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Quality of maternal and prenatal care: bridging the know-do gap

Final Report Summary - QUALMAT (Quality of maternal and prenatal care: bridging the know-do gap)

Executive Summary:
QUALMAT (Quality of prenatal and maternal care: Bridging the know-do gap) is a European Union financed Program within the 7th Framework (HEALTH-2007-3.5-4: Health care intervention research – improving pre-natal and maternal care). The project is collaboration between the Centre de Recherche en Santé de Nouna (Burkina Faso), Ghent University (Belgium), Heidelberg University (Germany), Karolinska Institute (Sweden), Muhimbili University of Health and Allied Sciences (Tanzania), and Navrongo Health Research Centre (Ghana), under the lead of the Institute of Public Health at the University of Heidelberg, Germany.

No health gap between the developed and developing countries is wider than that of maternal health. The majority of deaths are avoidable using known and effective standard interventions and tools. The low quality of health care is generally attributed to a lack of drugs, equipment and infrastructure. While gaps in inputs do exist and should be remedied, much can be done to improve the quality of care by focus on the processes, rather than inputs. Motivating health workers can go a long way to increasing the quality of care, even within the prevailing input constraints. A lack of motivation leads to an insufficient translation of knowledge into the optimal utilization of resources.

QUALMAT project assumes that a worker’s performance partly depends upon the level of training or competence of health providers. The relationship between health worker competence (can do) and performance (does do) is complex and the first does not directly cause the second. Even well trained health staff does not always perform to the best of their ability, and differences are found between how health providers know a task should be performed and how they actually perform it in practice. This is the so-called ’know-do gap’.

The ‘know-do’ gap represents a challenge that must be addressed to strengthen health service performance. The underlying principle of our work was to do this with the health workers so that the incentives and the performance assessment procedures they are built on have a higher chance of being accepted in the implementation phase. Our research clearly highlights the importance of including the nurses and midwives in the design of both performance assessment and incentives to reward good performance.

Project Context and Objectives:
The general objective of this research project was to improve maternal health through better pre-natal and maternal care services, offered by better-motivated health workers.

The specific scientific and technical objectives were:

• To analyse the policies of the three intervention countries with regard to maternal and neonatal care (MNC) quality improvement, salary structures, career paths, human resource development and retention (WP2).
• To assess the technical and human dimension of quality of MNC as well as the strengths and determinants of motivation of MNC providers (WP3 in close collaboration with WP5 and WP6)
• To relate the costs of the clinical decision support system (CDSS) implementation and their effect on quality improvement (WP4).
• To develop CDSS and validate it with observed quality information and use indicators for MNC worker performance assessment (WP7).
• To develop a performance-based incentive package for raising health workers motivation and MNC quality (WP5, WP6, WP8).
• To study the effect of performance based incentives and CDSS on motivation and on MNC quality (WP3, WP4, WP5, WP6).
• To engage policy makers from the start in a discussion about the intervention with the view to generalization to national scale (WP1,WP9).

The attached figure illustrates the relationship between the studies, planned intervention and expected outcomes.

Design of the study
The studies were planned with one intervention and one control district in each country. Nouna district has about 312.000 inhabitants, Kassena-Nankana district 143,000, and Lindi 216,000 (2002, Census). Respectively the control districts have: Solenzo 297.234 Builsa 95,800 and Mtwara 205.000 inhabitants. The QUALMAT project is a combination of a pre-post comparison intervention design and an intervention-control design. The opportunity for cross-country comparisons increases the generalizability of our results also to other countries.

QUALMAT build scientific collaborations and capacity with our African partners. So far, 15 papers have been published, and 5 have been submitted, 10 papers are under development or internal review before submission. A total of nine doctoral candidates from these countries are currently being trained. Research, improvements in quality, and capacity building are being successfully combined and are enhancing each other. There should be more room in EU research funding for such projects.
For a list of participating scientists, members of the consortium and publications, and for further information on QUALMAT, please visit our website: http://www.qualmat.net/.
For more information, please refer to the attached Pdf documents.

Project Results:
Within WP1 (project management) was assured the regular communication and coordination within the consortium. All studies (in parallel) within the work packages were coordinated in order to avoid any overload of the staff from the health facilities included as well as overlap of activities. All activities were synchronised with the local authorities, the requited ethical clearances were obtained and updated regularly. The technical infrastructures for the successful implementation of the CDSS was build in all intervention health facilities in the three African countries. WP1 took the responsibility, initiated and coordinated the management and maintenance of the data, coming from the CDSS implementation in the three countries through the design of a CDSS database. The build database will be available also after the end of the project and will be used for research purposes.

