Educating Families on Urgent Maternal Warning Signs: Learning From a Pilot to Improve Training and Tools for Maternal and Child Home Visiting Programs.

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

External relationships as implementation determinants in community-engaged, equity-focused COVID-19 vaccination events.

Background: While relationships and connectedness among organizations have been included in implementation theories, models, and frameworks, the increased attention to health equity in implementation science raises the urgency of understanding the role of relationships external to the implementing organization. This paper addresses this gap through an exploration of the role of external relationships in community-based, equity-focused interventions. Methods: This study focuses on an equity-focused, community-based COVID-19 vaccination intervention in Arkansas, drawing upon long-term community-engaged relationships among University of Arkansas for Medical Sciences and the Hispanic and Marshallese Islander communities. We used an exploratory qualitative descriptive design to examine barriers and facilitators to implementation of COVID-19 vaccination events analyzing in-depth qualitative interviews with implementation team members (n = 17). Results: All participants described pre-existing relationships among the implementing organization, partner organizations, and communities as a key implementation determinant for this equity-focused program. At the inter-organizational level, external relationships included formal connections and informal relationships among staff (e.g., communication channels from prior partnerships). At the individual level, strong external relationships with the community were facilitators leveraging long-term engagement, community familiarity, and staff from the communities of focus. Strong external relationships facilitated program reach in underserved communities through three mechanisms: (1) reduced time required to establish functional working relationships among partners; (2) accessibility and cultural congruence of health services; and (3) increased trust among community members. Barriers to implementation also existed in external relationships, but had less influence than facilitators. Conclusions: Achieving health equity in implementation science requires greater understanding of external relationships as implementation determinants. This exploratory study makes a significant contribution to the literature by describing the types of external relationships that facilitate equitable implementation and identifying the mechanisms through which they may work. We argue that approaches to community engagement drawn from community-engaged research approaches may be useful, as these processes require investment in building/maintaining formal and informal organizational and interpersonal relationships. Further research is needed to understand connections among external relationships and other implementation determinants.

Breastfeeding Intentions among Pregnant Women Enrolled in a Healthy Start Program in Arkansas.

INTRODUCTION: Exclusive breastfeeding is recognized as the optimal source of nutrition for infants. Although exclusive breastfeeding rates have increased overall in the United States, substantial inequities exist in breastfeeding among individuals of different socioeconomic statuses, races, and ethnicities. The purpose of this study was to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. METHODS: The current study included a cross-sectional design, with a sample of 242 pregnant women in Arkansas enrolled in a Healthy Start program. RESULTS: The majority of the participants (56.6%) indicated their infant feeding intentions included a combination of breastfeeding and formula feeding. There were substantial differences in breastfeeding intentions among women of different races/ethnicities, with 18.5% of Marshallese women indicating they planned to exclusively breastfeed, compared to 42.1% of White women, 47.6% of Black women, and 31.8% of Hispanic women (p < 0.001). Women over the age of 18 and with higher educational attainment were more likely to intend on exclusively breastfeeding. DISCUSSION: This is the first study to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. The study found that race/ethnicity and age were most strongly associated with breastfeeding intentions. These findings are critical to identifying populations for resource allocation and to developing culturally-tailored interventions to help women in Arkansas achieve their desired infant feeding methods.

Assessing the acceptability and implementation feasibility of a culturally adapted parenting intervention for Marshallese mothers: A study protocol.

Background: Pacific Islanders, including the Marshallese, face higher rates of obesity and obesity-related chronic conditions. Early-life interventions targeting eating patterns during the first 1000 days of life are essential to promote proper nutrition and growth. Marshallese mothers and caregivers are important decision-makers for feeding practices that could affect childhood obesity rates in Marshallese children. However, little is known about dietary patterns and practices of Marshallese families from birth to 12 months. Culturally-adapted approaches using community-based assets and Pacific Islander cultural values/practices have demonstrated effectiveness in reducing obesity but have not been developed for children. Methods: This article describes the protocol for a study to culturally adapt the Centering Parenting intervention for Marshallese mothers in Arkansas. Conclusion: This will be the first study to culturally adapt and implement Centering Parenting with Marshallese women in the United States. This study will be an important first step to assess the feasibility and acceptability of an abbreviated parenting intervention to reduce childhood obesity in Marshallese communities.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers.

