Improving Care Beyond Birth: A Qualitative Study of Postpartum Care After High-Risk Pregnancy.

Background: The postpartum period is a window to engage birthing people in their long-term health and facilitate connections to comprehensive care. However, postpartum systems often fail to transition high-risk patients from obstetric to primary care. Exploring patient experiences can be helpful for optimizing systems of postpartum care. Methods: This is a qualitative study of high-risk pregnant and postpartum individuals. We conducted in-depth interviews with 20 high-risk pregnant or postpartum people. Interviews explored personal experiences of postpartum care planning, coordination of care between providers, and patients' perception of ideal care transitions. We performed thematic analysis using the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change as a framework. COM-B allowed for a formal structure to assess participants' ability to access postpartum care and primary care reengagement after delivery. Results: Participants universally identified difficulty accessing primary care in the postpartum period, with the most frequently reported barriers being lack of knowledge and supportive environments. Insufficient preparation, inadequate prenatal counseling, and lack of standardized care transitions were the most significant barriers to primary care reengagement. Participants who most successfully engaged in primary care had postpartum care plans, coordination between obstetric and primary care, and access to material resources. Conclusions: High-risk postpartum individuals do not receive effective counseling on the importance of primary care engagement after delivery. System-level challenges and lack of care coordination also hinder access to primary care. Future interventions should include prenatal education on the benefits of primary care follow-up, structured postpartum planning, and system-level improvements in obstetric and primary care provider communication.

When a Toolkit Is Not Enough: A Review on What Is Needed to Promote the Use and Uptake of Immunization-Related Resources.

INTRODUCTION: Evidence-based resources, including toolkits, guidance, and capacity-building materials, are used by routine immunization programs to achieve critical global immunization targets. These resources can help spread information, change or improve behaviors, or build capacity based on the latest evidence and experience. Yet, practitioners have indicated that implementation of these resources can be challenging, limiting their uptake and use. It is important to identify factors that support the uptake and use of immunization-related resources to improve resource implementation and, thus, adherence to evidence-based practices. METHODS: A targeted narrative review and synthesis and key informant interviews were conducted to identify practice-based learning, including the characteristics and factors that promote uptake and use of immunization-related resources in low- and middle-income countries and practical strategies to evaluate existing resources and promote resource use. RESULTS: Fifteen characteristics or factors to consider when designing, choosing, or implementing a resource were identified through the narrative review and interviews. Characteristics of the resource associated with improved uptake and use include ease of use, value-added, effectiveness, and adaptability. Factors that may support resource implementation include training, buy-in, messaging and communication, human resources, funding, infrastructure, team culture, leadership support, data systems, political commitment, and partnerships. CONCLUSION: Toolkits and guidance play an important role in supporting the goals of routine immunization programs, but the development and dissemination of a resource are not sufficient to ensure its implementation. The findings reflect early work to identify the characteristics and factors needed to promote the uptake and use of immunization-related resources and can be considered a starting point for efforts to improve resource use and design resources to support implementation.

Cultural brokering in pregnancy care: A critical review.

People who speak languages other than English face structural barriers in accessing the US healthcare system. With a growing number of people living in countries other than their countries of birth, the impact of language and cultural differences between patients and care teams on quality care is global. Cultural brokering presents a unique opportunity to enhance communication and trust between patients and clinicians from different cultural backgrounds during pregnancy care-a critical window for engaging families in the healthcare system. This critical review aims to synthesize literature describing cultural brokering in pregnancy care. We searched keywords relating to cultural brokering, pregnancy, and language in PubMed, Embase, and CINAHL and traced references of screened articles. Our search identified 33 articles. We found that cultural brokering is not clearly defined in the current literature. Few of the articles provided information about language concordance between cultural brokers and patients or clinicians. No article described the impact of cultural brokering on health outcomes. Facilitators of cultural brokering included: interprofessional collaboration within the care team, feeling a family connection between the cultural broker and patients, and cultivating trust between the cultural broker and clinicians. Barriers to cultural brokering included: misunderstanding the responsibilities, difficulty maintaining personal boundaries, and limited availability and accessibility of cultural brokers. We propose cultural brokering as interactions that cover four key aims: (1) language support; (2) bridging cultural differences; (3) social support and advocacy; and (4) navigation of the healthcare system. Clinicians, researchers, and policymakers should develop consistent language around cultural brokering in pregnancy care and examine the impact of cultural brokers on health outcomes.

