Improving service uptake and quality of care of integrated maternal health services: The Kenya kwale district improvement collaborative

Background: Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack of progress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother. Methods: Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office. Results: The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012). Conclusion: Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries. Kwale district comprises two administrative divisions (Matuga and Kubo) with a combined total population of close to 160,000 [22]. The district is one of the poorest in the country with close to 50% of its inhabitants classified in the absolute poverty category [22]. Compared to the national average, the district has some of the poorest health indicators. Estimates put the infant mortality rate at about 90 per 1,000 live births compared to 77 per 1,000 live births nationally [22]. The child mortality rate is as high as 100–120 per 1,000 live births whilst the national rate is 74 per 1,000 live births [22]. Maternal mortality ratio is also high at 590-700/100,000 live births compared to the national average of 488 maternal deaths per 100,000 live births [22]. Most of the pregnant women start their ANC care visits late, and hence more than two thirds of all women never complete their scheduled antenatal care visits. Importantly, a sizeable proportion of those attending ANC clinics do not receive essential services such as having their ANC profiles done [23]. Furthermore, only one third of the estimated 6,000 annual deliveries in the district are assisted by a skilled health worker [22, 23]. Malaria contributes close to 40% of outpatient morbidity overall [22]. HIV prevalence is estimated at about 4% [24]. The majority of the inhabitants have difficulty in accessing health care facilities due to long distances [22]. Out-of-pocket payment for health care services is sometimes a financial barrier [22]. In this study we set out to examine whether quality improvement approaches can be applied to increase utilization of integrated health services (ANC, PMTCT, and skilled delivery) and improve adherence to clinical standards and guidelines in a rural district. Furthermore we wanted to determine if this can be achieved within the confines of the routine supportive supervision set up. To achieve this, we undertook a pre- and post-implementation evaluation of the impact of quality improvement activities on improving the above services. An improvement collaborative consists of a group of health workers drawn from different health facilities that work on the same set of indicators and meet regularly (usually every 3–6 months) to share working ideas [25]. This allows rapid diffusion of such ideas and their replication by other facilities in the collaborative. Through this approach, large scale district-wide improvement can be realized faster. All Ministry of Health facilities in Kwale District were included in this activity: one government-run hospital, three health centers and 17 dispensaries. These 21 facilities constituted the Kwale improvement collaborative. The district health office is managed by the District Health Management Team (DHMT) led by the District Medical Officer for Health (DMOH). The DHMT oversees health resources and services in the district and has overall responsibility to improve the health status of the community. For sustainability, all activities under this project were carried out by the Kwale DHMT with technical support from the United States Agency for International Development (USAID) Health Care Improvement Project (HCI). HCI provided one week training on quality improvement to the DHMT. This training involved core aspects of quality improvement such as:- applying system thinking as healthcare managers, using data to identify quality gaps, application of various quality improvement tools (process maps, the Ishikawa diagram, Pareto charts among others), developing an improvement plan, how to come up with change ideas and put them through the Plan-Do-Study-Act cycle, measuring improvement, and how to set up and mentor/coach improvement teams [25]. The DHMT members then worked with each of the 21 facilities in the district to assist them in forming a 7–12 member quality improvement team composed of facility health-care personnel, community health-care volunteers, and community representatives from the given facility’s catchment area. These 21 facility based improvement teams were to work on the same indicators and hence form a ‘collaborative’. The DMOH through a consultative process finally assigned each of the trained DHMT members two or three improvement teams to mentor/coach on quality improvement as part of their regular supportive supervision. As part of the implementation plan, the DHMT selected a set of 20 indicators to be used to monitor progress (Additional file 1). These were primary indicators that the district is required to routinely report on for ANC and related programs in Kenya. The facility improvement teams were continuously mentored/coached by the DHMT members on how to rigorously examine the process of service delivery, identify root causes of any problems, and finally develop and implement change