Objectives The effectiveness of early childhood education and care (ECEC) programs for children’s development in various domains is well documented. Adding to existing meta-analyses on associations between the quality of ECEC services and children’s developmental outcomes, the present meta-analysis synthesizes the global literature on structural characteristics and indicators of process quality to test direct and moderated effects of ECEC quality on children’s outcomes across a range of domains. Design A systematic review of the literature published over a 10-year period, between January 2010 and June 2020 was conducted, using the databases PsychInfo, Eric, EbscoHost, and Pubmed. In addition, a call for unpublished research or research published in the grey literature was sent out through the authors’ professional network. The search yielded 8,932 articles. After removing duplicates, 4,880 unique articles were identified. To select articles for inclusion, it was determined whether studies met eligibility criteria: (1) study assessed indicators of quality in center-based ECEC programs catering to children ages 0–6 years; and (2) study assessed child outcomes. Inclusion criteria were: (1) a copy of the full article was available in English; (2) article reported effect size measure of at least one quality indicator-child outcome association; and (3) measures of ECEC quality and child outcomes were collected within the same school year. A total of 1,044 effect sizes reported from 185 articles were included. Results The averaged effects, pooled within each of the child outcomes suggest that higher levels of ECEC quality were significantly related to higher levels of academic outcomes (literacy, n = 99: 0.08, 95% C.I. 0.02, 0.13; math, n = 56: 0.07, 95% C.I. 0.03, 0.10), behavioral skills (n = 64: 0.12, 95% C.I. 0.07, 0.17), social competence (n = 58: 0.13, 95% C.I. 0.07, 0.19), and motor skills (n = 2: 0.09, 95% C.I. 0.04, 0.13), and lower levels of behavioral (n = 60: -0.12, 95% C.I. -0.19, -0.05) and social-emotional problems (n = 26: -0.09, 95% C.I. -0.15, -0.03). When a global assessment of child outcomes was reported, the association with ECEC quality was not significant (n = 13: 0.02, 95% C.I. -0.07, 0.11). Overall, effect sizes were small. When structural and process quality indicators were tested separately, structural characteristics alone did not significantly relate to child outcomes whereas associations between process quality indicators and most child outcomes were significant, albeit small. A comparison of the indicators, however, did not yield significant differences in effect sizes for most child outcomes. Results did not provide evidence for moderated associations. We also did not find evidence that ECEC quality-child outcome associations differed by ethnic minority or socioeconomic family background. Conclusions Despite the attempt to provide a synthesis of the global literature on ECEC quality-child outcome associations, the majority of studies included samples from the U.S. In addition, studies with large samples were also predominately from the U.S. Together, the results might have been biased towards patterns prevalent in the U.S. that might not apply to other, non-U.S. ECEC contexts. The findings align with previous meta-analyses, suggesting that ECEC quality plays an important role for children’s development during the early childhood years. Implications for research and ECEC policy are discussed.

Background Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases. Methods This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression. Results We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores. Conclusion We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of “suspected PPH”, defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.