BACKGROUND: Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA. METHODS: This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures. RESULTS: Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research. CONCLUSIONS: Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Integrating Implementation Science with Quality Improvement to Improve Perinatal Outcomes.

Implementation science is an interdisciplinary field that seeks to contribute generalizable knowledge that can improve the translation of clinical evidence in routine care. To promote the integration of implementation science approaches with health care quality improvement, the authors offer a framework that links the Model for Improvement with implementation strategies and methods. Perinatal quality improvement teams can leverage the robust frameworks of implementation science to diagnose implementation barriers, select implementation strategies, and assess the strategies' contribution to improving care. Partnerships between implementation scientists and quality improvement teams could accelerate efforts by both groups to achieve measurable improvements in care.

Factors Associated With Marshallese and Hispanic Adults' Willingness to Receive a COVID-19 Booster Dose.

INTRODUCTION/OBJECTIVES: New variants of the SARS-CoV-2 virus that causes COVID-19 will continue to develop and spread globally. The Omicron variant identified in November 2021 has many lineages. Variants spread quickly and can infect previously vaccinated individuals, prompting the Centers for Disease Control and Prevention to update vaccination recommendations. While ~230 million Americans received the initially-recommended vaccine sequence, booster uptake has been much lower; less than half of fully vaccinated individuals report receiving a booster. Racial disparities also mark patterns of COVID-19 vaccination booster uptake. This study explored willingness and motivations to get a COVID-19 booster among a diverse sample of participants. METHODS: We used convenience sampling to recruit participants 18 years of age or older who attended a community vaccine event. We conducted informal interviews during the recommended 15-min post-vaccination wait time with 55 participants who attended vaccine events at Marshallese and Hispanic community locations and comprised the recruitment pool for individual interviews. Using a qualitative descriptive design, we conducted in-depth follow-up interviews with 9 participants (Marshallese n = 5, Hispanic n = 4) to explore willingness and motivations to get boosted. We used rapid thematic template analysis to review informal interview summaries and formal interviews. The research team resolved data discrepancies by consensus. RESULTS: Participants reported high willingness to get boosted, especially if boosters were recommended in the future to protect against serious illness and mitigate the spread of COVID-19. This finding underscores how essential including recommendations to get a COVID-19 booster from trusted sources in health messaging and educational campaigns may be for increasing booster uptake. Participants described their preference for receiving future COVID-19 boosters, reporting that they would attend similar vaccine events, especially those held at faith-based organizations and facilitated by the same community partners, community health workers, and research staff. This finding shows how community engagement can overcome barriers to vaccination (ie, transportation, language, and fear of discrimination) by providing services in preferred community locations with trusted community partners. CONCLUSIONS: Findings document high willingness to get a COVID-19 booster, emphasize the role of recommendations from trusted sources in motivating booster uptake, and highlight the importance of community engagement to address disparities in vaccination coverage and reach.

Reaching late adopters: factors influencing COVID-19 vaccination of Marshallese and Hispanic adults.

BACKGROUND: Marshallese and Hispanic communities in the United States have been disproportionately affected by COVID-19. Identifying strategies to reach late vaccine adopters is critical for ongoing and future vaccination efforts. We utilized a community-engaged approach that leveraged an existing community-based participatory research collaborative of an academic healthcare organization and Marshallese and Hispanic faith-based organizations (FBO) to host vaccination events. METHODS: Bilingual Marshallese and Hispanic study staff conducted informal interviews with 55 participants during the 15-minute post-vaccination observation period and formal semi-structured interviews with Marshallese (n = 5) and Hispanic (n = 4) adults post-event to assess the implementation of community vaccine events at FBOs, with a focus on factors associated with the decision to attend and be vaccinated. Formal interview transcripts were analyzed using thematic template coding categorized with the socio-ecological model (SEM). Informal interview notes were coded via rapid content analysis and used for data triangulation. RESULTS: Participants discussed similar factors influencing attitudes and behaviors toward receiving the COVID-19 vaccine. Themes included: (1) intrapersonal - myths and misconceptions, (2) interpersonal - protecting family and family decision-making, (3) community - trust of community location of events and influence of FBO members and leaders, (4) institutional - trust in a healthcare organization and bilingual staff, and (5) policy. Participants noted the advantages of vaccination delivery at FBOs, contributing to their decision to attend and get vaccinated. CONCLUSIONS: The following strategies may improve vaccine-related attitudes and behaviors of Marshallese and Hispanic communities not only for the COVID-19 vaccine but also for other preventive vaccinations: 1) interpersonal-level - develop culturally-focused vaccine campaigns targeting the family units, 2) community-level - host vaccination events at convenient and/or trusted locations, such as FBOs, and engage community and/or FBO formal or lay leaders as vaccine ambassadors or champions, and 3) institutional-level - foster trust and a long-term relationship with the healthcare organization and provide bilingual staff at vaccination events. Future research would be beneficial to investigate the effects of replicating these strategies to support vaccine uptake among Marshallese and Hispanic communities.

