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Background Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria. Methods This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses. Results Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012. Conclusion The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.
This was a prospective intervention study of EmOC services using a pre and post intervention design between June 2012, and April 2015 in Bauchi State, Nigeria. The study was conducted to evaluate interventions to improve the access and quality of EmOC services and reduce maternal mortality and morbidity. Baseline data were collected between June and July 2012. A follow-up assessment was conducted between March and April 2015. The study used methodologies and data collection instruments identical to those employed in 2012. The following interventions were implemented by Bauchi State MOH with support from TSHIP and other stakeholders between 2012 between 2015 based on the recommendations from the baseline survey. TSHIP supported renovations and minor repairs at hospitals and PHCs to increase and improve their readiness to respond to obstetric emergencies. A total of 10 hospitals and 14 PHCs among the surveyed health facilities were renovated. The government assessed and commenced renovation of additional 7 hospitals and 23 PHCs and health centers to increase access and utilization. TSHIP worked with Bauchi state to supply missing essential equipment for the labor and delivery room, antenatal and postnatal wards, and operation rooms for all the surveyed health facilities. This provided opportunity for the trained healthcare workers to practice competencies learnt during trainings for provision of quality EmOC services. TSHIP worked with the MOH to conduct training-of-trainers for 20 health professionals and these conducted several stepdown competency-based training activities (CBTs) to equip doctors, midwives and community health extension workers (CHEWs) with the knowledge and skills to provide safe care during labor and childbirth, prevent, detect and manage/refer obstetric complications. The trainers continued to serve as state trainers for subsequent state organized trainings to reach more health facilities. TSHIP worked with the MOH to strengthen the integrated supportive supervision (ISS) system at state and local government levels. It also facilitated arrangements that would enable various components within the health sector to work together to make supervision more integrated and supportive for better performance and improved quality of health care services. State and local government authority (LGA) supervision teams were formed, trained and equipped to conduct ISS at hospitals and PHCs on a quarterly basis. Zonal meetings of ISS teams were introduced and were held bi-annually to share experiences, lessons learned and to develop strategies that addressed challenges. This strengthened the state and LGA teams to plan, implement ISS and monitor progress. The state continued to conduct ISS services after the TSHIP project ended. TSHIP worked with MOH and other stakeholders to develop learning resource materials for MNH services. These included job aids/protocols on prevention and management of postpartum hemorrhage (PPH), Essential Newborn Care (ENC), care of the preterm and low birth weight babies, newborn resuscitation, management of severe pre-eclampsia and eclampsia, focused antenatal care (FANC), and care of the umbilical cord, among others. Bauchi state re-printed these job aids and distributed to other health facilities. Prior to TSHIP, Bauchi State’s health management information system used inadequate and inconsistent data reporting registers with poor availability of data at the Local Government Council and State levels. The Bauchi State Ministry of Health was supported to establish a multi-sectorial health data consultative committee (HDCC), responsible for cooperation, collaboration and coordination of health information system especially in the area of health data collection, flow, custody and release/disseminations. This led to improved data collection, reporting and quality. TSHIP worked with the MOH to re-activate ward development committees (WDCs) and trained community-based health volunteers (CBHVs), most of whom are traditional birth attendants (TBAs) to counsel households on the importance of ANC, childbirth in a health care facility, personal hygiene, breastfeeding, maternal and newborn danger signs, child spacing, use of misoprostol for prevention of bleeding after birth and chlorhexidine for prevention of umbilical cord infection. This was critical for improving the health seeking behavior of pregnant women and their families. Bauchi state has continued to procure misoprostol and chlorhexidine for community distribution and is supporting the CBHVs program across the state. Data for the baseline and endline surveys were obtained from 21 hospitals and 38 primary healthcare centers in Bauchi State. All the facilities studied were public facilities located in the state’s three senatorial zones that provide labor and childbirth services. Included in this survey were the clinical departments within each given facility that provided maternal and newborn care services. Of the 23 general hospitals in the state, two were excluded because they were inaccessible owing to insecurity. The primary healthcare centers administratively clustered around the included hospitals were sampled from the 318 primary healthcare centers distributed across the state. Data were collected in the baseline and follow-up surveys using EmOC evaluation tools developed by Averting Maternal Death and Disability [8]. The tools were based on the EmOC indicators specified in the international guidelines for monitoring use of maternal and neonatal services [7]. An identical modular questionnaire was adapted in 2012 and covered provider knowledge and competency for maternal and newborn care, EmOC signal functions, cesarean births, and maternal deaths, was used as well. Twenty-seven research assistants were trained for seven days in March 2015. Nine research teams were formed, with three teams per senatorial zone. In each zone, the teams obtained data from hospitals and primary healthcare facilities applying the same selection criteria as in 2012 and yielding the same sample size. Research assistants obtained data through individual interviews of the heads of facilities (managers) and health service providers and from the facilities’ records—including registers of labor and childbirth, partographs, the operating room, and the prenatal and postnatal wards. Data on maternal complications and deaths at each facility were collected from Health Management Information System (HMIS) data registers on a monthly basis for 12 months (October 2013 to September 2014). Direct observations were also carried out to determine availability of the basic, essential infrastructure, drugs, and supplies required to perform the signal functions. Data collected was captured into Epi Info version 7 (Centers for Disease Control and Prevention, Atlanta, GA, USA) by trained data clerks. Descriptive analyses including frequency distributions and bivariate analyses were performed with SPSS version 15 (SPSS Inc, Chicago, IL, USA). The unique identification numbers assigned to facilities at baseline were used in this study to trace each facility. The list of health care facilities with their codes was shared with the data collectors and supervisors during the training. Data collectors were required to carefully check all recorded responses and correct any possible errors. Study supervisors reviewed administered questionnaires on a daily basis and probed for and addressed data inconsistencies. The survey coordinator at the state level performed a second level review of the administered questionnaires. Data entry queries were run to identify any issue regarding inconsistent or missing information. Specific questionnaires were reviewed for the necessary corrections. In addition to using queries to detect data entry errors, the design of the data entry screen also included in-built validation measures. Ethical clearance for this study was granted by the Bauchi State Health Research and Ethics Committee (BHREC). Written informed consents were also obtained from the heads of the health facilities before the interviews and from patients for care that was observed. All data was anonymized and processed with the strictest confidentiality.
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