirth is crucial for improving access to maternal health. Implementing women-friendly delivery services, which prioritize women’s preferences and needs, can enhance the overall experience and encourage more women to seek care.

By implementing these recommendations, health facilities can improve the consistent delivery of essential newborn care and ultimately enhance access to maternal health services in Ethiopia.

AI Innovations Methodology

Based on the provided description, the study aims to identify facility-level factors that determine consistent delivery of essential newborn care (ENC) at health centers in Ethiopia. The study employed a retrospective cross-sectional study design and analyzed data collected from 425 health centers using program monitoring data. The methodology involved three types of data collection procedures: individual interviews with health workers, observation of facility settings, and retrospective review of patient medical records.

To simulate the impact of recommendations on improving access to maternal health, the following methodology can be used:

1. Identify potential recommendations: Review the findings of the study and identify areas where improvements can be made to enhance access to maternal health. This could include factors such as availability of essential obstetric drugs, consistent use of partographs, availability of women-friendly delivery services, etc.

2. Develop a simulation model: Create a simulation model that represents the current state of access to maternal health in the study area. This model should include relevant variables and their relationships, based on the findings of the study.

3. Introduce the recommendations: Incorporate the identified recommendations into the simulation model. This could involve adjusting variables such as the availability of essential obstetric drugs, promoting consistent use of partographs, improving women-friendly delivery services, etc.

4. Simulate the impact: Run the simulation model with the introduced recommendations and observe the changes in access to maternal health. Measure indicators such as the percentage of facilities demonstrating consistent delivery of ENC, improvements in availability of essential obstetric drugs, increased use of partographs, etc.

5. Analyze the results: Analyze the simulation results to determine the impact of the recommendations on improving access to maternal health. Compare the outcomes with the baseline data from the study to assess the effectiveness of the recommendations.

6. Refine and iterate: Based on the analysis of the simulation results, refine the recommendations if necessary and iterate the simulation process to further improve access to maternal health.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of specific recommendations on improving access to maternal health. This can inform decision-making and help prioritize interventions that are most likely to have a positive impact.

Auteur

Dima Health

Identifiers:

DOI: 10.1186/s12884-021-04358-4

Research Areas:

Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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