Quality of care during childbirth in low-resource settings: Applying an epidemiology lens to an implementation problem

While significant progress has been made towards improving health outcomes in low-resource settings, unacceptably high maternal mortality remains a problem. Efforts to improve maternal mortality in low-resource settings did not yield intended results. One hypothesized reason for insufficient maternal mortality progress is poor interpersonal quality of care during childbirth at health facilities. Qualitative studies support the assumptions of quality of care frameworks that connect structural inputs (e.g. drugs and supplies, equipment, human resources) to interpersonal quality. However, there is no quantitative evidence for this relationship. Further, although maternal health researchers developed quantitative tools to measure interpersonal quality of care, the construct is mainly operationalized as a single, bipolar dimension, measured as respectful maternity care (good care) or disrespect and abuse (poor care). To address these limitations, this dissertation used an epidemiologic perspective to test the underlying assumptions of quality of care frameworks and to create a robust measure of interpersonal quality of care. This dissertation consists of three parts: an empirical study to test the hypothesis that structural inputs have a positive effect on interpersonal quality of care; a systematic review of the literature of instruments measuring the construct of interpersonal quality of care and their reliability, validity, and dimensionality; and an empirical study to assess the dimensionality and construct validity of the Maternal Health Interpersonal Quality Scale, a measure of interpersonal quality of care. The first empirical study did not find meaningful associations between HIV structural inputs and maternal health structural inputs and interpersonal quality of care during childbirth. These results do not support the assumptions of quality of care frameworks nor qualitative evidence linking structural inputs and interpersonal quality of care. The systematic review suggested that the construct of interpersonal quality of care is not well-defined, that few instruments met psychometric standards for adequate reliability and validity, and that studies that assessed the instruments were generally of poor quality. The second empirical study found that interpersonal quality of care formed a two-dimensional, correlated structure, with one dimension measuring respectful maternity care and one dimension measuring disrespect and abuse. Overall, this dissertation used an epidemiologic lens to address an implementation problem in maternal health. While there is a need to improve interpersonal quality of care during childbirth, in order to impact change and to avoid implementation failure, it is imperative to ensure interventions have a strong evidence base and to use validated measures of the construct

Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study

Background Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women’s poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. Methods and findings We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21–0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05–0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19–0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. Conclusions After implementation of the combined intervention, the likelihood of women’s reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project’s facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486

A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study

Background: Concerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique. Methods and findings: In this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre–post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05–2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65–50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81–1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV. Conclusions: The CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis

Studying moderators of implementation: analysis from an intervention to reduce disrespect and abuse in facility-based childbirth

Background: Across the globe, women who deliver in health facilities report experiencing disrespect and abuse (D&A). In low- and middle-income countries, D&A is particularly catastrophic because it may cause women to opt against facility delivery, as well as violate their human rights. D&A is likely a frontline manifestation of multi-level problems in complex health systems; yet efforts to address D&A have typically focused on micro-levels - either health providers’ ethics or users’ demand for quality care. These have rarely achieved sustainable implementation mirroring clinical quality improvement challenges. Implementation science holds promise for investigating these challenges. The Consolidated Framework for Implementation Research (CFIR) assembles constructs from across the literature that can guide inquiry. Materials and methods: The Staha Project studies the magnitude and dimensions of D&A, and is testing mechanisms for its mitigation. It is based in two Tanzanian districts, with one assigned to intervention. Implementation is conducted by four facilities, catchment communities and local leadership. Implementation research includes patient and provider satisfaction surveys, observations, reports and qualitative interviews. Relevant CFIR constructs were selected to develop the lines of inquiry and as themes for qualitative analysis adapted iteratively based on data. We conducted descriptive analyses of quantitative data. Results: The intervention was developed through a participatory process grounded in baseline research to address meso- and micro-level drivers at the district level. A change process was elaborated including activation of a client service charter and a facility-based change process. Mutuality of respect emerged as the underlying value for the process. Results from the planning process and the first year of implementation will be presented using CFIR constructs. These will include findings related to the characteristics of the intervention, inner and outer settings, individual implementers and the process. Conclusions: The CFIR was a useful tool to establish lines of inquiry and frame analysis. Ongoing analysis permitted identification of areas for improvement. We found the strongest constructs were regarding the intervention, the individual, and the inner setting characteristics. The outer setting construct could be further developed, especially for interventions that go beyond health facilities

Drosophila muller f elements maintain a distinct set of genomic properties over 40 million years of evolution.

The Muller F element (4.2 Mb, ~80 protein-coding genes) is an unusual autosome of Drosophila melanogaster; it is mostly heterochromatic with a low recombination rate. To investigate how these properties impact the evolution of repeats and genes, we manually improved the sequence and annotated the genes on the D. erecta, D. mojavensis, and D. grimshawi F elements and euchromatic domains from the Muller D element. We find that F elements have greater transposon density (25-50%) than euchromatic reference regions (3-11%). Among the F elements, D. grimshawi has the lowest transposon density (particularly DINE-1: 2% vs. 11-27%). F element genes have larger coding spans, more coding exons, larger introns, and lower codon bias. Comparison of the Effective Number of Codons with the Codon Adaptation Index shows that, in contrast to the other species, codon bias in D. grimshawi F element genes can be attributed primarily to selection instead of mutational biases, suggesting that density and types of transposons affect the degree of local heterochromatin formation. F element genes have lower estimated DNA melting temperatures than D element genes, potentially facilitating transcription through heterochromatin. Most F element genes (~90%) have remained on that element, but the F element has smaller syntenic blocks than genome averages (3.4-3.6 vs. 8.4-8.8 genes per block), indicating greater rates of inversion despite lower rates of recombination. Overall, the F element has maintained characteristics that are distinct from other autosomes in the Drosophila lineage, illuminating the constraints imposed by a heterochromatic milieu

\u3ci\u3eDrosophila\u3c/i\u3e Muller F Elements Maintain a Distinct Set of Genomic Properties Over 40 Million Years of Evolution

The Muller F element (4.2 Mb, ~80 protein-coding genes) is an unusual autosome of Drosophila melanogaster; it is mostly heterochromatic with a low recombination rate. To investigate how these properties impact the evolution of repeats and genes, we manually improved the sequence and annotated the genes on the D. erecta, D. mojavensis, and D. grimshawi F elements and euchromatic domains from the Muller D element. We find that F elements have greater transposon density (25–50%) than euchromatic reference regions (3–11%). Among the F elements, D. grimshawi has the lowest transposon density (particularly DINE-1: 2% vs. 11–27%). F element genes have larger coding spans, more coding exons, larger introns, and lower codon bias. Comparison of the Effective Number of Codons with the Codon Adaptation Index shows that, in contrast to the other species, codon bias in D. grimshawi F element genes can be attributed primarily to selection instead of mutational biases, suggesting that density and types of transposons affect the degree of local heterochromatin formation. F element genes have lower estimated DNA melting temperatures than D element genes, potentially facilitating transcription through heterochromatin. Most F element genes (~90%) have remained on that element, but the F element has smaller syntenic blocks than genome averages (3.4–3.6 vs. 8.4–8.8 genes per block), indicating greater rates of inversion despite lower rates of recombination. Overall, the F element has maintained characteristics that are distinct from other autosomes in the Drosophila lineage, illuminating the constraints imposed by a heterochromatic milieu