Implementation of a three-pillar training intervention to improve maternal and neonatal healthcare in the Democratic Republic Of Congo: a process evaluation study in an urban health zone

ABSTRACT

Background

Numerous quality-improvement projects including healthcare professional training are conducted globally every year, but there is a gap between the knowledge obtained in the training and its implementation in practice and policy. A quality-improvement programme was conducted in eastern Democratic Republic of Congo (DRC) to reduce maternal and neonatal mortality and morbidity.

Objective

This study explores the implementation process, mechanisms of impact, and outcomes of a training intervention addressing labour and birth management and involving healthcare providers in an urban health zone in eastern part of DRC.

Methods

In 2019, master trainers were educated and in turn trained facilitators from seven participating healthcare facilities, which received the necessary equipment. Data comprised statistics on maternal and neonatal birth outcomes for the years before and after the training intervention, and focus group discussions (n = 18); and interviews (n = 2) with healthcare professionals, at the end of (n = 52) and after the training intervention (n = 59), respectively. The analysis was guided by a process evaluation framework, using descriptive statistics and content analysis.

Results

The three-pillar training intervention using a low-dose, high-frequency approach was successfully implemented in terms of fidelity, dose, adaptation, and reach. Several improved care routines were established, including improved planning, teamwork, and self-reflection skills, as well as improved awareness of the influence of the care environment, of having a respectful encounter, and of allowing a companion to be present with the birthing woman. The proportions of emergency caesareans decreased and of vaginal births increased without an increase in maternal and neonatal complications.

Conclusion

The findings of this study are encouraging and provide learnings for other healthcare facilities in DRC as well as other low-income countries. When designing similar training interventions, it is crucial to consider contextual factors such as incentives and to measure more salutogenic outcomes.

KEYWORDS:

• Healthcare providers
• maternal and newborn health
• Democratic Republic of Congo
• low-income countries
• implementation research

Responsible Editor

Maria Emmelin

Responsible Editor

Maria Emmelin

Acknowledgments

We would like to express our sincere appreciation to all the healthcare providers who participated in this study. We also want to thank Prof. Dr. Denis Mukwege, Susheela M. Engelbrecht at Jhpiego, Maria Hogenäs, Marthe Byamungu Makundane for their contribution, and the Statistical Consult Group for providing statistical assistance.

Authors’ contributions

MBo and MBe designed the study. SMN processed and finalised the ethical application, and informed and invited the healthcare facilities. FGDs and interviews were conducted by MBe on both occasions and together with MBo on the second occasion. MBe and MBo analysed the data and prepared the draft of the paper. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

The study was approved by the National Ethical Committee of Public Health: CNES 001/DPSKI/129PM/2019. All participants provided informed consent.

Paper context

As part of a quality-improvement programme in eastern DRC, intended to reduce maternal and neonatal mortality and morbidity, we explored the implementation of a three-pillar training intervention, guided by a framework for process evaluation. The study shows that using a low-dose, high-frequency approach and providing healthcare facilities with necessary equipment can improve care routines. The year after there were fewer emergency caesarean sections and more vaginal births.

Availability of data

The datasets used and/or analysed in this study are available from the corresponding author on reasonable request.

Additional information

Funding

This study was made possible through financial support from the Laerdal Foundation, the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, the Gothenburg Smyrna Church, and Sahlgrensringen. The funding bodies played no role in the data collection, the analysis, or in writing the manuscript.Laerdal Foundation ;Smyrna church;Sahlgrenska Akademin;