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Putting Women at the Center of Care

By the SPARQ Team

Expectations of poor-quality care deter women from accessing facility-based sexual and reproductive healthcare (SRH), putting them at risk of avoidable health complications. While safety and efficacy of treatment are paramount, the way that women experience care is equally important and will dictate whether and how SRH services are accessed in the future.

Improving person-centered care is an effective strategy to ensure that women receive dignified and individualized care when seeking SRH services. Person-centered care (PCC) places the woman at the center of her care, adapting to her individual circumstances, desires, and needs. PCC advocates for autonomy in decision-making, consented and informed care, respectful and dignified interactions with patients, the right to privacy and confidentiality, and services that are free of abuse or discrimination.  

This document summarizes strategies that have been demonstrated to improve the quality of PCC in family planning and maternity services in level 3, 4 and 5 hospitals in Nairobi and Kiambu counties in Kenya. The successful interventions described below can act as a roadmap for public facilities and their staff who seek to improve the way that women experience care in similar services.

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Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making.

By Vesel L, Nimako K, Jones RM, Munson M, Little S, Njogu H, Njuru I, Ogolla T, Kimenju G, Wegner MN, Rajasekharan S, Pearson N, Langer A.

Perinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.

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Expanding Access to Depression Treatment in Kenya Through Automated Psychological Support: Protocol for a Single-Case Experimental Design Pilot Study.

By Green EP, Pearson N, Rajasekharan S, Rauws M, Joerin A, Kwobah E, Musyimi C, Bhat C, Jones RM, Lai Y.

Task-sharing models such as the Thinking Healthy Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment for depression during pregnancy and in the postpartum period in low-resource settings, but there are significant barriers to scale-up.

This pilot study tests the ability of Healthy Moms, an intervention adapting Thinking Healthy for automated delivery via a mobile phone in conjunction with the artificial intelligence system Tess, to address this gap in assessing Healthy Moms’ perinatal depression intervention using a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya.

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Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya.

McConnell M, Rothschild CW, Ettenger A, Muigai F, Cohen J.

Short birth intervals are a major risk factor for poor maternal and newborn outcomes. Utilisation of modern contraceptive methods during the postpartum period can reduce risky birth intervals but contraceptive coverage during this critical period remains low.

We conducted a randomised controlled experiment to test whether vouchers for free contraception, provided with and without behavioural ‘nudges’, could increase modern contraceptive use in the postpartum period.

Key takeaway: Reducing financial barriers to postpartum contraception alone may not be enough to encourage take-up. Programmes targeting the postpartum period should consider addressing behavioural barriers to take-up.

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Providing support to pregnant women and new mothers through moderated WhatsApp groups: a feasibility study.

Patel SJ, Subbiah S, Jones R, Muigai F, Rothschild CW, Omwodo L, Ogolla T, Kimenju G, Pearson N, Meadows A, Nour NM

Group-based health services can improve maternal and newborn health outcomes. Group antenatal care and participatory learning and action cycles (PLA) with women's groups have been cited by the WHO as health systems interventions that can lead to improvements in adherence to care and health outcomes in pregnancy and the postpartum period.

We used a mixed-methods approach to assess the feasibility of a light touch group-based support intervention using the WhatsApp text-messaging platform. 

Key takeaway: A moderated mobile-based support group service for pregnant women and new mothers is safe and feasible. Additional research using experimental designs to strengthen evidence of the effectiveness of the support intervention is warranted.

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INTERGROWTH-21st Gestational Dating and Fetal and Newborn Growth Standards in Peri-Urban Nairobi, Kenya: Quasi-Experimental Implementation Study Protocol

Millar K, Patel S, Munson M, Vesel L, Subbiah S, Jones RM, Little S, Papageorghiou AT, Villar J, Wegner MN, Pearson N, Muigai F, Ongeti C, Langer A

The burden of preterm birth, fetal growth impairment, and associated neonatal deaths disproportionately falls on low- and middle-income countries where modern obstetric tools are not available to date pregnancies and monitor fetal growth accurately. The INTERGROWTH-21st gestational dating, fetal growth monitoring, and newborn size at birth standards make this possible.

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Using Value Stream Mapping to improve quality of care in low-resource facility settings

Ramaswamy R, Rothschild C, Alabi F, Wachira E, Muigai F, Pearson N

Value Stream Mapping, a Lean Management tool, was used to engage staff in prioritizing opportunities to improve clinical outcomes and patient-centered quality of care.

Implementation was accomplished through a five-step process: (i) leadership engagement and commitment; (ii) staff training; (iii) team formation; (iv) process walkthrough; and (v) construction and validation.

The Value Stream Map allowed the organization to come together and develop an end-to-end view of the process of care at JH and to select improvement opportunities for the entire system.

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Do active patients seek higher quality prenatal care?: A panel data analysis from Nairobi, Kenya.

Cohen J, Golub G, Kruk ME, McConnell M

We use a unique panel dataset from 2015 in which 402 pregnant women from peri-urban (the "slums" of) Nairobi, Kenya were interviewed three times over the course of their pregnancy and delivery, allowing us to follow women's care decisions and their perceptions of the quality of care they received. We define active antenatal care (ANC) patients as those women who switch ANC providers and explore the prevalence, characteristics and care-seeking behavior of these patients. We analyze whether active ANC patients appear to be seeking out higher quality facilities and whether they are more satisfied with their care. Women in our sample visit over 150 different public and private ANC facilities.

Key findings:

  • Active patients are more educated and more likely to have high risk pregnancies, but have otherwise similar characteristics to non-active patients.

  • Active patients are increasingly likely to pay for private care (despite public care being free) and to receive a higher quality of care over the course of their pregnancy.

  • Active patients appear more satisfied with their care over the course of pregnancy.

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Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya

McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J

Since the 2009 WHO and UNICEF recommendation that women receive home-based postnatal care within the first three days after birth, a growing number of low-income countries have explored integrating postnatal home visit interventions into their maternal and newborn health strategies.

This randomized trial evaluates a pilot program in which community health workers (CHWs) visit or call new mothers three days after delivery in peri-urban Kiambu County, Kenya.

Key takeaways:

  • CHW-administered postnatal checklists can lead to better recognition of postnatal problems and more timely care-seeking.

  • CHWs can affordably deliver many of the benefits of postnatal checklists.