Defining re-implementation.

BACKGROUND: The first attempt to implement a new tool or practice does not always lead to the desired outcome. Re-implementation, which we define as the systematic process of reintroducing an intervention in the same environment, often with some degree of modification, offers another chance at implementation with the opportunity to address failures, modify, and ultimately achieve the desired outcomes. This article proposes a definition and taxonomy for re-implementation informed by case examples in the literature. MAIN BODY: We conducted a scoping review of the literature for cases that describe re-implementation in concept or practice. We used an iterative process to identify our search terms, pilot testing synonyms or phrases related to re-implementation. We searched PubMed and CINAHL, including articles that described implementing an intervention in the same environment where it had already been implemented. We excluded articles that were policy-focused or described incremental changes as part of a rapid learning cycle, efforts to spread, or a stalled implementation. We assessed for commonalities among cases and conducted a thematic analysis on the circumstance in which re-implementation occurred. A total of 15 articles representing 11 distinct cases met our inclusion criteria. We identified three types of circumstances where re-implementation occurs: (1) failed implementation, where the intervention is appropriate, but the implementation process is ineffective, failing to result in the intended changes; (2) flawed intervention, where modifications to the intervention itself are required either because the tool or process is ineffective or requires tailoring to the needs and/or context of the setting where it is used; and (3) unsustained intervention, where the initially successful implementation of an intervention fails to be sustained. These three circumstances often co-exist; however, there are unique considerations and strategies for each type that can be applied to re-implementation. CONCLUSIONS: Re-implementation occurs in implementation practice but has not been consistently labeled or described in the literature. Defining and describing re-implementation offers a framework for implementation practitioners embarking on a re-implementation effort and a starting point for further research to bridge the gap between practice and science into this unexplored part of implementation.

Barriers and facilitators to use of a digital clinical decision support tool: a cohort study combining clickstream and survey data.

OBJECTIVES: This research aimed to understand the barriers and facilitators clinicians face in using a digital clinical decision support tool-UpToDate-around the globe. DESIGN: We used a mixed-methods cohort study design that enrolled 1681 clinicians (physicians, surgeons or physician assistants) who applied for free access to UpToDate through our established donation programme during a 9-week study enrolment period. Eligibility included working outside of the USA for a limited-resource public or non-profit health facility, serving vulnerable populations, having at least intermittent internet access, completing the application in English; and not being otherwise able to afford the subscription. INTERVENTION: After consenting to study participation, clinicians received a 1-year subscription to UpToDate. They completed a series of surveys over the year, and we collected clickstream data tracking their use of the tool. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) The variation in use by demographic; (2) the prevalence of barriers and facilitators of use; and (3) the relationship between barriers, facilitators and use. RESULTS: Of 1681 study enrollees, 69% were men and 71% were between 25 and 35 years old, with the plurality practicing general medicine and the majority in sub-Saharan Africa or Southeast Asia. Of the 11 barriers we assessed, fitting the tool into the workflow was a statistically significant barrier, making clinicians 50% less likely to use it. Of the 10 facilitators we assessed, a supportive professional context and utility were significant drivers of use. CONCLUSIONS: There are several clear barriers and facilitators to promoting the use of digital clinical decision support tools in practice. We recommend tools like UpToDate be implemented with complementary services. These include generating a supportive professional context, helping clinicians realise the tools' use and working with health systems to better integrate digital, clinical decision support tools into workflows.

Segmenting Clinicians' Usage Patterns of a Digital Health Tool in Resource-Limited Settings: Clickstream Data Analysis and Survey Study.