Since the launch of QUALMAT the work in WP2 has consisted of developing a complete research protocol, designing interview guides, applying for ethical clearance, performing data collection, data analysis, report writing and prepared manuscripts that were published called “How to know what you need to do”, Baker et al. 2012 about the maternal health guidelines, in Implementation Science. WP2 team members have worked closely with Swedish, German and Burkina team members of WP7 assuring that results from WP2 have been considered in design of studies evaluating needs and attitudes before intervention of CDSS in Burkina Faso. The main results were that rural maternal staff have a great fascination and interest in using the CDSS for care but expressed reservations about “easiness of use” of CDSS and risk of double-work parallel with ordinary documentation of activities at the healthcare centres. Team member within WP2 was mainly responsible for the supervision of one PhD student from Burkina Faso, registered at Karolinska Institutet, who works in close collaboration with other two PhD students within WP7 from Tanzania and Ghana.

In WP3 the quality of antenatal and childbirth care before and after the QUALMAT project intervention implementation and between the intervention and non-intervention study health facilities was assessed. Pre-intervention quality assessment results were published in two papers in Tropical Medicine and International Health and a third paper on the pre-quality assessment results is accepted for publication by BJOG. The pre-intervention quality assessment found that counselling and health education practices are poor; laboratory investigations are often not performed; examination and monitoring of mother and newborn during childbirth are inadequate; partographs are not used. Equipment required to provide assisted vaginal deliveries (vacuum extractor or forceps) was absent in all surveyed facilities. Findings from the post-intervention quality assessment show that the QUALMAT intervention did not have an impact on the quality of ANC and childbirth care provided in the study primary health care facilities. Compared with the pre-intervention quality findings and the quality findings in non-intervention facilities the quality scores found in the intervention facilities during the post-intervention assessment are mostly a bit higher however this increase is rarely statistically significant and when quality scores are significant higher the quality is often still unsatisfied.

Within WP4 the routine cost for maternal health care services were collected and analysed. Two scientific papers are published on the results in Tanzania and Ghana. Further additional costs of the technological intervention (clinical decision support system) was collected and analysed in Tanzania and Ghana. In the two countries we used two methodology approaches for CDSS cost evaluation with variations in terms of type of cost included. In addition there are differences in health facilities location and overall country settings. The variations in the reported cost are mainly based on the inclusion/exclusion of salaries for the staff, used the CDSS and higher transportation cost in Tanzania due to logistic challenges in accessing the health facilities involved in the project. Two papers for the results in Ghana and Tanzania are submitted to scientific journals. These data serve as a basis for pre- and post-intervention comparison in the planned cost-effectiveness analysis of the CDSS introduction. Two PhD students were registered at the University of Heidelberg and intended time for completion of their doctoral work is end of 2014/beginning of 2015.

Our research in WP5 and WP6 showed that health workers are likely to be motivated by a large set of internal (personality traits) and external factors (recognition, additional training, money, improvement of working conditions). However, financial incentives scored highest in all three countries. This finding was very similar across the three African study countries. A transparent and fair assessment of performance was found to be key. For this purpose, we developed a performance scoring system, which was based on information from the routine health information system/supervision visits etc. Innovative technology was also an important tool to assess changes in healthcare delivery by healthcare employees.

The incentive scheme was chosen in the three countries to contain both non-monetary and monetary incentives and is designed according to the human resource policy in the three countries. A study was carried out to evaluate the effects of the motivation schemes on health worker performance and, hence, the quality of care. The study findings will allow us to understand the important factors of staff motivation and to facilitate adequate management for improvement of maternal and neonatal healthcare.

