New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations

Background: In 2020, an estimated 287 000 women died globally from pregnancy‐related causes and 2 million babies were stillborn. Many of these outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of maternal health, antenatal care (ANC) is a key moment in terms of contact with the health system, yet it remains an underutilized platform. This paper describes the protocol for a study conducted in collaboration with Ministries of Health and country research partners that aims to employ implementation science to systematically introduce and test the applicability of the adapted WHO ANC package in selected sites across four countries. Methods: Study design is a mixed methods stepped-wedge cluster randomized implementation trial with a nested cohort component (in India and Burkina Faso). The intervention is composed of two layers: (i) the country- (or state)-specific ANC package, including evidence-based interventions to improve maternal and newborn health outcomes, and (ii) the co-interventions (or implementation strategies) to help delivery and uptake of the adapted ANC package. Using COM-B model, co-interventions support behaviour change among health workers and pregnant women by (1) training health workers on the adapted ANC package and ultrasound (except in India), (2) providing supplies, (3) conducting mentoring and supervision and (4) implementing community mobilization strategies. In Rwanda and Zambia, a fifth strategy includes a digital health intervention. Qualitative data will be gathered from health workers, women and their families, to gauge acceptability of the adapted ANC package and its components, as well as experience of care. The implementation of the adapted ANC package of interventions, and their related costs, will be documented to understand to what extent the co-interventions were performed as intended, allowing for iteration. Discussion: Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which will ultimately lead to stronger health systems with better maternal and perinatal outcomes. On the basis of the study results, governments will be able to adopt and plan for national scale-up, aiming to improve ANC nationally. This evidence will inform global guidance. Trial registration number: ISRCTN, ISRCTN16610902. Registered 27 May 2022. https://www.isrctn.com/ISRCTN16610902

Drivers of improved health sector performance in Rwanda: a qualitative view from within

Contains fulltext : 172356.pdf (publisher's version ) (Open Access)BACKGROUND: Rwanda has achieved great improvements in several key health indicators, including maternal mortality and other health outcomes. This raises the question: what has made this possible, and what makes Rwanda so unique? METHODS: We describe the results of a web-based survey among district health managers in Rwanda who gave their personal opinions on the factors that drive performance in the health sector, in particular those that determine maternal health service coverage and outcomes. The questionnaire covered the six health systems building blocks that make up the WHO framework for health systems analysis, and two additional clusters of factors that are not directly covered by the framework: community health and determinants beyond the health sector. RESULTS: Community health workers and health insurance come out as factors that are considered to have contributed most to Rwanda's remarkable achievements in the past decade. The results also indicate the importance of other health system features, such as managerial skills and the culture of continuous monitoring of key indicators. In addition, there are factors beyond the health sector per se, such as the widespread determination of people to increase performance and achieve targets. This determination appears multi-levelled and influenced by both intrinsic and extrinsic motivation. CONCLUSION: It is the comprehensiveness and combination of interventions that drive performance in Rwanda, rather than a single health systems strengthening intervention or a set of interventions that target a specific disease. There is need for policy makers and scholars to acknowledge the complexity of health systems, and the fact that they are dynamic and influenced by society's fabric, including the overall culture of performance management in the public sector. Rwanda's robust model is difficult to replicate and fast-tracking elsewhere in the world of some of the interventions that form part of its success will require a holistic approach

Maternal death audit in Rwanda 2009-2013: a nationwide facility-based retrospective cohort study

OBJECTIVE: Presenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care. DESIGN: Nationwide facility-based retrospective cohort study. SETTINGS: All cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort. POPULATION: 987 audited cases of maternal death. MAIN OUTCOME MEASURES: Characteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams. RESULTS: 987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related. CONCLUSIONS: The facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures

Before and after implementation of group antenatal care in Rwanda: a qualitative study of women’s experiences

BackgroundThe Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women's experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements.MethodsWe completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation.ResultsBefore implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout.DiscussionThese results are consistent with other published reports of women's perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women's experiences of care.ConclusionGroup antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model.Trial registrationThis trial is registered at clinicaltrials.gov as NCT03154177

A low cost, re-usable electricity-free infant warmer: evaluation of safety, effectiveness and feasibiliy.