BACKGROUND: Evidence-based digital health tools allow clinicians to keep up with the expanding medical literature and provide safer and more accurate care. Understanding users' online behavior in low-resource settings can inform programs that encourage the use of such tools. Our program collaborates with digital tool providers, including UpToDate, to facilitate free subscriptions for clinicians serving in low-resource settings globally. OBJECTIVE: We aimed to define segments of clinicians based on their usage patterns of UpToDate, describe the demographics of those segments, and relate the segments to self-reported professional climate measures. METHODS: We collected 12 months of clickstream data (a record of users' clicks within the tool) as well as repeated surveys. We calculated the total number of sessions, time spent online, type of activity (navigating, reading, or account management), calendar period of use, percentage of days active online, and minutes of use per active day. We defined behavioral segments based on the distributions of these statistics and related them to survey data. RESULTS: We enrolled 1681 clinicians from 75 countries over a 9-week period. We based the following five behavioral segments on the length and intensity of use: short-term, light users (420/1681, 25%); short-term, heavy users (252/1681, 15%); long-term, heavy users (403/1681, 24%); long-term, light users (370/1681, 22%); and never-users (252/1681, 15%). Users spent a median of 5 hours using the tool over the year. On days when users logged on, they spent a median of 4.4 minutes online and an average of 71% of their time reading medical content as opposed to navigating or managing their account. Over half (773/1432, 54%) of the users actively used the tool for 48 weeks or more during the 52-week study period. The distribution of segments varied by age, with lighter and less use among those aged 35 years or older compared to that among younger users. The speciality of medicine had the heaviest use, and emergency medicine had the lightest use. Segments varied strongly by geographic region. As for professional climate, most respondents (1429/1681, 85%) reported that clinicians in their area would view the use of a online tool positively, and compared to those who reported other views, these respondents were less likely to be never-users (286/1681, 17% vs 387/1681, 23%) and more likely to be long-term users (655/1681, 39% vs 370/1681, 22%). CONCLUSIONS: We believe that these behavioral segments can help inform the implementation of digital health tools, identify users who may need assistance, tailor training and messaging for users, and support research on digital health efforts. Methods for combining clickstream data with demographic and survey data have the potential to inform global health implementation. Our forthcoming analysis will use these methods to better elucidate what drives digital health tool use.

Estimating maternity ward birth attendant time use in India: a microcosting study.

OBJECTIVES: Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice. SETTING: We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care. PARTICIPANTS: We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist. RESULTS: When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour. CONCLUSIONS: We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant's time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time. TRIAL REGISTRATION NUMBER: NCT02148952.

COVID-19 Vaccine To Vaccination: Why Leaders Must Invest In Delivery Strategies Now.

Worldwide, leaders are implementing nonpharmaceutical interventions to slow transmission of the novel coronavirus while pursuing vaccines that confer immunity to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. In this article we describe lessons learned from past pandemics and vaccine campaigns about the path to successful vaccine delivery. The historical record suggests that to have a widely immunized population, leaders must invest in evidence-based vaccine delivery strategies that generate demand, allocate and distribute vaccines, and verify coverage. To generate demand, there must be an understanding of the roots of vaccine hesitancy, involvement of trusted sources of authority in advocacy for vaccination, and commitment to longitudinal engagement with communities. To allocate vaccines, qualified organizations and expert coalitions must be allowed to determine evidence-based vaccination approaches and generate the political will to ensure the cooperation of local and national governments. To distribute vaccines, the people and organizations with expertise in manufacturing, supply chains, and last-mile distribution must be positioned to direct efforts. To verify vaccine coverage, vaccination tracking systems that are portable, interoperable, and secure must be identified. Lessons of past pandemics suggest that nations should invest in evidence-informed strategies to ensure that coronavirus disease 2019 (COVID-19) vaccines protect individuals, suppress transmission, and minimize disruption to health services and livelihoods.

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India.

BACKGROUND: Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality. METHODS: Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality. FINDINGS: Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality. INTERPRETATION: Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex. FUNDING: Bill & Melinda Gates Foundation. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Nurses' and auxiliary nurse midwives' adherence to essential birth practices with peer coaching in Uttar Pradesh, India: a secondary analysis of the BetterBirth trial.

BACKGROUND: The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants-nurses and auxiliary nurse midwives (ANMs)-during and after a peer coaching intervention for the WHO Safe Childbirth Checklist. METHODS: This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point). RESULTS: Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68). CONCLUSIONS: Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency. TRIAL REGISTRATION: ClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111-1131-5647.