Within WP7 and 8 we also showed that, even in peripheral health facilities, a state-of-the art laptop-based electronic clinical decision support system (CDDS) can successfully be implemented.
WP7 evaluated the target situation and target user population for the design of an eCDSS. The system was designed and piloted prior to distribution to the rural health facilities countries. The eCDSS was jointly developed (Heidelberg and three southern partners) and translated into the local context of maternity and neonatal care in the three African countries. The system was designed to provide guidance and clinical decision support during the antenatal care visits and delivery. The eCDSS interactive software ‘suggests’ preventive measures and patient counselling at appropriate points in patient care. In addition, electronic documents for training purposes are provided and may be updated on request of local medical authorities. The system was translated into French and Kiswahili for use in Burkina Faso and Tanzania respectively. The software runs as a stand-alone, Java-based application on any standard hardware. The scope of the software was based on the World Health Organization’s guideline, ‘Pregnancy, Childbirth, Postpartum and Newborn Care: a guide for essential practice’, where also local Guidelines were integrated. It was designed for users without computer experience, and was extensively discussed and tested with them. The QUALMAT CDSS was implemented in 18 rural primary healthcare centres after intense basic and software-specific training for all providers involved in maternal care. In conclusion technology provides: (1) sources for performance assessment, (2) access to learning tools, and (3) “guideline adherence” tool as well as an additional motivational tool (many of the health staff used computers for the first time in their lives and found it to be fun). The final version was running from April 2012 till the end of the project with an exciting continuity and increasing number of patients being cared for by using this system. No major long-term interruption of the eCDSS was detected in any site.
WP7 developed studies to investigate questions on usability and accep¬tance of the system, as well as assessing the influence of the system on local workflows in the rural setting of primary health care in the three countries involved. Two PhD students are registered and work under this WP. The implementation of the software was accompanied by WP3, 4, and 5 with research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users), and on pharmaco-¬eco¬nomic questions.
The implementation of the software was accompanied by WP3, 4, and 5 with research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users), and on pharmaco-¬eco¬nomic questions. WP7 developed studies to investigate questions on usability and accep¬tance of the system, as well as assessing the influence of the system on local workflows in the rural setting of primary health care in the three countries involved. Three PhD students are registered and work under this WP.
The QUALMAT CDSS was implemented in 18 rural primary healthcare centres after intense basic and software-specific training for all providers involved in maternal care. In conclusion technology provides: (1) sources for performance assessment, (2) access to learning tools, and (3) “guideline adherence” tool as well as an additional motivational tool (many of the health staff used computers for the first time in their lives and found it to be fun). Solar panels were provided and installed in the health facilities without grid connection.
Both interventions (incentive schemes and CDSS) started later due to longer period needed for set up of electricity in all included health facilities and also longer time needed for the development of the CDSS. The table below shows the dates for the real start and end of the interventions in the three African countries. Since in the three countries the interventions started at different dates, for the purposes of the alignment in planned studies design and in order to have comparable data, the consortium decided to have one official start date for all three countries to be considered for the official peer reviewed publications- November 2012.
Table: Timeline of the implementation of Incentive schemes and CDSS.

Country Real Incentive start /end; Real CDSS start /end
Burkina Faso 1st January 2011- Most financial incentive were coming from workers contributions and then started before the CDSS use /April 2014 June 2012 /April 2014
Ghana July 2012 /April 2014 April 2012 /April 2014
Tanzania August 2012 /February 2014 June 2012 /April 2014

In the frame of WP9 QUALMAT dissemination concept was developed. Considerable number of scientific meetings and conferences were attended by the members of the consortium, where the results out of the project were presented. This project is also very successful in terms of scientific papers. Three issues of a newsletter were developed to widely disseminate the activities of the project.The consortium considered as most important to share the experiences with local staff and with authorities the main findings out of the project and this was done through dissemination seminars.

The study and control health facilities, included in QUALMAT are presented in Table 1.

Burkina Faso Ghana Tanzania
Name of health facility
Intervention district Nouna Health District Kassena-Nankana District Lindi District
Referral facility District Hospital District Hospital Nyangao Hospital and Sokoine Hospital
PHC facility 1 Bourasso Paga Health Centre Kitomanga Health centre
PHC facility 2 Koro KNE Health Centre Nyangamala Health Centre
PHC facility 3 Nouna Sirigu Clinic Pangaboyi Health Centre
PHC facility 4 Bomborokuy Kologo Health Centre Rutamba Health Centre
PHC facility 5 Doumbala Navrongo Health Centre Mtua Health Centre
PHC facility 6 Dokuy Chiana Health Centre Rondo Health Centre

Control district Solenzo Health District Builsa District Mtwara District
Referral facility District Hospital District Hospital Mtwara Regional Hospital
PHC facility 1 Solenzo (2) Siniensi Health Centre Mahurunga Health Centre
PHC facility 2 Balavé Doninga Health Centre Kitere Health Centre
PHC facility 3 Kouka Kanjarga Health Centre Nanyamba Health Centre
PHC facility 4 Dar Salam Fumbisi Health Centre Nanguruwe Health Centre
PHC facility 5 Ban Wiaga Health Centre Mnima Health Centre
PHC facility 6 Sanaba Chuchuliga Health Centre Msimbati Health Centre

The current S&T results out of the project are published already in 15 peer-reviewed papers, which are submitted to the EU. Other 5 papers are submitted and are under review. The additional final findings out of the last period data collection within different WPs are currently under analysis and are planned to be published by end of the year and beginning of 2015. Please refer to the list of publications.


Potential Impact:
Please refer to the attached full report for the use and dissemination of foregrounds, as well as the main dissemination activities, incl. full list with publications out of the project and planned dissemination meetings.
List of Websites:
www.qualmat.net
Please refer to the attached pdf files for the relevant contacts within the consortium.