Learning from health system actor and caregiver experiences in Ghana and Nepal to strengthen growth monitoring and promotion.

BACKGROUND: Globally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs. METHODS: We conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation. RESULTS: Health workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use. CONCLUSION: This study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).

Antenatal care in Nepal: a qualitative study into missed opportunities in the first trimester.

BACKGROUND: Use of timely antenatal care has been identified as key to facilitating healthy pregnancies worldwide. Although considerable investment has been made to enhance maternal health services in Nepal, approximately one-third of women do not attend antenatal care until after the first trimester (late). These women miss out on the benefits of screening and interventions that are most effective in the first trimester. OBJECTIVE: This study aimed to identify the missed opportunities of women who do not attend antenatal care in the first trimester, and to explore some of the factors underlying late attendance and consider potential solutions for minimizing these missed opportunities in the future. STUDY DESIGN: This study was conducted in 3 hospitals in Nepal. Focus groups (n=18) with a total of 48 postnatal women and 49 staff members, and 10 individual interviews with stakeholders were conducted. Purposive sampling facilitated the obtainment of a full range of maternity experiences, staff categories, and stakeholder positions. Data were qualitative and analyzed using a thematic approach. RESULTS: Limited awareness among women of the importance of early antenatal care was reported as a key factor behind attendance only after the first trimester. The family and community were described as significant influencers in women's decision-making regarding the timing of antenatal care. The benefits of early ultrasound scanning and effective supplementation in pregnancy were the major missed opportunities. Increasing awareness, reducing cost, and enhancing interprofessional collaboration were suggested as potential methods for improving timely initiation of antenatal care. CONCLUSION: Limited awareness continues to drive late attendance to antenatal care after the first trimester. Investment in services in the first trimester and community health education campaigns are needed to improve this issue and enhance maternal and neonatal outcomes.

A systematic review and narrative synthesis of antenatal interventions to improve maternal and neonatal health in Nepal.

BACKGROUND: Maternal and neonatal mortality rates remain high in many economically underdeveloped countries, including Nepal, and good quality antenatal care can reduce adverse pregnancy outcomes. However, identifying how to best improve antenatal care can be challenging. OBJECTIVE: To identify the interventions that have been investigated in the antenatal period in Nepal for maternal or neonatal benefit. We wanted to understand their scale, location, cost, and effectiveness. STUDY DESIGN: Online bibliographic databases (Cochrane Central, MEDLINE, Embase, CINAHL Plus, British Nursing Index, PsycInfo, Allied and Complementary Medicine) and trial registries (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform) were searched from their inception till May 24, 2020. We included all studies reporting any maternal or neonatal outcome after an intervention in the antenatal period. We screened the studies and extracted the data in duplicate. A meta-analysis was not possible because of the heterogeneity of the interventions and outcomes, so we performed a narrative synthesis of the included studies. RESULTS: A total of 25 studies met our inclusion criteria. These studies showed a variety of approaches toward improving antenatal care (eg, educational programs, incentive schemes, micronutrient supplementation) in different settings (home, community, or hospital-based) and with a wide variety of outcomes. Less than a quarter of the studies were randomized controlled trials, and many were single-site or reported only short-term outcomes. All studies reported having made a positive impact on antenatal care in some way, but only 3 provided a cost-benefit analysis to support implementation. None of these studies focused on the most remote communities in Nepal. CONCLUSION: Our systematic review found good quality evidence that micronutrient supplementation and educational interventions can bring important clinical benefits. Iron and folic acid supplementation significantly reduces neonatal mortality and maternal anemia, whereas birth preparedness classes increase the uptake of antenatal and postnatal care, compliance with micronutrient supplementation, and awareness of the danger signs in pregnancy.

Maternal Near Miss Analysis in Three Hospitals of Nepal: An Assessment Using Three Delays Model.

