Optimising the use of caesarean section: a generic formative research protocol for implementation preparation

BACKGROUND: Caesarean section rates are rising across all geographical regions. Very high rates for some groups of women co-occur with very low rates for others. Both extremes are associated with short and longer term harms. This is a major public health concern. Making the most effective use of caesarean section is a critical component of good quality, sustainable maternity care. In 2018, the World Health Organization published evidence-based recommendations on non-clinical interventions to reduce unnecessary caesarean section. The guideline identified critical research gaps and called for formative research to be conducted ahead of any interventional research to define locally relevant determinants of caesarean birth and factors that may affect implementation of multifaceted optimisation strategies. This generic formative research protocol is designed as a guide for contextual assessment and understanding for anyone planning to take action to optimise the use of caesarean section. METHODS: This formative protocol has three main components: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers and administrators. The document review and readiness assessment include tools for local mapping of policies, protocols, practices and organisation of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to twelve identified interventions that may optimise use of caesarean section. Each intervention is designed as a "module" and includes a description of the intervention, supporting evidence, theory of change, and in-depth interview/focus group discussion guides. All study instruments are included in this protocol. DISCUSSION: This generic protocol is designed to underpin the formative stage of implementation research relating to optimal use of caesarean section. We encourage researchers, policy-makers and ministries of health to adapt and adopt this design to their context, and share their findings as a catalyst for rapid uptake of what works

The communication and emotional support needs to improve women's experience of childbirth care in health facilities in Southwest Nigeria: A qualitative study

OBJECTIVE: To improve women's childbirth experiences in health facilities, their psychosocial and communication needs have to be met. However, what constitutes these specific needs is poorly understood, particularly in Sub-Saharan Africa. This paper explores women's needs for communication and emotional support during facility-based childbirth. METHODS: Qualitative research was conducted in a large referral maternity hospital and its catchment communities in Akure, Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted among women of reproductive age, midwives, doctors, and facility administrators. Thematic analysis was used to synthesize findings, and then interpreted within the context of this study and existing quality of care framework. RESULTS: Forty-two IDIs and 10 FGDs are included in this analysis. Participants reported such needs as communication in simple words in local language by healthcare staff, having their husbands as birth companions, spiritual support, and prayers from family members and healthcare providers. CONCLUSION: To increase, improve, and sustain facility-based childbirth in Nigeria, health systems should appreciate the uniqueness and importance of each woman's needs during childbirth. Practical and sustainable actions should be taken to meet these needs, within the confines of the acceptable sociocultural norms

A service concept and tools to improve maternal and newborn health in Nigeria and Uganda

OBJECTIVE: The "Better Outcomes in Labor Difficulty" (BOLD) project used a service design process to design a set of tools to improve quality of care during childbirth by strengthening linkages between communities and health facilities in Nigeria and Uganda. This paper describes the Passport to Safer Birth concept and the tools developed as a result. METHODS: Service design methods were used to identify facilitators and barriers to quality care, and to develop human-centered solutions. The service design process had three phases: Research for Design, Concept Design, and Detail Design, undertaken in eight hospitals and catchment communities. RESULTS: The service concept "Better Beginnings" comprises three tools. The "Pregnancy Purse" provides educational information to women throughout pregnancy. The "Birth Board" is a visual communication tool that presents the labor and childbirth process. The "Family Pass" is a set of wearable passes for the woman and her supporter to facilitate communication of care preferences. CONCLUSION: The Better Beginnings service concept and tools form the basis for the promotion of access to information and knowledge acquisition, and could improve communication between the healthcare provider, the woman, and her family during childbirth

Using a service design model to develop the “Passport to Safer Birth” in Nigeria and Uganda

OBJECTIVE: To demonstrate how a human-centered service design approach can generate practical tools for good-quality childbirth care in low-resource settings. METHODS: As part of the WHO "Better Outcomes in Labour Difficulty" (BOLD) project, a service design approach was used in eight Ugandan and Nigerian health facilities and communities to develop the "Passport to Safer Birth." There are three phases: Research for Design, Concept Design, and Detail Design. These generated design principles, design archetype personas, and Passport prototypes. Data collection methods included desk research, interviews, group discussions, and journey mapping to identify touchpoints where the woman interacts with the health system. RESULTS: A total of 90 interviews, 12 observation hours, and 15 group discussions were undertaken. The resulting design principles were: a shared and deeper understanding of pregnancy and childbirth among family and community; family readiness for decision-making and action; and the woman's sense of being in control and being cared for. Four archetype personas of women emerged: Vulnerable; Passive; Empowered; Accepter. Subsequent development of the Passport to Safer Birth tools addressed three domains: Care Mediator; Expectation Manager; and Pregnancy Assistant. CONCLUSION: The service design approach can create innovative, human-centered service solutions to improve maternity care experiences and outcomes in low-resource settings

Negotiating quality standards for effective delivery of labor and childbirth care in Nigeria and Uganda

OBJECTIVE: "Negotiated standards" describe a level of quality of care that is acceptable and achievable within a specific health system, based on consensus between key stakeholders. This paper presents the development of negotiated standards for effective labor and childbirth care in selected hospitals and communities in Nigeria and Uganda. METHODS: A four-step development process involving different methodologies. The process included: (1) review and synthesis of internationally recognized intrapartum clinical principles and practices; (2) primary qualitative research to assess values and preferences of women and healthcare providers, and practices that align with these preferences; (3) draft contextualization of effective and ineffective behaviors to reflect values and preferences; and (4) WHO-mediated negotiations between relevant stakeholders, including community members, providers, and administrators. RESULTS: The primary outcomes of this process were a comprehensive set of effective behaviors and clinical practices covering the main domains of quality of care, which are practical and easy to communicate, implement, and audit across all levels of healthcare delivery. CONCLUSION: The process demonstrates that health facilities and providers can be motivated to adopt standards of care that uphold the values and preferences of both service users and providers, while adhering to international best practices