Achieving better maternal and newborn outcomes: coherent strategy and pragmatic, tailored implementation

The recent paper on Achieving better maternal and newborn outcomes by Stephen Hodgins (1) is a welcome exhortation to describe better what happens to mothers and newborns in low- and middle- income countries at the point of care, and to pay more attention to the differences in context that may affect implementation and evaluation of evidence-based interventions in complex, "real-life" settings. While there is much that remains to be done to ensure that mothers and newborns do in fact turn up for screening and treatment (still only half of mothers in sub-Saharan Africa receive "skilled" delivery, UNICEF global databases 2012), Dr. Hodgins draws needed attention to the importance of context-driven solutions, a more holistic approach to health and health care, and the crucial role of leadership and management, to ensure that mothers and infants do in fact receive "skilled" care on arrival. The paper also importantly draws attention to the need to move from the "what" - what evidence-based medical interventions are known to save lives - to the "how" - how to implement those interventions with available resources in the multitude of different local settings that defy rigidly prescriptive practice guidelines.

To add to this wise guidance, we draw attention to current efforts underway to introduce, across several nations in sub-Saharan Africa, adaptive designs at scale that embrace the essential principles outlined in the paper: Context-Driven, Content-Focused Solutions; Coherent, Linked- Up Care; and Informed and Empowered Managers.

In Ghana, these principles underlie a eight-year program to accelerate that country's efforts to reach its Millennium Development Goals 4 and 5. Building on Ghana's already sound national maternal, newborn and child health (MNCH) program, Project Fives Alive!, a partnership between the Institute for Healthcare Improvement, the National Catholic Health Service and the Ghana Health Service, has introduced a fast-moving quality improvement program that teaches local providers and system leaders to use data to detect gaps in performance and to test local ideas for implementing the content of the MNCH program.

An essential design feature is a learning system that harvests what works and what does not in different settings, and shares that knowledge with an exponentially expanding set of health districts that are networked into the program (2). Working simultaneously in and between communities, primary care settings and hospitals, leaders, managers and frontline health workers can adopt and adapt local proven strategies to ensure that MNCH content is consistently delivered and track the effects of their interventions with reliable data-feedback systems.

These principles are now being deployed at an even larger scale across six eastern and southern African countries that are collectively trying to eliminate mother-to-child transmission of HIV (MTCT) in the postnatal period. The six-country partnership, Partnership for HIV-free Survival, is using a cross-country QI learning platform to test and share local ideas to implement each country's version of the latest World Health Organization (WHO) MTCT guidelines. The local ideas are tracked by a simple set of performance metrics, thus enabling system leaders to use a package of the most successful ideas on how to implement the guidelines to rapidly scale up the program, knowing that they have already been validated and field tested in the local health systems.

Both of these ambitious programs will be evaluated by external groups who are familiar with realist quantitative and qualitative evaluation methods that can answer the question as to not only did the program work, but how did it work. Hodgins also addresses the growing sentiment (3) that more adaptive evaluation designs - and less reliance solely on randomized controlled trials - are needed to account for contextual variation encountered in different health systems when implementing large-scale programs. References

1. Hodgins S. Achieving better maternal and newborn outcomes: coherent strategy and pragmatic, tailored implementation. Glob Health Sci Pract August 12, 2013 vol. 1 no. 2 p. 146-153. doi: 10.9745/GHSP-D-13- 00030.

2. Twum-Danso NAY, Akanlu GB, Osafo E, Sodzi-Tettey S, Boadu RO, Atinbire S, Adondiwo A, Amenga-Etego I, Ashagbley F, Boadu EA, Dasoberi I, Kanyoke E, Yabang E, Essegbey IT, Adjei GA, Buckle GB, Awoonor-Williams JK, Nang-Beifubah A, Twumasi A, McCannon CJ, Barker PM. A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation processes. Int J Qual Health Care. 2012 Dec;24(6):601-1.

3. Victora CG, Habicht J, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health 2004;94:400-5. doi:10.2105/AJPH.94.3.400 PMID:14998803.

Conflict of Interest:

None declared