Browsing by Author "Walker, Dilys"

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    Implementing an Intrapartum Package of Interventions to Improve Quality of Care to Reduce the Burden of Preterm Birth in Kenya and Uganda
    (Implementation science communications, 2021-01-28) Namazzi, Gertrude; Achola, Kevin Abidha; Nicole, Santos; Otieno, Phelgona; Waiswa, Peter; Walker, Dilys
    Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication. Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative. In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake. Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up.
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    Ultrasound at labour triage in eastern Uganda: A mixed methods study of patient perceptions of care and providers' implementation experience.
    (Public Library of Science, 2021-12-12) Isabirye, Nathan; Kisa, Rose; Santos, Nicole; Shah, Sachita; Mulowooza, Jude; Walker, Dilys; Waiswa, Peter
    In settings where antenatal ultrasound is not offered routinely, ultrasound use when a woman first presents to the maternity ward for labour (i.e., triage) may be beneficial. This study investigated patients' perceptions of care and providers' experience with ultrasound implementation during labour triage at a district referral hospital (DH) and three primary health centers (HC) in eastern Uganda. This was a mixed methods study comprising questionnaires administered to women and key informant interviews among midwives pre- and post-ultrasound introduction. Bivariate analyses were conducted using chi-square tests. Qualitative themes were categorized as (1) workflow integration; (2) impact on clinical processes; (3) patient response to ultrasound; and (4) implementation barriers. A total of 731 and 815 women completed questionnaires from the HCs and DH, respectively. At the HC-level, triage quality of care, satisfaction and recommendation ratings increased with implementation of ultrasound. In contrast, satisfaction and recommendation ratings did not differ upon ultrasound introduction at the DH, whereas perceived triage quality of care increased. Most participants noted a perceived improvement in midwives' experience and knowledge upon introduction of ultrasound. Women who underwent a scan also reported diverse feelings, such as fear or worry about their delivery, fear of harm due to the ultrasound, or relief after knowing the baby's condition. For the midwives' perspective (n = 14), respondents noted that ultrasound led to more accurate diagnoses (e.g., fetal position, heart rate, multiple gestation) and improved decision-making. However, they noted health system barriers to ultrasound implementation, such as increased workload, not enough ultrasound-trained providers, and irregular electricity. While triage ultrasound in this context was seen as beneficial to mothers and useful in providers' clinical assessments, further investigation around provider-patient communication, system-level challenges, and fears or misconceptions among women are needed.