ideas addressing the problem. The team members met at least once fortnightly to review progress and plotted their data monthly to monitor the impact of any changes that had been implemented. Importantly, each team documented every single change idea they were developing and testing in their improvement files. A quality improvement advisor from HCI provided ongoing support and guidance to the DHMT in carrying out activities for the duration of the project. HCI also provided financial support to cater for sharing forums and met the minimal field transport costs for the DHMT to enable them visit and coach their respective facilities at least once a month. Sharing forums were organized every 3–4 months in line with the requirements of an improvement collaborative [8, 25]. During these sessions, representatives from all 21 teams met and exchanged their successes and challenges in improving care. These forums enabled diffusion of emerging working ideas across sites. At the end of the project all change ideas tested by teams were reviewed. The teams further ranked each of the change ideas to determine their feasibility and identify ideas that can be recommended to other districts in similar settings. Ranking was based on four parameters:- i) Number of sites that implemented the specific idea. Therefore an idea that was implemented and shown to be working by more sites scored higher. ii) Simplicity/how easy it was for the team to implement the idea. Iii) Scalability, how easily the idea could be replicated in other similar settings. iv) Relative importance, its contribution to the results achieved. Each parameter had 5 as the highest score and 1 as the lowest; therefore the maximum score an idea could get was 20 and a minimum 4. Finally a detailed guide of how each change idea was implemented was prepared (Additional file 2). This guide will be used in the dissemination of these change ideas to other districts keen on improving their services and further inform the national Ministry of Health on how to implement quality improvement approaches in rural settings in Kenya. A large number of change ideas were developed and implemented by health facilities teams for the five key focus areas of intervention: ANC coverage, ANC quality of care, health facility deliveries, PMTCT, and community linkages (Additional file 2). These ideas were shared among all teams, and multiple teams tried the same ideas. Some of the successful change ideas implemented by teams and rated highly using the criteria described above are summarized in Table 1. Highly ranked change ideas recommended by the collaborative for implementation in similar settings Certain change ideas were more challenging to implement. For example attempts were made to integrate antenatal care services into outreach services for vaccination but this idea faced logistical challenges and was not done by most facilities. Although some facilities improved 24-hour coverage by rearranging staff duty schedules and moving the staff members to the staff quarters on facility premises, this was not feasible in all facilities due to shortage of personnel, security concerns and lack of staff quarters. Importantly, to tackle financial barriers, some facilities tested the feasibility of staggering any required payments over the entire pregnancy period rather than asking the mothers to pay the entire amount at once. Overall the teams developed and tested over fifty change ideas. A full description of each of the change idea is provided (Additional file 2). Given that this project was embedded within the Government of Kenya, Ministry of Health’s routine improvement and supportive supervision strategy, and that regularly collected, anonymized secondary data were used for the analysis with no patient contact; the study was exempt from Institutional Review Board submission according to the Office of Human Research Protection (OHRP) guidelines [26]. Twenty indicators targeting integrated reproductive health services were selected by the DHMT to be used by the improvement teams in monitoring their facilities’ progress in improving access and quality of care (Additional file 1). Data used to calculate the 20 indicators were collected and entered into routine government registers by the quality improvement teams on a daily basis. The data were abstracted monthly by the health facility staff from the government registers for quality improvement activities. For the purposes of this study, aggregated, anonymous data for the district were collected from the records of the District Health Management Office. Raw data on the 20 indicators in the five technical focus areas were collected and entered into routine government registers by the quality improvement teams daily. Aggregate district data were obtained from the district health information office. The aggregate data were then entered into excel spreadsheets for preliminary manipulation then transferred into STATA 11.0 (Stata Corp, College Station, TX) for further analysis. We compared proportions using the x2 test or Fisher exact test where appropriate and further explored for trends using the x2 test for trend. Ministry of Health estimates for denominators for each of the health facilities’ catchment area were used in calculating coverage.