Evidence from district level inputs to improve quality of care for maternal and newborn health: interventions and findings

Governance is achieved through a combination of strategies including clinical competence, patient involvement, risk management, use of information, staff management, maintaining medical registries, and implementation of continuous quality improvement (CQI) tools. Accountability involves audit and feedback mechanisms that entail a systematic approach to ensure that the services are accountable for delivering quality healthcare. Audits involve any summary of clinical performance of healthcare professionals over a period of time which is presented to them in a written, electronic or verbal format for self-accountability. Healthcare professionals are prompted to modify their practice if the feedback is inconsistent with the standards or accepted guidelines. Audit tools for evaluating maternal and perinatal deaths have been an integral part of quality improvement in obstetric care. These are effective in defining the context specific problem and propose solutions. Although these mechanisms have been used widely as a strategy to improve professional practice, they have not shown consistent effectiveness majorly due to the inconsistencies and variations involved in implementation [2, 3].

Supervision plays a key role in primary healthcare (PHC) service delivery and it requires the district level staff to supervise the public health activities and provide appropriate clinical care [4‐6]. Good leadership is also critical to the success of district health systems as it relies on how leaders work together to enable the health system to achieve its goals [7]. It involves strategic planning for the provision of services, resource allocation, and set priorities for improved performance. Aspects of leadership and supervision involve problem solving, reviewing records, observing clinical practice, mentoring and guidance on matters of personal, professional and educational development in context to patient care. Supervision in district health structures is difficult to implement due to time and costs involved and also the increasing numbers of district level facilities in even increasingly remote areas [8]. One of the emerging concepts is the involvement of local opinion leaders in district health leadership to promote knowledge transfer of evidence into practice and ultimately improve health care [9]. Since these individuals are perceived as credible and trustworthy, they may play a key role in assisting individuals to identify the best evidence-based healthcare practice and facilitate behavior change [10].

It involves provision of monetary benefits as a source of motivation for performing desired health related actions. Financial interventions are aimed at creating a greater demand for health services and include scale-up of preventive health interventions, as well as provision of free access to basic health care. In recent years there has been an increase in the utilization of financial support platforms to reduce out of pocket client expenditure and strengthen service delivery and utilization at the district level. The targeted health services can include seeking care, behavior modification, immunization, compliance to health professional’s clinical behavior and performance. Incentives directed towards care providers include capitation (payment for each patient enrolled), fee for service and pay for performance. Those directed towards users involve conditional cash transfers (CCT), vouchers, health insurance and fee exemptions. Diverse and innovative financial support platforms are being implemented in some of the fragile states such as Cambodia, Afghanistan, Pakistan and Haiti as well as more established economies of Latin American countries [11, 12] however, impact on quality of care for MNH is still emerging [13].

It is one of the essential building blocks of health system [14] that captures, manages and transmits information related to the health of individuals or activities of organizations. It involves district level routine information systems, disease surveillance, hospital patient administration, electronic health records, human resource management and communication systems. Health information system is vital for public health decision making, health sector reviews, planning and resource allocation and program monitoring and evaluation. Weak information systems are a critical challenge to achieving the MNH related Millennium Development Goals. The major challenges identified in this domain include issues related to completeness, accuracy and timeliness, especially in low middle income countries (LMIC). These challenges limit its use in routine district health care planning, monitoring, and evaluation. Other factors associated with poor quality data in resource constrained settings include duplicate, parallel reporting channels and insufficient capacity to analyze and use data for decision making. Recently, there is an increased emphasis on utilizing electronic communication systems including mobile phones, telephone based follow-up and counseling, after-hours telephone access, and screening. As the field is still nascent, a limited but growing body of evidence exists to support the role of mobile technologies in improving MNH outcomes [15‐17]. Despite the anticipated benefits of mHealth; wide-scale impacts of mHealth on MNH outcomes need to be explored further [18, 19].

