Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making

Abstract

Background Perinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21 st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting. Methods The study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making. Results Facility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement. Conclusions The findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.

Implementation science in maternity care: a scoping review

“…Collectively, these findings demonstrate the challenges of implementation science in maternity care within nations that are less than affluent. To manage sociocultural barriers, it can be helpful to adapt an intervention to a given context [113,140,159,161]-this might Mixed-methods 27 Case study 12 [139][140][141][142][143][144][145][146][147][148][149][150] Pre-post study 8 [151][152][153][154][155][156][157][158] Ethnography 6 [159][160][161][162][163][164] Cohort study 4 [165][166][167][168] Pilot-test 8 [169][170][171][172][173][174][175][176] Longitudinal survey 2 [177,178] Quasi-experimental 1 [179] Randomised controlled trial 2 [180,…”

“…Some of the 144 publications focused on feasibility testing and/or gauging organisational readiness for change (9.0%) [67, 116, 119, 124-127, 153, 171-173, 178, 182]. This often involved identifying factors that might help or hinder implementation via stakeholder interviews or focus groups [126,127,171,178,182]. Many of these efforts informed policies, guidelines and/or implementation plans [116,124,125,172,182].…”

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

“…In some low-income settings, access to ultrasound was limited due to lack of staff and other resources, as well as the costs incurred for women and the distance they would have to travel to attend appointments [ 53 – 56 ]. Some midwives in these contexts expressed the desire for training in the use of ultrasound, so that they could make decisions when other staff were not available [ 55 , 57 ]. There were varying beliefs in relation to the safety of ultrasound as well as the diagnosis that could be made through its use [ 19 , 34 , 41 , 49 , 52 , 58 ].…”

“…Women generally trusted it as a valued technology that could provide confirmation of their pregnancy and reassurance of fetal wellbeing [ 19 , 28 , 30 , 43 , 64 , 66 , 73 ]. For providers, it was an important tool, particularly for the detection and management of complications [ 39 , 43 , 53 , 57 , 74 – 76 ]. However, some respondents reported that a reliance on ultrasound results in the potential for overuse, and consequent neglect of other forms of antenatal care [ 19 , 53 , 74 ].…”

Implementation of the INTERGROWTH-21 st gestational dating and fetal and newborn growth standards in Nairobi, Kenya: women’s experiences with ultrasound and newborn assessment

“…Full details of the study design and methods can be found in the protocol paper [23]. Provider experiences, uptake of the standards, and the association between the implementation of the standards and clinical decision-making outcomes are discussed in a separate paper [24].…”