Early Reflections on Mphatlalatsane, a Maternal and Neonatal Quality Improvement Initiative Implemented During COVID-19 in South Africa

Odendaal, Willem; Goga, Ameena; Chetty, Terusha; Schneider, Helen; Pillay, Yogan; Marshall, Carol Lynn; Feucht, Ute Dagmar; Hlongwane, Tsakane; Kauchali, Shuaib; Makua, Manala

doi:10.9745/ghsp-d-22-00022

Cited by 7 publications

(5 citation statements)

References 49 publications

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“…In particular, the evaluation will consider the COVID-19 burden of disease in intervention and control districts and the heterogeneity in maternal and perinatal care during and between COVID-19 waves. As the Mphatlalatsane intervention broadened from the QI methodology to supporting MNH health services during the COVID-19 pandemic [ 16 ], we cannot discount the effect of the pandemic when evaluating the causality between the Mphatlalatsane intervention and MNH outcomes. Moreover, the process evaluation will capture the nuanced changes that were occurring as the Mphatlalatsane Initiative was evolving and the iterative way the intervention was delivered with changes responsive to health system requirements (adaptive function ).…”

Section: Discussionmentioning

confidence: 99%

“…In 2017, the Mphatlalatsane Initiative was launched to provide a national unified response to improve the quality and equity of SRMNH care at the cusp of the National Health Insurance reform, using the Institute for Health Improvement QI methodology [ 16 ]. The final output is anticipated to be a proven and replicable model of catalytic health systems and clinical interventions to reduce unintended pregnancies and maternal and newborn deaths.…”

Section: Introductionmentioning

confidence: 99%

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Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation

Chetty¹,

Singh²,

Odendaal³

et al. 2023

JMIR Res Protoc

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Background The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels. Objective Our evaluation aims to determine the effect of various exposures, including the COVID-19 pandemic, and a system-level, complex, patient-centered quality improvement (QI) intervention (the Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected South African facilities. The objectives are to determine whether Mphatlalatsane reduces the institutional maternal mortality ratio, neonatal mortality rate, and stillbirth rate (objective 1) and improves patients’ experiences (objective 2) and quality of care (objective 3). Objective 4 assesses the contextual and implementation process factors, including the COVID-19 pandemic, that shape Mphatlalatsane uptake and variation. Methods This study is an implementation science type 2 hybrid effectiveness, controlled before-and-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For objective 1, intervention and control facility-level data from the District Health Information System are compared for changes in institutional maternal and neonatal mortality and stillbirth rates and associations with QI, the COVID-19 pandemic, and both. This first analysis includes data from 18 facilities, regardless of their allocation to intervention or comparison, to obtain a general idea of the effect of the COVID-19 pandemic. For objectives 2 to 3, data collectors abstract data from maternal and neonatal records, interview participants, and conduct neonatal facility assessments. For objective 4, interviews, program documentation, surveys, and observations are used to assess how contextual factors at the macro-, meso-, and microlevels explain variation in intervention uptake and outcome. The intervention dose is measured at the microlevel only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. Results From preliminary analysis, across the 3 provinces, maternal and neonatal deaths increased during the COVID-19 pandemic, whereas stillbirths remained unchanged. Maternal satisfaction with quality of care was >90%. The COVID-19 pandemic severely disrupted the QI teams functioning. However, the QI teams regained their pre–COVID-19 momentum by adapting the QI model, with advisers providing mentoring and support. Variation in adoption at the mesolevel was related to stable and motivated leadership (particularly at the facility level), poor integration into routine processes, and buy-in from senior district managers who were affected by competing priorities. Varying referral and specialist outreach systems, staff availability and development, and service delivery infrastructure are plausible factors in variable outcomes. Conclusions Few evaluations rigorously evaluated the effect of health system interventions on improving health services and outcomes. Results will inform the scaling up of successful intervention components and strategies to mitigate the effects of the COVID-19 pandemic or similar emerging epidemics on maternal and neonatal mortality. International Registered Report Identifier (IRRID) DERR1-10.2196/42041

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation

Chetty¹,

Singh²,

Odendaal³

et al. 2023

JMIR Res Protoc

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“…Team leaders and team members did not receive additional payment for participating in Mphatlalatsane . (More detail about the programme design and pre-implementation history can be found here [ 36 ].)…”

Section: Methodsmentioning

confidence: 99%

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

Odendaal,

Chetty,

Goga

et al. 2023

BMC Health Serv Res

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Background Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022. Methods We conducted a qualitative process evaluation of the contextual and implementation process factors’ influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces. Results Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders’ intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools. Conclusions Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

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“…This study forms part of a wider project, referred to as "Mphatlalatsane", implemented to improve maternal and neonatal health (MNH) outcomes through quality improvement approaches at the facility and district level in three South African provinces [24]. District 1 is a metropolitan district; Districts 2 and 3 are mostly rural districts, consisting of a mix of small and medium-sized towns, farms, and mining areas.…”

Section: Study Settingmentioning

confidence: 99%

Managing Local Health System Interdependencies: Referral and Outreach Systems for Maternal and Newborn Health in Three South African Districts

Schneider,

Mianda,

Odendaal

et al. 2023

Systems

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In complex health systems, referral and outreach systems (ROS) are formal strategies for connecting and managing interdependencies between facilities in service delivery pathways. Well-functioning maternal and newborn ROS are critical to successful outcomes, and therefore, a good lens through which to examine the management of local interdependencies. We conducted a qualitative study of maternal–newborn ROS, involving interviews with 52 senior, middle, and frontline managers, in three health districts of three different provinces in South Africa. We analyse the differences in functioning of ROS as an interplay of setting (urban, rural), individual facility strengths and weaknesses, the quality of emergency medical services (EMS), and the wider provincial strategic and organisational context. ROS are strengthened by sub-district governance arrangements that recognise and enable connectedness—in particular, between primary health care and district hospital services; by informal, day-to-day communication and collaboration across levels and professions; and by hybrid clinical–managerial players as system brokers and systems thinkers. We also identify leverage points, places where small shifts could have wider system effects, most notably in the design and functioning of EMS, and in addressing small, but significant bottlenecks in supply chains in lower level facilities that negatively impact the system as a whole.

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Early Reflections on Mphatlalatsane, a Maternal and Neonatal Quality Improvement Initiative Implemented During COVID-19 in South Africa

Cited by 7 publications

References 49 publications

Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation

Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

Managing Local Health System Interdependencies: Referral and Outreach Systems for Maternal and Newborn Health in Three South African Districts

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