Toward communities as systems: asequential mixed methods study tounderstand factors enablingimplementation of a skilled birthattendance intervention in NampulaProvince, Mozambique

Posted by Share-Net Intl on August 15, 2018 at 3:10 pm



Skilled birth attendance, institutional deliveries, and provision of quality, respectful care are key
practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized
improved service delivery and demand for these practices, alongside humanization of the birth process.
An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional
delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual
factors that may have contributed to the observed increase in institutional deliveries.


A descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess
institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site
selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity
of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert
panels_each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels
were convened to formulate the story” of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding.


The two sitesskilled birth attendance coverage of estimated live births reached 80 and 100%, respectively.
Eight contextual and human factors were found as dominant themes. Though both sites achieved increases,
implementation context differed significantly with compelling examples of both respectful and disrespectful care. In
one site, facility and community actors worked together as complementary systems to sustain improved care and
institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely
in absence of health system counterparts.
(Continued on next page)


Findings support global health recommendations for combined health system and community
interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity
of communities to act as systems both in partnership to and independent of the formal health system.


Maternal health, Skilled birth attendance, Respectful care, Health system strengthening, Community
system strengthening, Context, Implementation, CFIR, Mozambique

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