Midwife-led obstetric units working ‘CLEVER’: Improving perinatal outcome indicators in a South African health district

Abstract

Background. South Africa did not meet its Millennium Development Goals with regard to the reduction in maternal and under-5 mortality. Furthermore, many birthing women do not receive intrapartum care with empathy and endure disrespect ful and abusive care. Objectives. To implement a multicomponent, context-specific intervention package to change the complex interplay between preventable maternal and perinatal mortality and morbidity and poor clinical governance and supervision in midwife-led labour units. Methods.A mixed-methods intervention study was conducted in Tshwane District, South Africa, in 10 midwife-led obstetric units (MOUs), from which a purposive sample consisting of five units was selected for the intervention. The intervention took place in three phases: (i) baseline measurement; (ii) implementation of the so-called 'CLEVER' intervention package in the five intervention units, based on the results of the first phase; and (iii) a review of health systems improvements and perinatal outcomes. The intervention had three pillars: (i) feedback of the baseline measurement to the intervention units to raise awareness and solicit participation; (ii) health systems strengthening; and (iii) intensive weekly engagement for 3 months, with further monthly support afterwards. Observation of barriers during baseline activities contributed to the health systems strengthening and improvement strategies during implementation. Results. Perinatal outcome indicators for the year before the intervention were compared with data for the year in which the intervention took place and the year after the intervention. Significant declines were observed in in-facility fresh stillbirths, meconium aspiration and birth asphyxia in the intervention MOUs from 2015 to 2017. The control group showed some decline during the period owing to support from district clinical specialist team members. Conclusions. CLEVER as a context-specific, multicomponent, clinically focused intervention package may have contributed to improved perinatal morbidity and mortality rates in MOUs.

CLEVER maternity care: A before-and-after study of women’s experience of childbirth in Tshwane, South Africa

“…The same survey of women’s experiences was repeated in the third phase of the intervention as part of the end-line measurement of the effects of working CLEVER. 31 …”

“…Results on the significant improvements in the rates of fresh stillbirths, birth asphyxia and meconium aspiration have been reported elsewhere. 31 This paper reports the changes in women’s experiences of childbirth before and after the implementation of the CLEVER package in the Tshwane district. The research question was as follows: which of the experiences of women delivering in intervention MOUs changed significantly from baseline to end-line when compared with those of women delivering in control MOUs?…”

Systems thinking: A turning point for improving respectful obstetric care in South African health districts

“…It is based on a stages-of-change framework and conditions for sustaining the intervention are embedded in the design. [22] All the package components are based on evidence from previously tested interventions in LMICs with positive impact and measured outcomes. The framework of the World Health Organization (WHO) for health systems strengthening and its standards of care and quality statement documents [23][24][25] informed some of the pathways proposed in CLEVER.…”

“…The interventions in the package can be individually adapted for the context of each labour ward. The CLEVER package includes the following components: [22] • Clinical care with obstetric triage and handover rounds with risk assessment Health systems gaps are addressed on micro-, meso-and macrolevels, while clinical governance is addressed by nominating advanced midwives as unit champions and by involving the facility managers.…”

“…Any review of the scalability of an intervention and ways to enhance it should be based on the previous determinants of success during the implementation phase of an innovation. [25] The strategy of nominating leader midwives or champions as role models to roll out CLEVER in participating labour wards could enhance the scalability of the intervention, [22] while facility manager support provides accountability. 4.…”