Quality Innovations in Maternal and Newborn Health

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Dr. Kim Ozano: Hello listeners and welcome to Connecting Citizens to Science.

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I'm Dr.

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Kim Ozano and this is a podcast where we hear about current research and debates in global health.

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I'm excited to bring you the first of a three-part mini series today, focused on sharing insights from a quality improvement programme for the integration of HIV, tuberculosis, and malaria services and antenatal and postnatal care.

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This miniseries will both celebrate the programme's achievements, but also, very importantly, illuminate the transformative impact it has had on integrated maternal and newborn healthcare services.

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So, maternal health refers to the health of women during pregnancy, childbirth, and the postnatal period, and each of these stages should be a positive experience.

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In this episode, our guests will tell us how the quality improvement programme implemented over the last five years has strengthened the capacity of the health workforce to respond to the needs of women and newborns.

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The conversation highlights the importance of being both responsive and adaptable to changing health landscapes.

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Prof. Charles Ameh: Knowing how much increase there was in terms of mental illnesses and gender based violence post COVID, we had to do a piece of research to understand what are the barriers in this settings to really optimising this approach.

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Dr. Kim Ozano: Our co-host and guests take us on a journey from responding to COVID 19 to building health systems resilience for the future, whilst considering the emerging challenges faced by women, including declining mental health and rising domestic violence, especially post COVID.

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We will also hear how these findings have changed the experiences of those delivering health on the front line and the practices that they have changed and what this means for the future of maternal and newborn health.

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Dr. Oladipo Aremu: She was so thrilled that she could be treated like this in Nigeria.

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to the extent that she had to post our experience on the Facebook and everybody read it.

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Dr. Kim Ozano: To help us explore today, we have two guests and a co-host.

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Our first guest is Dr.

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Oladipo Aremu a consultant, obstetrician and gynaecologist from Adeoye Teaching Hospital Ibadan, Oyo State, Nigeria and he is one of the master trainers for the programme.

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We also have with us Professor Charles Ameh, who is the Professor and Head of Department of International Public Health at the Liverpool School of Tropical Medicine, and the lead for the programme we will be talking about today.

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Our co-host for this miniseries is Dr.

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Rael Mutai, the Regional Technical Advisor for Maternal and Newborn Health in Kenya and Tanzania, and the Country Director in Kenya from the Liverpool School of Tropical Medicine.

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So without further ado, let's get into this very important conversation.

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Rael, it's so good to have you with us on the podcast today.

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Set us up for this episode by highlighting some of the problems that the programme was facing and also how the programme was addressing some of the gaps.

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Dr. Rael Mutai: Thank you, Kim.

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This programme specifically set out to improve the quality of care provided to mothers and newborns.

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In the three countries where the programme is implemented, Kenya, Nigeria, and Tanzania, many mothers and newborns still lose their lives during pregnancy, during birth, and the immediate period just following delivery, and there is therefore need to invest and to implement the interventions which have been proven to make a positive contribution to the health of mothers and newborns.

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This would include building the capacity of the healthcare workers to address emergencies, providing the basic supplies, this would include emergency medicines that are required, certain basic equipment to be able to assess the women as they present to just screen for infectious diseases including HIV, TB, and malaria.

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We noticed that in most setups, are many barriers that makes it not possible for women to achieve these very basic services.

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And so the project set out to collaborate with the ministries of health, the subnational entities, subnational governments and the frontline health care workers to come together and really address this gap, so that for every mother that presents themselves receives the complete package of care.

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This programme is working with the health care workers, building their competencies using innovative approaches, including a blended learning approach, working with universities, working with the Ministry of Health, the frontline health care workers themselves to be able to strengthen the entire health system to be able to deliver positive outcomes for mothers and newborns.

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So, welcome Professor Ameh.

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Prof. Charles Ameh: Thank you so much for that.

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So this 5 year running programme started in the year 2000 and with funding from Takeda Pharmaceuticals to be implemented in 3 countries, Kenya, Nigeria and Tanzania.

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At that point, it was clear that to contribute to further reduction of deaths during pregnancy, childbirth, and the period after childbirth, that it was important to ensure that healthcare providers are trained to the highest possible level, and that women have point of care tests.

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They are treated with respect, we're able to screen them for mental health issues, domestic violence, and respond in a way that is quite supportive.

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So all of these are part of the current WHO recommendations for antenatal and postnatal care.

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So, we started addressing some of the needs of the health care facilities to make sure they had the equipment and then training the health care workers and then COVID 19 struck.

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So, what that meant was that it prevented us from doing things as usual.

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And then we had to now become innovative.

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Now, this was quite important when you look at post pandemic preparedness and health system resilience.

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The first research was was a blended learning approach for reproductive health workers feasible in a low resource setting?

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And our findings were that this was feasible, it increases knowledge and skills, and it was also cost effective but we were not sure how this compares to the standard approach, which is the face to face approach.

