A practice improvement package at scale to improve management of birth asphyxia in Rwanda: a before-after mixed methods evaluation

Abstract

Background Helping Babies Breathe (HBB) is a competency-based educational method for an evidence-based protocol to manage birth asphyxia in low resource settings. HBB has been shown to improve health worker skills and neonatal outcomes, but studies have documented problems with skills retention and little evidence of effectiveness at large scale in routine practice. This study examined the effect of complementing provider training with clinical mentorship and quality improvement as outlined in the second edition HBB materials. This “system-oriented” approach was implemented in all public health facilities (n = 172) in ten districts in Rwanda from 2015 to 2018. Methods A before-after mixed methods study assessed changes in provider skills and neonatal outcomes related to birth asphyxia. Mentee knowledge and skills were assessed with HBB objective structured clinical exam (OSCE) B pre and post training and during mentorship visits up to 1 year afterward. The study team extracted health outcome data across the entirety of intervention districts and conducted interviews to gather perspectives of providers and managers on the approach. Results Nearly 40 % (n = 772) of health workers in maternity units directly received mentorship. Of the mentees who received two or more visits (n = 456), 60 % demonstrated competence (received > 80% score on OSCE B) on the first mentorship visit, and 100% by the sixth. In a subset of 220 health workers followed for an average of 5 months after demonstrating competence, 98% maintained or improved their score. Three of the tracked neonatal health outcomes improved across the ten districts and the fourth just missed statistical significance: neonatal admissions due to asphyxia (37% reduction); fresh stillbirths (27% reduction); neonatal deaths due to asphyxia (13% reduction); and death within 30 min of birth (19% reduction, p = 0.06). Health workers expressed satisfaction with the clinical mentorship approach, noting improvements in confidence, patient flow within the maternity, and data use for decision-making. Conclusions Framing management of birth asphyxia within a larger quality improvement approach appears to contribute to success at scale. Clinical mentorship emerged as a critical element. The specific effect of individual components of the approach on provider skills and health outcomes requires further investigation.

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

“…An example of this came from a convergent mixed methods process evaluation of continuous quality improvement in South Africa [ 69 ] where health workers were discouraged by layers of managerial approval. In such cases across multiple PHC contexts, QI tasks were perceived to be time consuming—reducing health workers’ confidence in the QI initiative—and abandoned [ 45 , 48 , 49 , 52 , 54 , 58 , 59 , 62 , 67 , 69 , 71 – 75 , 81 , 83 – 85 , 90 ].…”

“…Still, familiarity with patient-centered approaches to PHC, regular review meetings where gaps and root causes to poor service quality were discussed, and internal supervision where knowledge was shared, and additional skills acquired was reported in the literature as important enablers. On the other hand, health workers in PHC who felt inadequately skilled in technical and clinical aspects and in the use of technology reported difficulties engaging effectively in QI [ 71 , 74 , 83 ].…”

“…Paying attention to the preferences of PHC clients when designing QI interventions that affect them was thought to enable QI in addition to health workers’ inputs to intervention design and was outlined by Mutambo and colleagues [ 77 ] who explored HCWs’ perspectives during the setting up of child-friendly spaces in PHC clinics in KwaZulu-Natal, South Africa. However, Umunyana and others [ 71 ] in Rwanda and Olaniran and colleagues [ 86 ] in Nigeria reported that QI interventions that do not allow implementers to make or suggest adaptations might lead to such initiatives being viewed as alien and imposed, potentially leading to their rejection and failure.…”

“…Elaborating on the importance of subject matter specialists for advancing QI initiatives, in Uganda [ 50 ] participants received excellent support from a mental health specialist who had good knowledge of clinical practice guidelines, joining champions to bolster QI. The development of skills and knowledge also increases when trained team members report back to fellow health care workers, enabling key QI concepts such as Pareto charts, root cause analysis, and PDSA cycles to percolate in the team for a shared understanding [ 71 , 72 ], with regular on-job training [ 69 ]. One-off training that leaves QI team members without adequate knowledge and skills needed to implement QI were characterized as barriers [ 72 ].…”

“…Studies discussed the role of medical equipment and data infrastructure in relation to QI [ 69 , 71 , 75 , 77 , 81 , 83 , 85 , 88 ]. Participatory and data-driven QI activities, revising data and tools to ensure harmonization of reporting systems were found to facilitate QI.…”