Title: NIHR Global Health Research Group on Improving Quality of Maternal Healthcare in Africa
Funder: Department of Health and Social Care

Abstract: BACKGROUND: A majority of maternal deaths occur in Sub-Saharan Africa, and nearly all are preventable with good quality healthcare. Both Malawi and Zambia are committed to improve maternal and neonatal health outcomes, but are not making adequate progress._x000D_ This new programme of work will build upon the collaboration formed by the NIHR DIPLOMATIC research group._x000D_ _x000D_ AIM: Our aim is to improve maternal and neonatal health outcomes in Malawi and Zambia, by strengthening the quality of maternity care._x000D_ _x000D_ TEAM: Senior leadership of the group are all based in Malawi and Zambia. They will partner with other leading international researchers and methodologists, but a decision has been made to shift the locus of control to Malawi._x000D_ _x000D_ RESEARCH PLAN: The aim will be delivered through 4 themes:_x000D_ _x000D_ Theme 1. Data driving improvement_x000D_ High quality maternal and neonatal health data is key for quality improvement. We will provide real-time digital reporting of maternal deaths, near-miss cases, and quality of care data, accessible via online dashboards. This will be used to identify critical improvement needs and measure progress._x000D_ We will link facility and community data to understand the gaps in facility data._x000D_ _x000D_ Theme 2. Placing users at the centre of change_x000D_ We will use qualitative methods to understand the experience of users, in particular adolescents and women with mental health problems. Their narratives will identify how services can better support their needs and inform priority setting._x000D_ We will optimise a brief tool to measure maternity users’ experience and evaluate its use in practice._x000D_ _x000D_ Theme 3. Prioritisation and co-design_x000D_ Many changes to improve maternal health are identified at a facility level, yet the root causes span the whole system. We will conduct an annual maternal health needs prioritisation meeting, identifying and championing issues for sector wide focus._x000D_ To target prioritised issues we will train managers and practitioners in intervention design using the Behaviour Change Wheel methodology and support them in the co-design process._x000D_ _x000D_ Theme 4. Implementing and evaluating change_x000D_ Sites across Malawi and Zambia will implement behaviour change interventions and robustly evaluate the implementation process._x000D_ The first intervention has been prioritised. This will evaluate a package of “Enhanced Antenatal Care”, seeking to improve compliance with evidence based antenatal care._x000D_ We found identification of sexually transmitted infections is poor during antenatal care. We will address how services can be changed to improve this._x000D_ Behavioural change interventions will be developed by site teams and field tested in their facility. The most effective of these pilots will be selected for a multi-site roll-out and evaluation._x000D_ _x000D_ COMMUNITY ENGAGEMENT AND INVOLVEMENT (CEI): This is embedded across the work, with strong elements of user engagement and co-design throughout. A specific maternal and neonatal health CEI group will be established in Malawi and Zambia, and provided training. _x000D_ _x000D_ CAPACITY BUILDING: Plans include 3 PhD studentships and support for integrated MSc student projects. Ongoing research skills, policy engagement and management training will be provided at all levels of the team._x000D_ _x000D_ COMMUNICATING FOR IMPACT: In addition to high quality scientific outputs we are superbly positioned to communicate the work and maximise impact. We will support this with “policy and impact committees” and policy briefs.

Lay abstract: Our VISION is to reduce the numbers of women and babies dying unnecessarily during pregnancy and after birth, in Malawi and Zambia._x000D_ _x000D_ Around the world a woman dies in childbirth every 2 minutes. Nearly all these women are dying in poor countries. The world has recognised this tragic injustice, and committed through the SDG goals to reduce maternal mortality to a global average of less than 70 deaths per 100,000 births. Yet unfortunately, in both Malawi and Zambia, the rates are several times this high (349 per 100,000 births in Malawi and 213 per 100,000 births in Zambia) and urgent improvement is needed to accelerate progress towards this target. _x000D_ Similarly, reducing stillbirths and neonatal deaths is critically important, and very poor progress has been made in improving these outcomes. _x000D_ _x000D_ We have worked with partners across Malawi and Zambia to develop a coordinated programme of work, carefully co-designed to work towards this vision. This plan is based on the strategic input of users, health workers and government, and aligned with wider regional and international plans._x000D_ _x000D_ DATA DRIVING IMPROVEMENT: Harnessing the power of real time health data, including detailed reviews that take place after mothers have died or nearly-died due to complications during or after pregnancy. We will support use of this data to support improvements in health systems and quality of care._x000D_ _x000D_ PLACING PATIENTS AT THE CENTRE OF CHANGE: Better understand the needs and wishes of women and families to inform and guide quality improvement efforts._x000D_ _x000D_ PRIORITISE AND PLAN IMPROVEMENT: Use health data and user experience to prioritise and plan what areas should be the focus of actions, and help coordinate the needed actions across complicated health systems_x000D_ _x000D_ IMPLEMENT CHANGE: Carry out carefully planned activities to improve the care delivered to patients. These activities across many sites will target the barriers to good quality care to help the health care workers and health system function. We aim to help ensure that patients get the correct care every time they need it. We will measure how well these activities work in reality and see how we can improve in future. _x000D_ _x000D_ These activities recognise the challenges of improving quality in complex, resource limited health systems. The work involves users, providers and policy makers to bring about sustainable improvements in quality of care, and health outcomes._x000D_ _x000D_ Equity: We will ensure that the DIPLOMATIC collaboration is a strong example of an equitable partnership. The group is led from Malawi, with the senior leadership team all based in Africa. There are important opportunities for learning between Malawi and Zambia and meaningful and enriching collaborations with UK based researchers._x000D_ _x000D_ Capacity building: Throughout all these activities we will support developing the next generation of African research leaders including research degrees and research training and support. We will also be working with policy makers and health care managers and doctors, midwifes and paramedical staff to improve knowledge and skills on improving quality of care._x000D_ _x000D_ Communication: We will build on our strong existing relationships with policy makers to enable our research findings to inform policy. We will also work to communicate our work to the public in both the UK and Africa and other researchers to maximise the impact that the research will have to improve maternal and newborn health.

Research activity codes: 2.4 SURVEILLANCE AND DISTRIBUTION;7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH