Quality of maternal and newborn care in limited-resource settings: a facility-based cross-sectional study in Burkina Faso and Côte d'Ivoire.

OBJECTIVE: To assess and compare the quality of intrapartum and immediate postpartum care across levels of healthcare in Burkina Faso and Côte d'Ivoire using validated process indicators. DESIGN: Health facility-based cross-sectional study with direct observation of healthcare workers' practices while caring for mother-newborn pairs during intrapartum and immediate postpartum periods. SETTING: Primary healthcare facilities and their corresponding referral hospitals in the Central-North region in Burkina Faso and the Agneby-Tiassa-Mé region in Côte d'Ivoire. PARTICIPANTS: Healthcare providers who care for mother-newborn pairs during intrapartum and immediate postpartum periods, the labouring women and their newborns after childbirth. MAIN OUTCOME MEASURES: Adherence to essential best practices (EBPs) at four pause points in each birth event and the overall quality score based on the level of adherence to the set of EBPs observed for a selected pause point. RESULTS: A total of 532 and 627 labouring women were included in Burkina Faso and Côte d'Ivoire, respectively. Overall, the compliance with EBPs was insufficient at all the four pause points, even though it varied widely from one EBP to another. The adherence was very low with respect to hand hygiene practices: the care provider wore sterile gloves for vaginal examination in only 7.96% cases (95% CI 5.66% to 11.06%) in Burkina Faso and the care provider washed hands before examination in 6.71% cases (95% CI 3.94% to 11.20%) in Côte d'Ivoire. The adherence was very high with respect to thermal management of newborns in both countries (>90%). The overall mean quality scores were consistently higher in referral hospitals in Burkina Faso at all pause points excluding immediate post partum. CONCLUSIONS: Women delivering in healthcare facilities do not always receive proven EBPs needed to prevent poor childbirth outcomes. There is a need for quality improvement interventions.

Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project.

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context-mechanism-outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by 'bridging' communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a 'buzz' for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs' motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective.

An exploratory analysis of the regionalization policy for the recruitment of health workers in Burkina Faso.

BACKGROUND: Health personnel retention in remote areas is a key health systems issue wordwide. To deal with this issue, since 2002 the government of Burkina Faso has implemented a staff retention policy, the regionalized health personnel recruitment policy, aimed at front-line workers such as nurses, midwives, and birth attendants. This study aimed to describe the policy's development, formulation, and implementation process for the regionalization of health worker recruitment in Burkina Faso. METHODS: We conducted a qualitative study. The unit of analysis is a single case study with several levels of analysis. This study was conducted in three remote areas in Burkina Faso for the implementation portion, and at the central level for the development portion. Indepth interviews were conducted with Ministry of Health officials in charge of human resources, regional directors, regional human resource managers, district chief medical officers, and health workers at primary health centres. In total, 46 in depth interviews were conducted (February 3 - March 16, 2011). DEVELOPMENT: The idea for this policy emerged after finding a highly uneven distribution of health personnel across urban and rural areas, the availability of a large number of health officers in the labour market, and the opportunity given to the Ministry of Health by the government to recruit personnel through a specific budget allocation. FORMULATION: The formulation consisted of a call for job applications from the Ministry of Health, which indicates the number of available posts by region.The respondents interviewed unanimously acknowledged the lack of documents governing the status of this new personnel category. IMPLEMENTATION: During the initial years of implementation (2002-2003), this policy was limited to recruiting health workers for the regions with no possibility of transfer. The possibility of job-for-job exchange was then approved for a certain time, then cancelled. Starting in 2005, a departure condition was added. Now, regionalized health workers can leave the regions after undergoing a competitive selection process. CONCLUSION: The policy was characterized by the absence of written directives and by targeting only one category of personnel. Moreover, there was no associated incentive-financial or otherwise-which poses the question of long-term viability.

Which incentive package will retain regionalized health personnel in Burkina Faso: a discrete choice experiment.

BACKGROUND: The lack of motivation of health workers to practice in rural areas remains a crucial problem for decision-makers, as it deprives the majority of access to health care. To solve the problem, many countries have implemented health worker retention strategies. However, the development of such strategies requires an understanding of the preferences of health workers. The objective of the study was to identify a package for attracting and retaining health workers in underserved areas. METHODS: A cross sectional study was conducted in three health regions of Burkina Faso in 2012. A discrete choice experiment was used to investigate preferences for incentive packages among health workers recruited under the regionalized policy. In-depth interviews and focus group discussions with health workers currently working in the East and Sahel regions and policy makers, and a literature review on attraction and retention in low income countries, were performed to identify the attributes and levels. These attributes were: the regionalized recruitment policy, health insurance, work equipment, housing, and specific incentive compensation. The final design resulted in 16 choice sets. A multinomial logistic regression was used to determine the influence of socio-demographic characteristics on choice of a given option. A probit logistic regression model was then used to analyze the effect of these difference variables on choice, to identify the incentive package best suited to health workers. In total, questionnaires were administered to 315 regional health workers. RESULTS: For all participants, choice of package was strongly influenced by length of commitment under the policy and provision of housing. Sex, number of years in profession, and location also influenced the choice of package. Women are twice more likely to choose a package with free housing and the cancellation of the policy. CONCLUSION: It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. In addition, the methodology of discrete choice experiment has been particularly useful, not only for better understanding the factors explaining the reluctance of health workers to work in underserved areas, but also to provide practical advice to the government, to improve its retention policy.