Marshallese Mothers' and Marshallese Maternal Healthcare Providers' Perspectives on Contraceptive Use and Reproductive Life Planning Practices and Influences.

Pacific Islander communities experience significant maternal and infant health disparities including high maternal and infant mortality. Contraception and reproductive life planning prevent approximately one-third of pregnancy-related deaths and neonatal deaths. We report the results of formative research devoted to understanding Marshallese mothers' as well as their maternal healthcare providers' practices and influences related to contraceptive use and reproductive life planning. This study used an exploratory, descriptive qualitative design to explore Marshallese mothers' and maternal healthcare providers' practices and influences of contraception use and reproductive life planning. Twenty participants were enrolled in the study, 15 Marshallese mothers and five Marshallese maternal healthcare providers. For the Marshallese mothers, two themes emerged: (1) Reproductive Life Planning Practices and Information; and (2) Reproductive Life Planning Influences. For the Marshallese maternal healthcare providers, two themes emerged: (1) Reproductive Life Planning Practices; and (2) Reproductive Life Planning Influences. This is the first study to document Marshallese mothers' and maternal healthcare providers' practices and influences with contraceptive use and reproductive life planning. Study results will inform the development of a culturally-adapted contraception and reproductive life planning tool with an educational program for Marshallese family units and maternal healthcare providers serving Marshallese women.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare.

BACKGROUND: Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN: We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS: Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. CONCLUSION: We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Maternal Warning Signs Education During Home Visiting: Results from a Formative Evaluation in Maryland.

Background: Maternal mortality rate reviews have identified the need for improved patient education regarding the warning signs of maternal complications to reduce preventable deaths. Maternal and child home visiting programs have the potential to deliver this education in communities. Aims: This study sought to evaluate the baseline provision of warning signs education among home visiting programs in Maryland and to assess the acceptability of and preferences for warning signs education materials among program staff. Materials and Methods: This sequential exploratory, mixed-methods study included qualitative interviews and focus group discussions followed by a web-based survey of all home visiting programs providing early postpartum visits in Maryland. Results: Twenty-five home visiting program staff took part in qualitative data collection, and survey responses were submitted by a manager from 40 of 58 eligible home visiting programs (69% response rate). All survey respondents agreed that home visiting programs should provide warning signs education and more than 80% of programs provided some warning signs education during pregnancy and the postpartum period. Printed pamphlets were provided by 68% of programs for pregnancy complications and 43% for postpartum complications. Only 33% of respondents were satisfied with their existing warnings signs education materials; 98% were interested in new illustrated pamphlets and 88% were interested in education videos. Qualitative participants considered pamphlets with simple designs, limited text, and visuals, as the most accessible for home visiting clients. Conclusions: There are opportunities to strengthen and expand warning signs education in Maryland through home visiting programs using new printed and video education materials.

Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland.

OBJECTIVE: To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates. METHODS: This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance. RESULTS: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle. CONCLUSION: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh.

BACKGROUND: Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016. METHODS: This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance. RESULTS: At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens. CONCLUSIONS: Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Caregiver acceptability of the guidelines for managing young infants with possible serious bacterial infections (PSBI) in primary care facilities in rural Bangladesh.

