Interventions to improve the quality of maternal care in Ethiopia: a scoping review

Introduction

Every day, pregnancy- and childbirth-related complications lead to the deaths of almost 800 women and 6,700 neonates globally. Moreover, approximately 5,400 stillbirths occur daily, with 40% of these fatalities occur during labor and delivery (1). Sub-Saharan African countries have recorded 546 maternal deaths per 100,000 live births, whereas developed regions have recorded only 12 deaths per 100,000 live births. Almost 94% of maternal deaths are associated with inadequate maternal care (2, 3). Ethiopia is a sub-Saharan African country that experiences a significant burden of neonatal mortality, with 30 deaths per 1,000 live births (4). It is crucial to prioritize quality maternal care to enhance the survival rates of both mothers and newborns (5).

Quality maternal and newborn care has been prioritized to catalyze action and support of the Sustainable Development Goal (SDG-3) global target of a maternal mortality ratio of less than 70 (5, 6). Almost half of the maternal population and more than 60% of neonatal deaths arise from poor quality care (7). Increasing access to healthcare services is needed to improve maternal and neonatal health (8); however, the paramount importance lies in quality of care.

The quality of care in the healthcare system is described from the perspective of healthcare providers, managers, and patients using elements such as safety, effectiveness, patient-centeredness, equity, and the provision of care (9). Improving the utilization of evidence-based guidelines through quality improvement initiatives proves effective, but implementing and maintaining them can be challenging (10).

Ensuring high-quality care is essential to reduce maternal morbidity and mortality. In 2016, the World Health Organization (WHO) established a quality of care (QoC) strategy for improving care for pregnant women and newborns. The strategy focuses on three areas of intervention to improve the quality of clinical care: enhancing the care experience and creating an enabling environment and system for quality care (11, 12), aligned with the strategies of ending preventable death and the Every Newborn Action Plan (13, 14). The quality of care could be affected by different factors, including a shortage of human resources (15); social, political, economic, and health system factors (16, 17); the knowledge, attitudes, and skills of healthcare providers; physical infrastructure; supply; leadership; provider's client relationship (18); mistreatment; and lack of support (19). Interventions were categorized based on the three systems of Donabedian's model of healthcare quality (input, process, and output) and the eight domains outlined in the WHO standard of care framework (20). The WHO recommends a comprehensive intervention strategy to make pregnancy safer: capacity development, increasing awareness, strengthening linkage, and improving the quality of services (21). In addition, interventions aimed at promoting health, such as enhancing the health of mothers and newborns, improving care provided at home, increasing community support for maternal health, increasing access to and use of skilled professionals, and empowering women, all work together to improve the quality of maternity care (22).

Evidence suggests that culturally appropriate maternity care interventions, such as home visits, formation of community-based health support groups, financial and community-based intervention packages, promoting awareness of women's rights, and educational training, improve the quality of maternal and newborn care (23–26). Moreover, improving the quality of midwifery education to meet international standards positively impacts the quality of maternity care (7). Interventions can be categorized as setting standards; implementing quality improvement programs; establishing performance-based initiatives (financial and non-financial); engaging and empowering clients; changing the clinical practices of healthcare workers; providing information and education to healthcare workers, managers, and policymakers; and implementing legislation and regulations for healthcare delivery (27).

In Ethiopia, the quality of maternity care became one of the areas of focus in 2014 and one of the four pillars of the Health Sector Transformation Plan (HSTP) II (2020–2025), which aimed at reducing maternal mortality to 279 per 100,000 live births, neonatal mortality to 21 per 1,000 live births, increasing skill delivery to 76%, and achieving antenatal care (ANC) coverage of 81% (28), which could be addressed through quality care interventions. Overall, quality improvement is observed throughout the continuum of care and improved emergency services (29, 30). Despite different maternal care quality improvement interventions in Ethiopia, maternal morbidity, adverse birth outcomes, and neonatal mortality rates remain steady. To the best of our knowledge, a scoping review targeting quality improvement interventions has not been conducted. As such, this review aims to identify, map, summarize, and inform priority research questions related to quality care interventions aimed at improving maternal and neonatal health in Ethiopia.