BACKGROUND: Maternal Near Miss cases have similarities with those dying from such complications and so present an important opportunity to improve practice. This study was conducted to assess the prevalence of Maternal Near Miss events and identify the delays experienced. METHODS: This was a facility-based cross-sectional study conducted in three tertiary referral hospitals from three provinces of Nepal. All the women surviving a near miss event during six months data collection period were included in the study. RESULTS: There were 67 near miss cases, 7 maternal deaths, and 9158 live births in the study hospitals during the data collection period. This resulted in Maternal Near Miss ratio of 7.31/1000 live births and facility-based Maternal Mortality Ratio of 76/100,000 live births. Severe obstetric haemorrhage (54%) was the most frequent clinical cause of near miss, followed by hypertensive disorders (43%). At least one type of delay was experienced by 85% women. First delay occurred in 63% (42 of 67) cases, second delay occurred in 52% (33 of 62) cases and third delay occurred in 55% (37 of 67) cases. CONCLUSIONS: This study found out that all three delays were common among women experiencing maternal near miss event. Raising awareness regarding dangers signs, improving referral system and strengthening ability of health workers can help in reducing these delays.

Who are dying and why? A case series study of maternal deaths in Nepal.

OBJECTIVES: To identify delays and associated factors for maternal deaths in Nepal. DESIGN: A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis. SETTING: Sixty-two maternal deaths in six districts in three provinces of Nepal. RESULTS: Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths. CONCLUSIONS: The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants.

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal's transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal's maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal.

BACKGROUND: Globally, many mothers and their babies die during pregnancy and childbirth. A key element of optimizing outcomes is high-quality antenatal care. The Government of Nepal has significantly improved antenatal care and health outcomes through high-level commitment and investment; however, only 69% of patients attend the 4 recommended antenatal appointments. OBJECTIVE: This study aimed to evaluate the quality and perceptions of antenatal care in Nepal to understand compliance with the Nepalese standards. STUDY DESIGN: This cross-sectional study was conducted at a tertiary referral and private hospital in Kathmandu and a secondary hospital in Makwanpur, Nepal. The study recruited 538 female inpatients on postnatal wards during the 2-week data collection period from May 2019 to June 2019. A review of case notes and verbal survey of women to understand the pregnancy information they received and their satisfaction with antenatal care were performed. We created a summary score of the completeness of antenatal care services received ranging from 0 to 50 (50 indicating complete conformity with standards) and investigated the determinants of attending 4 antenatal care visits and patient satisfaction. RESULTS: The median antenatal care attendance was 4 visits at the secondary and referral hospitals and 8 visits at the private hospital. However, 24% of the patients attended <4 visits. Furthermore, 117 of 538 patients (22%) attended the first-trimester visit, and 65 of 538 patients (12%) attended visits at all points recommended in the standards. More than 90% of the women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, and HIV and syphilis screening. Approximately 50% of the women had urinalysis at every visit (interquartile range, 20-100). Moreover, 509 of 538 patients (95%) reported receiving pregnancy information, but retention was variable: 509 of 538 patients (93%) received some information about danger signs, 290 of 502 patients (58%) remembered headaches, and 491 of 502 patients (98%) remembered fluid leaking. The antenatal care completeness score revealed that the private hospital offered the most complete clinical services (mean, 28.7; standard deviation, 7.1) with the secondary hospital performing worst (mean, 19.1; standard deviation, 7.1). The factors influencing attendance at 4 antenatal care visits in the multivariable model were beginning antenatal care in the first trimester of pregnancy (odds ratio, 2.74; 95% confidence interval, 1.36-5.52) and having a lower level of education (no school: odds ratio, 0.46 [95% confidence interval, 0.23-0.91]; grades 1-5: odds ratio, 0.49 [95% confidence interval, 0.26-0.92]). Overall, 303 of 538 women (56%) were satisfied with their antenatal care. The multivariable analysis revealed that satisfaction was more likely in women attending the private hospital than in women attending the referral hospital (odds ratio, 3.63; 95% confidence interval, 1.68-7.82) and lower in women who felt the antenatal care facilities were not adequate (odds ratio, 0.35; 95% confidence interval, 0.21-0.63) and who wanted longer antenatal appointments (odds ratio, 0.5; 95% confidence interval, 0.33-0.75). CONCLUSION: Few women achieved full compliance with the Nepali antenatal care standards; however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counseling training for staff, investment in health promotion and delivery of core services are needed. It is important that these interventions address key issues, such as attendance in the first trimester of pregnancy, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested before widespread investment or implementation.