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Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project
  1. Nehla Djellouli1,
  2. Sue Mann1,
  3. Bejoy Nambiar1,
  4. Paula Meireles2,
  5. Diana Miranda2,
  6. Henrique Barros2,
  7. Fadima Y Bocoum3,
  8. W Maurice E Yaméogo3,
  9. Clarisse Yaméogo3,
  10. Sylvie Belemkoabga3,
  11. Halima Tougri3,
  12. Abou Coulibaly3,
  13. Seni Kouanda3,
  14. Vernon Mochache4,
  15. Omar K Mwakusema4,
  16. Eunice Irungu4,
  17. Peter Gichangi4,
  18. Zione Dembo5,
  19. Angela Kadzakumanja5,
  20. Charles Vidonji Makwenda5,
  21. Judite Timóteo6,
  22. Misete G Cossa6,
  23. Malica de Melo6,
  24. Sally Griffin6,
  25. Nafissa B Osman7,
  26. Severiano Foia7,8,
  27. Emilomo Ogbe9,
  28. Els Duysburgh9,
  29. Tim Colbourn1
  1. 1 UCL Institute for Global Health, London, UK
  2. 2 Faculdade de Medicina, Universidade do Porto, Porto, Portugal
  3. 3 Institutde Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
  4. 4 International Centre for Reproductive Health—Kenya (ICRHK), Mombasa, Kenya
  5. 5 Parent and Child Health Initiative (PACHI), Lilongwe, Malawi
  6. 6 International Centre for Reproductive Health—Mozambique (ICRHM), Maputo, Mozambique
  7. 7 Faculdade de Medicina, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
  8. 8 Chiúta District Health Department, Tete, Mozambique
  9. 9 International Centre for Reproductive Health of the Ghent University (UG-ICRH), Ghent, Belgium
  1. Correspondence to Dr Tim Colbourn; t.colbourn{at}ucl.ac.uk

Abstract

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context–mechanism–outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by ‘bridging’ communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a ‘buzz’ for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs’ motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective.

  • maternal health
  • child health
  • health systems evaluation

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • Handling editor Seye Abimbola

  • Contributors ND was one of the evaluators; she coordinated and supervised data collection in all sites, designed the data analysis plan, led the qualitative data analysis and drafted the manuscript. SM was one of the evaluators; she designed the realist evaluation protocol, contributed to the qualitative data analysis and helped revise the paper, contributing intellectual content. BN was one of the evaluators; he contributed to evaluation design and analysis, and helped revise the paper, contributing intellectual content. PM coordinated the participatory evaluation workshops in all sites, contributed to the qualitative data analysis as part of the evaluation team and commented on earlier drafts. DM and HB contributed to the qualitative data analysis as part of the evaluation team. FYB, WMEY, CY and SB conducted the qualitative fieldwork in Burkina Faso. HT was involved in the implementation of the MOMI interventions in Burkina Faso, collected quantitative data and commented on earlier drafts. AC was involved in the implementation of the MOMI interventions in Burkina Faso and collected quantitative data. SK coordinated the MOMI research at the Burkina Faso study site and the quantitative monitoring at all four sites. VM and OKM conducted the qualitative fieldwork in Kenya. VM was also involved in the implementation of the MOMI interventions in Kenya. EI was involved in the implementation of the MOMI interventions in Kenya and contributed to the interpretation of the results during stakeholder workshops. PG coordinated the MOMI research at the Kenya study site and contributed to the interpretation of the results during stakeholder workshops. ZD and AK conducted the qualitative fieldwork in Malawi. ZD was also involved in the implementation of the MOMI interventions in Malawi. CM coordinated the MOMI research at the Malawi study site and contributed to the interpretation of the results during stakeholder workshops. JT, MGC and MM conducted the qualitative fieldwork in Mozambique. MM was also involved in the implementation of the MOMI interventions in Mozambique. SG coordinated the MOMI research at the Mozambique study site and helped revising the paper. NBO coordinated the MOMI research at the Mozambique study site and commented on drafts of the paper. SF was involved in the implementation of the MOMI interventions in Mozambique and contributed to the interpretation of the results during stakeholder workshops. EO coordinated the MOMI consortium along with ED and contributed to the interpretation of the results during stakeholder workshops. ED was the overall MOMI consortium scientific coordinator and helped revising the paper. TC was one of the evaluators; he designed and led the quantitative component of the evaluation, contributed to evaluation design and analysis, and helped revise the paper, contributing intellectual content. All authors read and approved the final version of the manuscript.

  • Funding This paper is an output from the project ‘Missed Opportunities in Maternal and Infant health: reducing maternal and newborn mortality and morbidity in the year after childbirth through combined facility and community-based interventions—MOMI’. The research leading to these results has received funding from the European Community’s Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 265448. MOMI is a collaborative project between International Centre for Reproductive Health—Ghent University (Belgium), Institute de Recherche en Sciences de la Santé (Burkina Faso), International Centre for Reproductive Health (Kenya), Parent and Child Health Initiative Trust (Malawi), International Centre for Reproductive Health Mozambique, Eduardo Mondlane University (Mozambique), Medical Faculty of the University of Porto (Portugal) and University College London (UK).

  • Competing interests None declared.

  • Ethics approval Ethics Committee for Research in Health of Burkina Faso; the University of Nairobi/Kenyatta National Hospital ethical review committee (Kenya); the National Health Sciences Research Council (Malawi); the National Health Bioethics Council (Mozambique).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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