Methods

Identifying the research questions

The protocol was drafted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) and has been registered on Figshare (31). A scoping review was used because of the broader nature (32) of quality maternal and neonatal care interventions. The review was based on Arksey and O’Malley's scoping review framework (33) and expanded to the Joanna Briggs Institute (JBI) framework for methodology consideration (34). We followed five essential steps of the Arksey and O'Malley methods in the review process. First, we identified the research questions. Second, we identified relevant studies. Third, we chose which studies to include. Fourth, we organized and recorded the data. Finally, the results were summarized and reported (35). The preferred reporting item checklist and explanation used for reporting are given in Supplementary File S1 (36).

BB and YA developed the research questions. The population, concept, and context frameworks were used to establish the eligibility of the research questions. The population included women/healthcare facilities, and the concept focused an intervention related to quality care within the Ethiopian context.

Inclusion criteria

We included publications focusing on quality interventions (QI) to improve maternal and neonatal health in Ethiopia. All maternal and neonatal QI studies published in English were included. Papers with a study design, interrupted time series studies, before-and-after studies, program evaluations, randomized control trials (RCT), quasi-experimental designs, comparative cross-sectional studies, cohort studies, qualitative studies, and reports were included. Articles without full text or data that were challenging to extract were excluded.

Search strategy

We thoroughly searched various bibliographic databases, including PubMed, Google Scholar, and the Cochrane Library, and performed manual search for unpublished sources to ensure comprehensive coverage of relevant literature. Medical subject headings, keywords, and free-text search terms were used. An extensive and comprehensive search was performed from the PubMed database using alternatives (all field options) (Supplementary File S2). A literature search was conducted between March 20 and June 4, 2022.

Evidence screening and selection

First, a systematic search was conducted in all identified/accessed databases, search engines, and unpublished articles. Second, all retrieved studies were exported to Endnote version 7 (Thomson Reuters, London) reference manager, and duplicated studies were removed. Third, unrelated articles were excluded from the title review. Two investigators (BB and DB) independently screened titles, abstracts, and full texts to determine the eligibility of each study. During the review process, articles lacking full text were identified through discussions with the reviewers. Disagreements were resolved by consensus or a third party (YT).

Data extraction

The data extraction tool was developed using the JBI manual of the evidence synthesis framework for scoping reviews (37). The extracted data were based on several tools, including author(s)/year of publication, study setting, aim/purpose, methods employed, type of intervention/comparator (duration of intervention), and key findings (Table 1).

Table 1

Table 1. Characteristics of included studies.

Collating, summarizing, and reporting the results

The scoping review findings were reported following the PRISMA-ScR guidelines. Data were presented using text, figures, and tables to describe the concept, population, and context. The interventions were classified into three systems based on Donabedian's model of healthcare quality (input, process, and output) and eight domains of the WHO's standard of care (56).

Results

Search results

Articles were searched from PubMed (n = 6,170), Cochrane Library (n = 13), Registries (n = 46), and gray literature (n = 67), yielding a total of 6,296 articles, of which 5,430 remained after duplication removal. Following title and abstract screening, 38 articles were reviewed for full text. Finally, 19 articles were selected for inclusion in the scoping review (Figure 1).

Figure 1

Figure 1. PRISMA flow diagram.

Characteristics of included studies

Nineteen studies were included in the review. As per the review, n = 2 studies were conducted in all regions of Ethiopia; n = 6 studies were conducted in four regions of Amhara, Oromia, SNNP, and Tigray; n = 1 study was conducted in three regions of Amhara, Oromia, and SNNP; n = 2 studies were conducted in three regions of SNNP, Tigray, and Oromia; n = 3 studies were conducted in two regions of Amhara and Oromia; n = 2 studies were conducted in Oromia; n = 2 studies were conducted in Amhara; and n = 1 study was conducted in SNNPR. Almost all articles were published after 2013, and only one study was conducted in 2011. As per the current review, nine studies (12, 38–42, 46, 47) focused on maternal and child health (MCH) [ANC, intrapartum, postnatal care (PNC)] intervention, two studies (43, 49) focused on ANC intervention, three studies (41, 44, 45) focused on intrapartum, two studies (51, 52) focused on PNC, and three studies (48–50) focused on respectful maternity care.

Most studies (n = 10) were pre–post intervention (project evaluation) studies (42, 46–54), n = 1 study was a RCT (45), n = 4 studies were facility-based cross-sectional studies (40, 41, 43, 44), and n = 1 study was a (55) quasi-experimental time series.