We aim to systematically review and summarize the available evidence from relevant systematic reviews on the impact of the outlined district level inputs (panel 1) to improve the quality of care for women and newborns.

We included 14 [22‐35] reviews evaluating the effectiveness of governance and accountability mechanisms. The median quality score was 7.5 on AMSTAR rating scale. Most of the reviews evaluated a set of pre-selected process and outcome indicators as the outcomes reported in the individual studies varied widely. Three reviews reported MNH related outcomes [22, 26, 29] including immunization rates, mammography uptake, perinatal and maternal morbidity and mortality. Other reported outcomes included compliance, performance improvement and rate of prescription for generic drugs. Most of the studies included in these reviews were conducted in high income countries (HIC). The characteristics and findings of the included reviews are presented in Table 2.

The effectiveness of audit and feedback mechanisms varied widely for various outcomes ranging from nil to moderate effect. Implementation involved a baseline audit followed by rounds of audit and feedback at defined intervals. In some settings audit and feedback was provided in combination with financial incentives. Audit and feedback was found to be positively associated with childhood immunization with the effect estimate ranging from 17% absolute decrease to 49% increase. However, the exact magnitude could not be ascertained due to the limited number of low quality design studies [22]. For the screening uptake, feedback resulted in higher proportion of physicians with completed mammograms and it was most effective when targeting test ordering and prevention activities, and when associated with low baseline adherence to recommended care or more intense feedback [26]. A review evaluating the effectiveness of maternity ward audits did not find any trial for inclusion but reported that serial data suggests benefit [29].

For outcomes other than MNH, audit and feedback was found to improve health care workers performance and compliance with desired practice by 7% and 4.3% respectively [23, 35]. It was also associated with 40% increase in rate of prescription for generic drugs [28]. Feedback involved verbal, written or both provided either by the supervisor, professional standards review organization or employer representative. Majority of the feedback provided included action plans or correct solution information with the feedback. Some of the reported factors influencing audit and feedback included problems with staff coordination, lack of strong evidence base for some topics, poor access to published work and high-quality clinical data, organizational factors and lack of time and motivation [32, 33].

We included seven [28, 36‐41] reviews evaluating the impact of leadership and supervision with a median quality score of 8 on AMSTAR criteria. Included reviews focused on the impact of leadership and supervision for the primary health workers [36, 37]; involvement of local community leaders [38], nursing leadership [39, 41] and supervising counselors or psychotherapist [40]. Due to the wide range of reported outcomes, data could not be pooled for any outcome except for compliance in one review evaluating the impact of involving opinion leaders [38]. None of the reviews reported outcomes specific to MNH while other reported outcomes included compliance, patient satisfaction, provider’s practice and knowledge. The evidence was from both LMIC and HIC. The characteristics and findings of the included reviews are presented in Table 3.

Involving local opinion leaders to promote evidence-based practice resulted in a 12% [RD: 12%, 95% CI: 6- 14.5%] absolute increase in compliance with the desired practice [38]. These opinion leaders were identified using the sociometric method in which healthcare professionals were asked to complete a self-administered questionnaire to identify educationally influential colleagues. Once identified, they were involved in informal or formal teaching through one to one teaching, community outreach education visits, small group teaching, preceptor-ships and delivering. Involving local opinion leaders was found comparable to other strategies used to disseminate and implement evidence based practice in health care including distribution of educational materials, audit and feedback and educational outreach. Another review based on a single RCT demonstrated a substantial increase in the number of trials of vaginal delivery after previous cesarean section in hospitals with the involvement of local opinion leaders [28]. The impact of supervision on the quality of primary health care in LMIC was inconclusive due to low quality studies [37]. Nursing leadership and supervision suggested improvements in patient satisfaction and reduction of adverse events; however, the evidence is inconclusive for complications and mortality rates [39, 41].