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So that was the second piece of research.

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And the results from that in terms of the improvement in skills, it was the same for whether you use the blended learning approach or the face to face approach.

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So the blended learning approach was not inferior in any way.

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And the blended learning approach was much more cost effective compared to the face to face approach.

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The third big finding, you know, from the implementation research was the increase in number of women who were coming for postnatal care.

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So, after delivery, first 48 hours after delivery, a significant increase in the number of women coming for care.

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And we think this is linked to the quality of care, improved quality of care by healthcare workers.

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Now the fourth piece of research has to do with the uptake of screening for gender based violence and mental health illnesses within antenatal care.

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As part of the training, we provided the tools and the techniques for discussing these issues and how to support women.

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And we have recorded an uptake in all these facilities where we've supported, and because this is really new within those contexts.

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Knowing the how much increase there was in terms of mental illnesses and gender based violence post COVID, we had to do a piece of research to understand what are the barriers in this settings to, you know, really optimising this approach.

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And we're able to record that in two countries and our recommendation going forward is that that is factored in to future programme design so that this is done optimally within the settings.

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So this is what the evidence says, but I think I'll be really interested in listening to our colleague, Dr.

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Oladipo Aremu.

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What are you hearing from your colleagues in terms of the impact of this programme in improving the quality of care and respectful maternity care?

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Dr. Oladipo Aremu: Thank you very much.

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Let me first of all appreciate the sponsor of this programme, the Liverpool School of Tropical Medicine.

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They've been able to help us bridge a lot of gaps in healthcare service delivery.

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Some of the things -that we learned have been put into practice, and this has really helped to improve our service delivery in Nigeria, especially in the facility where I work, that is Adeoyo Maternity Hospital.

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What we have observed in the field, in our environment, people want to rely on the testimony of others.

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There's a particular group of people that will, if you want to introduce something to them, they will ask you whether you have ever experienced that and whether the treatment you are recommending to them was able to work for you, before they would take it.

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I share the experience of a patient that I saw at the antenatal clinic.

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She was offered a seat.

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I greeted her, introduced myself, and even gave her the option of seeing a female colleague.

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Initially she declined the surgery, but she was able to give her consent because they took her around the ward to see other patients who have had surgery.

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We also found out that her blood pressure was high.

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We took time to explain to her some of the things that can happen to the mother and to the baby.

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So after she was discharged, she posted her experience on our Facebook that she never expected to be treated this way, and she was like 'Look at how they spend so much time trying to explain everything to me'.

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So she was able to share a story many people saw it and then they also contacted her.

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The programme has been so impactful in improving our service delivery.

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Dr. Rael Mutai: Thank you very much, Professor Ameh, thank you very much, Dr.

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Aremu.

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What are the next steps or lessons for others because all countries across the region are grappling with the issue of quality of care, poor maternal and newborn outcomes, and yet, we are supposed to be meeting certain targets in the next few years, and therefore there is really need to put in a little more effort.

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Prof. Charles Ameh: I think some of the evidence we've generated around different ways of training healthcare workers, it's going to change the way things are done going forward.

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And we're just going to advocate that all of this is linked to accredited continuous professional development, because that is your key to sustainability.

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And then seeing how this can be linked to pre-service training so that we have that solid continuum.

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The next thing will be what we have learned from the quality improvement approach, building that resilience within the teams in those facilities that they can solve problems, by working together, identifying a problem and seeking solutions.

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The other thing that has come forward from this programme was that we were able to build in mental health screening, gender based violence screening within antenatal care.

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Our research found out how this can be optimised.

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What are the facilitators and barriers to doing this within those contexts?

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And so some of that information can be channelled back to improve this programme delivery in some of these places.

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Last point I want to make is that we saw from our results, whereas we increased that word of mouth, women telling the story of the experience, women coming to the facilities, but we did not see significant improvement in the number of women coming earlier than 13 weeks.

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So in the first trimester, and that is so important.

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So what that has told us and our recommendation for funders implementing such programmes, is that they should deliberately have a demand site intervention.

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So some community based demand site creation, um, to make sure that as soon as women are pregnant, they're encouraged to come to hospital, they don't have to wait until after five, six months or eight months of pregnancy.

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Dr. Oladipo Aremu: I think in this environment, people tend not to want to come to the hospital early to register for antenatal care.

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On the average, in our center, people tend to come in the middle three months, and that's what we have experienced.

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Though we've experienced an upsurge in the number of pregnant women coming to register for antenatal care, the other challenges are still there.

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The economic challenges being witnessed in the country, which is also affecting some of our patient.

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Dr. Kim Ozano: It sounds like you as a programme were really adapting very well to the changing landscape that was emerging over the period of this programme.

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It would be nice to know a little bit more about the motivation for that adaptation and flexibility.

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Is it something that you built into the programme early on, or did it come as a result of COVID 19?