INTRODUCTION: Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016). METHODS: We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines. RESULTS: Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses. CONCLUSION: Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.

Factors that influence the scale up of new interventions in low-income settings: a qualitative case study of the introduction of chlorhexidine cleansing of the umbilical cord in Bangladesh.

There is a well-recognized need for empirical study of processes and factors that influence scale up of evidence-based interventions in low-income countries to address the 'know-do' gap. We undertook a qualitative case study of the scale up of chlorhexidine cleansing of the umbilical cord (CHX) in Bangladesh to identify and compare facilitators and barriers for the institutionalization and expansion stages of scale up. Data collection and analysis for this case study were informed by the Consolidated Framework for Implementation Research (CFIR) and the WHO/ExpandNet model of scale up. At the national level, we interviewed 20 stakeholders involved in CHX policy or implementation. At the district level, we conducted interviews with 31 facility-based healthcare providers in five districts and focus group discussions (FGDs) with eight community-based providers and eight programme managers. At the community level, we conducted 7 FGDs with 53 mothers who had a baby within the past year. Expanded interview notes were thematically coded and analysed following an adapted Framework approach. National stakeholders identified external policy and incentives, and the engagement of stakeholders in policy development through the National Technical Working Committee for Newborn Health, as key facilitators for policy and health systems changes. Stakeholders, providers and families perceived the intervention to be simple, safe and effective, and more consistent with family preferences than the prior policy of dry cord care. The major barriers that delayed or decreased the public health impact of the scale up of CHX in Bangladesh's public health system related to commodity production, procurement and distribution. Bangladesh's experience scaling up CHX suggests that scale up should involve early needs assessments and planning for institutionalizing new drugs and commodities into the supply chain. While the five CFIR domains were useful for categorizing barriers and facilitators, additional constructs are needed for common health systems barriers in low-income settings.

Implementation research to support Bangladesh Ministry of Health and Family Welfare to implement its national guidelines for management of infections in young infants in two rural districts.

BACKGROUND: World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country. IMPLEMENTATION SUPPORT: Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures. METHODS: We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590. DISCUSSION: This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.

Implementation outcomes of the national scale up of chlorhexidine cord cleansing in Bangladesh's public health system.

BACKGROUND: Chlorhexidine (CHX) cleansing of the umbilical cord stump is an evidence-based intervention that reduces newborn infections and is recommended for high-mortality settings. Bangladesh is one of the first countries to adopt and scale up CHX nationally. This study evaluates the implementation outcomes for the CHX scale up in Bangladesh and identifies and describes key milestones and processes for the scale up. METHODS: We adapted the RE-AIM framework for this study, incorporating the WHO/ExpandNet model of Scale Up. Adoption and incorporation milestones were assessed through program documents and interviews with national stakeholders (n = 25). Provider training records served as a measure of reach. Implementation was assessed through a survey of readiness to provide CHX at public facilities (n = 4479) and routine data on the proportion of all live births at public facilities (n = 813 607) that received CHX from December 2016 to November 2017. Six rounds of a rolling household survey with recently-delivered women in four districts (n = 6000 to 8000 per round) measured the effectiveness and maintenance of the scale up in increasing population-level coverage of CHX in those districts. RESULTS: More than 80 000 providers, supervisors, and managers across all 64 districts received a half-day training on CHX and essential newborn care between July 2015 and September 2016. Seventy-four percent of facilities had at least 70% of maternal and newborn health providers with CHX training, while only 46% had CHX in stock on the day of the assessment. The provision of CHX to newborns delivered at facilities steadily increased from 15 059 newborns (24%) in December 2016 to 71 704 (72%) in November 2017. In the final household survey of four districts, 33% of newborns were reported to receive CHX, and babies delivered at public facilities had 5.04 times greater odds (95% CI = 4.45, 5.72) of receiving CHX than those delivered at home. CONCLUSIONS: The scale up of CHX in Bangladesh achieved sustained national implementation in public health facilities. Institutionalization barriers, such as changes to supply logistics systems, had to be addressed before expansion was achieved. For greater public health impact, implementation must reach deliveries that take place at home and in the private sector.