We included 10 [12, 42‐50] reviews and 1 [11] overview of reviews with median data quality score of 8.5 on AMSTAR criteria. Six reviews evaluated provider-directed incentives in the form of pay for performance, economic incentives, results based financing (RBF), salary, capitation or fee-for-service (FFS); while others focused on user-directed incentives including CCTs, vouchers, health insurance or user fee exemption. Seven reviews reported outcomes specific to MNH while meta-analysis was conducted in only two of the reviews [42, 50]. Reported MNH outcomes included immunization coverage, service utilization, institutional delivery, antenatal care (ANC), post natal care (PNC), skilled birth attendant, child nutritional status and anthropometry while other reported outcomes were consultation rates, compliance, prescription rates, referrals and hospital/Emergency Department (ED) visits. Most of the reviews were from LMIC. The characteristics and findings of the included reviews are presented in Table 4.

Among user directed financial strategies, CCT demonstrated significant improvements in preventive clinic visits (RR: 1.26, 95% CI: 1.09, 1.45), Diphtheria, pertussis and tetanus (DPT) immunization (RR: 1.08, 95% CI: 1.03, 1.14), health service utilization, child nutritional status and health outcomes [42, 45] with non-significant impacts on full immunization, stunting and wasting [42]. An unpublished review on the impact of a range of financial platforms on MNH reported significant overall impact on maternal health indicators with maternal voucher schemes (RR: 2.97, 95% CI:2.38-3.71), user fee exemption (RR: 1.57, 95% CI: 1.33-1.85) and community based health insurance (RR: 1.77, 95% CI: 1.29-2.44) while CCTs and national health insurance (NHI) did not show any significant impacts [50]. Maternal voucher schemes were reported to be the most effective strategy and demonstrated significant improvements across all range of outcomes including institutional delivery (RR: 3.7, 95% CI: 2.03, 6.73), skilled birth attendance (RR: 3.81, 95% CI: 2.92, 4.95), complicated delivery (RR: 1.53, 95% CI: 1.14, 2.05), ANC (RR: 3.08, 95% CI: 2.23, 4.25) and PNC (RR: 2.66, 95% CI: 1.59, 4.44) [50].

Among provider-directed financial strategies, target payments to primary care physicians (PCP) and pay-for performance showed positive trends for immunization rates [43] while the findings were inconclusive for provider performance, service utilization, compliance or quality of primary health care [11, 43, 47, 49]. We did not find any evidence for the impact on patient outcomes.

We included fifteen [19, 51‐65] reviews pertaining to computerized communication, electronic health record system, telephone follow-up and counseling, interactive telephone systems, after-hours telephone access and telephone screening. The quality of included reviews ranged from 3 to 10 on AMSTAR criteria. Reported MNH outcomes included immunization rates, mammography uptake, and newborn health outcomes [51, 64] while other reported outcomes included technology adoption, patient satisfaction, professional behavior and knowledge. All the reviews were from HIC only. The characteristics and findings of the included reviews are presented in Table 5.

Distance communication significantly improved immunization rates (Range: 6.4%-27.2%) and number of mammograms (Range: 14%-25%) [51] with non-conclsuive evidence on the use of telemedicine to support parents of high-risk newborns receiving intensive care [64]. Distance medicine technology also reported greater continuity of care by improving access and it should not be limited to physician-to-physician communication only [51]. Evidence also suggests that telephone consultation might reduce the number of surgery contacts and out-of-hours visits by general practitioners [53, 54]. All the technological aspects of the interventions were reported to be well accepted by patients with some evidence of clinical benefits [56].

There is very limited evidence on interventions to promote information communication technologies (ICT), improvements in knowledge about the electronic sources of information and use of electronic databases and digital libraries by healthcare professionals [61, 65]. Studies examining physician use of electronic records found mostly neutral or mildly positive effects on patient satisfaction (3.7%, 95% CI: 2.9-5.2%) [60] while computer based guideline implementation resulted in improved adherence [63]. No change in professional behavior was reported following electronic retrieval of health information.