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I would really also like to hear more about the screening for mental health and domestic violence.

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This is something that's quite new.

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We've not heard about it very much on our podcast and it would be great to know about what instigated you to start doing that screening.

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Prof. Charles Ameh: I think what came first was that we tried to implement the new WHO recommendations for a positive pregnancy experience.

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That is really loaded.

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It has over 40 recommendations, which include mental health, gender based violence, and these are very sensitive topics, especially in a lot of the environments where we work.

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And now, don't forget that with COVID 19, the incidence of mental health illnesses increased, domestic violence increased significantly, and we were now implementing a programme within the pandemic, and so we had to rethink what we do going forward even though we, we cover these topics as part of that training programme and as part of the quality improvement programme.

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So during the pandemic, what happened was that maternity services were closed essentially.

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Healthcare workers were diverted to other places.

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All forms of continuous professional development was closed because, I mean, first of all, you have a shortage.

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You can't remove healthcare workers, you can't prioritise training.

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But then we found a way to say that, well, training can continue because there's self directed learning.

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And if we link this to professional points from the professional licensing organisations, that is a pull factor, so these things will happen.

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So we feel we've been able to contribute overall to that pandemic preparedness, health system resilience, and I think for the next pandemic, it's not a matter of if it is when, um, the health system is better prepared as a result of the research outputs from this programme.

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Dr. Kim Ozano: We're going to go to the final piece of advice.

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Rael, I think it's good to start with yourself, what advice from your experience would you have for other people trying to improve the care for mothers and children globally?

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Dr. Rael Mutai: From my experience and more so from this project, my advice is that there is a lot of work that still needs to be done around the quality of maternal and newborn care.

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And for us to make advances, It's really about countries, contextualising the global guidelines.

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The global guidelines on standards of care are available for most of these countries, but unless it is contextualised to the country setup and , the processes are put in place to really actualise on the frontline, because it is what happens when a mother comes to that will help us to seek health care in that small facility that makes the difference.

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So we need to build the capacities of the competencies of the health care workers, address the gaps in the infrastructure and equipment so that in the end, the service that we are giving meets the minimum standard and ensure us that we reduce the needless and the preventable deaths that we are experiencing currently.

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Dr. Kim Ozano: Thank you very much.

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And to our listeners, we're going to hear much more about that capacity strengthening element in episode two.

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So do tune in for that so you can hear about more of the details that have been introduced in this first episode.

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Dr.

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Aremu, what advice would you give to others who are trying to improve the experiences for mothers and their babies globally?

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Dr. Oladipo Aremu: For others who would like to also embark on this journey, my one advice is that they should always try to involve the policymaker and also the end care user.

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And they should also try to put in place a sustainability plan, because with some other projects that we have seen in the past, once people have been trained and there is no plan for sustainability, the programme stops.

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And this is not good for the huge investment, and sustainability can be in the form of a step down training by those who have been trained and also to put in place something like a mentor - mentee relationship among those who have been trained.

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Dr. Kim Ozano: Good advice there.

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Excellent.

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Thank you very much.

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And Professor Ameh, you have so much learning here, what is really the priority moving forward thinking globally?

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Prof. Charles Ameh: I think it is critical to work with the partners on the ground, with international teams to co-create these interventions.

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Yes, there are international evidence based recommendations, but, um, there's difference from moving from evidence to practice, so that you are learning, you are improving, and you should be intentional of gathering information of what works and what doesn't work and how you disseminate this because this is making sure that other people don't make the same mistakes.

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So this is key to ownership, sustainability and scaling up best practices.

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Dr. Kim Ozano: This is the end of a five year programme.

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You are in the process of disseminating those findings.

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What next?

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What should our listeners be looking out for?

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Prof. Charles Ameh: I think what we should look out for is how a lot of these learnings are taken up within the various countries and the various institutions.

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And I know that in a lot of these countries, they are looking at internal sources of funding to scale up to other districts, to other regions of the country.

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Some of them are thinking about how some of the techniques introduced to the training can be mainstream through pre graduation education, for example.

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So there are various things that different countries have taken up and they would like to scale up.

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But one thing is universal, is how they can reproduce these results in a lot more facilities, um, within those countries.

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Dr. Kim Ozano: Excellent.

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It sounds like it's the end of one journey and the beginning of the next.

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So thank you to our guests, Dr.

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Rael Mutai, Dr.

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Oladipo Aremu and Professor Charles Ameh for sharing your valuable insights with us today.

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And listeners, this episode marks the beginning of our exploration into how quality care can transform maternal and newborn health.

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In our next episode, we will be focusing on innovative ways that have been employed to strengthen the capacity of the health workforce for improved outcomes for women and newborns.

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Then in our final episode, we'll be diving deeper into the theme of sustainable change, looking at what it takes to create lasting improvements in maternal healthcare delivery.

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Until next time, bye for now.