Setting: Rural Rwandan hospitals, where thermoregulation is critical yet a challenge for pre-term, low-birth-weight (LBW) or sick newborns. Objective: To assess the safety, effectiveness, and feasibility of an inexpensive, reusable, non-electric warmer to complement kangaroo mother care (KMC). Methods: Prospective single-arm, non-randomized intervention study. Enrolled infants were hypothermic or at risk of hypothermia due to prematurity/LBW. Infants used the warmer in conjunction with KMC or as the sole source of external heat. Temperatures of the infant, warmer and air were measured for up to 6 h. Results: Overall, 33 patients used the warmer for 102 encounters: 43 hypothermic and 59 at risk of hypothermia. In 7/102 encounters (7%), the infant developed a temperature of >37.5°C (37.6°-38.2°C). For 43 hypothermic encounters and 59 at-risk encounters, hypothermia was corrected/prevented in respectively 41 (95%) and 59 (100%) instances. The warmer maintained goal temperature for the study duration in ⩾85% of uses. Two/12 warmers broke down after <10 uses. In no instances was the warmer used incorrectly. Conclusion: Our results are promising for this prototype design, and warrant testing on a wider scale

A low cost, re-usable electricity-free infant warmer: evaluation of safety, effectiveness and feasibiliy.

Setting: Rural Rwandan hospitals, where thermoregulation is critical yet a challenge for pre-term, low-birth-weight (LBW) or sick newborns. Objective: To assess the safety, effectiveness, and feasibility of an inexpensive, reusable, non-electric warmer to complement kangaroo mother care (KMC). Methods: Prospective single-arm, non-randomized intervention study. Enrolled infants were hypothermic or at risk of hypothermia due to prematurity/LBW. Infants used the warmer in conjunction with KMC or as the sole source of external heat. Temperatures of the infant, warmer and air were measured for up to 6 h. Results: Overall, 33 patients used the warmer for 102 encounters: 43 hypothermic and 59 at risk of hypothermia. In 7/102 encounters (7%), the infant developed a temperature of >37.5°C (37.6°-38.2°C). For 43 hypothermic encounters and 59 at-risk encounters, hypothermia was corrected/prevented in respectively 41 (95%) and 59 (100%) instances. The warmer maintained goal temperature for the study duration in ⩾85% of uses. Two/12 warmers broke down after <10 uses. In no instances was the warmer used incorrectly. Conclusion: Our results are promising for this prototype design, and warrant testing on a wider scale

Evaluation of human-papillomavirus testing and visual inspection for cervical cancer screening in Rwanda

Background A pilot screening campaign in Rwanda, based on careHPV-testing followed by visual inspection with acetic acid triage (careHPV+VIA triage), was evaluated against other WHO-recommended screening options, namely HPV screen-and-treat and VIA screen-and-treat. Methods 764 women aged 30-69 underwent at visit 1: i) VIA, and cervical cell collection for ii) careHPV in Rwanda, and iii) liquid-based cytology and GP5+/6+ HR-HPV PCR in The Netherlands. All 177 women positive by VIA, careHPV and/or PCR were recalled, of whom 84% attended. At visit 2, VIA was again used to triage screen-positive women for treatment and to obtain biopsies from all women either from visible lesions or at 12 o’clock of the squamocolumnar junction. Cross-sectional screening indices were estimated primarily against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), after imputation of missing histology data, based on 1-visit or 2-visit approaches. Results In a 1-visit screen-and-treat approach, VIA had sensitivity and specificity of 41% and 96%, respectively, versus 71% and 88% for careHPV, and 88% and 86% for PCR. In a 2-visit approach (in which hHSIL+ imputed among women without visit 2 were considered untreated) careHPV sensitivity dropped to 59% due to loss of 13% of hHSIL+. For careHPV+VIA triage, sensitivity dropped further to 35%, as another 24% of hHSIL+ were triaged to no treatment. Conclusions CareHPV was not as sensitive as gold-standard PCR, but detected considerably more hHSIL+ than VIA. However, due to careHPV-positive hHSIL+ women being lost to follow-up and/or triaged to no treatment, 2-visit careHPV+VIA triage did not perform better than VIA screen-and-treat

Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial.

BackgroundResearch on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success.MethodsWe studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis.FindingsIn total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed.InterpretationGroup antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits.Trial registrationClinicalTrials.gov NCT03154177