Reports have targeted different types of interventions to improve the quality of MCH care. Based on the type of intervention, four studies focused on mobile and electronic health (eHealth) (38, 42, 45, 47), n = 5 studies focused on quality improvement standards (12, 38–40, 44), and n = 10 studies focused on human resource mobilization (training for healthcare providers, health extension workers, traditional birth attendants, and the community health development army, pregnant mothers, and supply material resources needed for MCH services) (43, 46, 48–55) (Table 1).

Data extraction and synthesis intervention based on WHO's eight domains of quality care

Quality improvement interventions were summarized based on the WHO eight domains of quality care for mothers and newborns: most (15) interventions focused on domain 1 (evidence-based routine care and management of complications) (12, 38–41, 43–46, 50–55), 13 reports focused on domain 2 (the health information system enables the use of data to ensure early, appropriate action to improve the care of every woman and newborn) (38–41, 44–47, 51, 53–55), 9 studies focused on domain 7 (the availability of competent and motivated staff) (12, 38, 39, 45, 46, 52–54), 4 studies focused on domain 4 (effective communication) (38, 42, 46, 47), and 4 studies addressed the medicine and equipment required for maternal and newborn care (39, 43, 50, 52). Very few studies focusing on domains 3 (38), 5 (44, 48, 50), and 6 (50) were related to the functional referral system, promotion of respectful and dignified care, and emotional support, respectively (Table 2).

Table 2

Table 2. Alignment of quality improvement intervention with WHO’s quality of maternal and newborn care standards.

Discussion

Quality improvement of maternal and newborn care has been one of the national agenda in averting maternal and neonatal mortality. The current scoping review revealed that improving the quality of maternal and newborn care in Ethiopia is a complex and challenging task. Various sources have been identified, such as quality improvement strategies, ranging from community engagement to health system strengthening, including mHealth, community involvement, health education, standard-based practice, health workforce empowerment, and the supply of resources for MCH services. The key themes that emerged from the literature were the impact of mHealth interventions (safe delivery applications, SMS messages, and video shows), using MCH standards (WHO safe delivery checklist, quality standards, and reports), community involvement, and empowerment of healthcare providers for improving MCH care. However, a notable research gap exists regarding the impact of material resources, physical environment, and accessibility on the quality of maternal and newborn care, which needs further investigation.

The review studies suggested that the place of ANC-1 visit does not have a significant effect on the completion of the continuum of care; only 13.9% completed the continuum of care, with 6.6% of them receiving the Ministry of Health recommended ANC and only 25% attending PNC visits (7). This finding was supported by a study conducted in Ethiopia (43). Completion of the continuum of care may be influenced by factors other than the first ANC visit, such as socioeconomic status, mass media exposure, accessibility of the healthcare institution, and quality of care received during the first ANC visit (57, 58). Moreover, the flexibility of the healthcare system may influence women to seek their first ANC visit in alternative settings. Seeking care at a formal healthcare facility for an initial ANC visit can improve the likelihood of receiving timely and appropriate care throughout the continuum. Factors such as accurate risk assessment, early detection of complications, and effective referral systems are more likely to be present in formal healthcare settings (59). As such, it is essential to consider the holistic perspective encompassing multiple factors influencing the continuum of care.

The use of the Safe Childbirth Checklist (SCC) is associated with improved essential birth practice and reduced pregnancy complications, reducing the rate of severe pre-eclampsia (60, 61). According to a randomized control trial, the use of the WHO checklist had an impact on the safety culture among healthcare providers. The trial showed that healthcare providers were more likely to call attention to problems with patient care and report errors during periods of excessive workload when using the checklist (62). Evidence showed that knowledge and skills related to neonatal resuscitation deteriorate after 6 months of training (63), indicating the knowledge and skills of healthcare professionals should be emphasized greatly.

Community engagement and empowerment are also of paramount importance in improving quality care. Community involvement in decision-making processes and utilization related to MCH care helps ensure that services are responsive to their needs and preferences (64). Implementing community-oriented strategies improves skilled birth attendants (65), enhances knowledge and healthy behaviors related to MCH care (66), and reduces neonatal mortality (67). Improving maternal and child healthcare can be achieved by creating a peer support network. This approach can increase access to vital information, reduce isolation, and encourage positive health-seeking behavior (68). Community based outreach activities played a key role in identifying barriers to accessing care and improving MCH services (69). Emphasizing the involvement of the community is crucial for need assessment, community-led planning, and establishing a healthy community. Future efforts should prioritize community perspectives and involve them in culturally sensitive approaches.

The review identified technologies to improve maternal and newborn care, such as mHealth (using phone-based communication, SMS messaging, and mobile applications) to deliver healthcare services and information (38, 42, 45, 47). Studies also showed that SMS-based intervention could improve antenatal attendance, immunization rates, and mother's knowledge of MCH (70). SMS messages to pregnant women and new mothers can serve as reminders for assessing MCH services. Using mobile phone-based health behavior interventions in pregnancy improves behaviors, positive beliefs, and health outcomes (71, 72). Mobile health applications have proven beneficial for providers in making informed decisions while delivering care, collecting data, and providing health education (73, 74). Moreover, using voice counseling, job aid applications, direct messaging, and interactive media as a means of behavioral change communication had a significant impact on improving MCH care (75). Insufficient attention is given to intervention across different geographical areas. In addition, digital literacy, Internet, and electric sources must be addressed to ensure equitable access to mHealth. As such, focus should be given to the usability, applicability, and sustainability of mHealth for MCH services.

In addition, evidence showed that the quality of maternal and newborn care depends on facility readiness (infrastructure, supplies, health workforce, service delivery approach), adherence to guidelines, and provision of skilled care (76). However, the challenge lies in the equitable distribution of resources to ensure that all women, regardless of their geographical area, religion, or ethnicity, have access to quality maternity care. In summary, quality maternal and newborn care could be achieved through different partners’ involvement, prioritizing quality MCH services, promoting equity through universal healthcare coverage, improving facility capability, and strengthening the healthcare system through resources (5). Collecting, monitoring, and evaluating data are important for quality improvement in healthcare. Standardized indicators and metrics can help identify gaps, measure outcomes, and inform decision-making.

Despite the overall positive findings, it is important to note that most of the included studies focused on providing care (pre- and postinterventions). Moreover, the review focused on strategies for improving maternity care rather than assessing the effectiveness of quality interventions. The strength of this scoping review is the inclusion of both published and gray literature. The PRISMA-ScR checklist was used, with no restriction on the publication date. However, it is essential to acknowledge that language restriction was applied, which may introduce a potential bias. Moreover, literature was not searched from EMBASE, PsycINFO, CINHAL, HINARI, and Maternity and Infant Care databases due to their.

Future research should focus on the impact of the physical environment (healthcare setup, medical equipment, drugs, and supplies), culture, sustainability, and cost-effectiveness of interventions on the quality of MCH care. Long-term impact of quality intervention should also be investigated. In addition, the impact of healthcare providers’ knowledge, skills, attitudes, satisfaction, and adherence to MCH guidelines on quality maternal care should be considered. Projects focusing on capacity building, knowledge, and skill retention could significantly improve maternal and newborn care. Finally, mixed-method studies should be conducted to investigate the facilitation and barriers of quality improvement interventions for maternal and newborn care. Moreover, studies on emotional and functional referral systems to improve the quality of maternal and newborn care should be conducted.

Conclusions

In conclusion, this scoping review identifies and maps various maternal and newborn quality improvement interventions in Ethiopia, focusing on mobile and electronic health, quality improvement standards, and human resource mobilization. This review found that community involvement, health education, mHealth, data-driven approaches, and strengthening the health system are crucial strategies for improving maternal and newborn care in Ethiopia. Future research should consider the impact of the physical environment, culture, sustainability, cost-effectiveness, and long-term effects of interventions, as well as healthcare providers’ knowledge, skills, attitudes, satisfaction, and adherence to guidelines.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material; further inquiries can be directed to the corresponding author.

Author contributions

BB: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YA: Conceptualization, Methodology, Supervision, Writing – review & editing. DB: Formal analysis, Investigation, Methodology, Writing – review & editing. GN: Conceptualization, Methodology, Software, Supervision, Writing – review & editing. TM: Conceptualization, Formal analysis, Methodology, Writing – review & editing. TL: Investigation, Visualization, Writing – review & editing. KG: Data curation, Validation, Writing – review & editing. YT: Conceptualization, Data curation, Investigation, Methodology, Resources, Validation, Visualization, Writing – review & editing.

Funding

The authors declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fgwh.2024.1289835/full#supplementary-material

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