Table 3 RMC related new ideas tested in the health facilities

New idea

(What?)

New Idea

(How?)

Women’s engagement: Enhancing the Pregnant Women Conference (PWC)

Enhance PWC by having open discussion with pregnant women about the continuum of care and challenges they face. Pregnant women are encouraged to ask questions and patients’ stories (near misses and complications) are heard. Such stories were obtained from the Maternal Death Surveillance and Response team. Women are requested to bring their antenatal care (ANC) appointment card. ANC lab tests were provided as appropriate by taking lab reagents and equipment to the PWC site.

Numbers of pregnant women who attended PWC and their feedback is documented. Facility head analyzes the data and feedback from women is shared with QI team weekly for decision making and as input in QI project design.

Content of messages during PWC were modified to include birth position preparedness, birth attendant preference, availability of lab investigation at no costs, opportunity for birth companion during labor and birth, efforts to maintain women’s privacy.

During monthly PWC, coffee ceremony is added as courtesy to women.

Reduce waiting time: Give priority to pregnant women in card room and lab.

Health center head will inform/orientate card room staff to give priority to ANC attendees, and during health education of ANC attendees, card room staff will withdraw all ANC cards first, reducing waiting time.

Setting a system to obtain pregnant women’s medical records in advance based on their appointment week (Some used 12 months labelled box to put mothers’ cards based on the appointment month while others used an Excel-based tracking system).

Staff orientation, especially to midwives, to send full lab investigations for all pregnant women with ‘ANC’ written on the top of lab request form. Lab technicians give priority and take samples first from ANC attendees once the form is received.

Reduce waiting time: Avail ANC drugs in ANC room

Discussion was made among QI team members, reaching consensus to make ANC drugs available in ANC room to eliminate pharmacy service point. Prescription is collected at the end of the day and given to pharmacy department for drug management.

Confidential care by dedicating separate ANC rooms

Dedicating separate rooms for ANC, family planning and post-natal care in facilities where it used to be provided in a single room.

^aBirth Companion: inform pregnant women about option of having a birth companion present during labor/birth

Midwives inform pregnant women of this service and encourage her to identify and inform a birth companion of her choice ahead of labor onset.

^aPresence of birth companion during labor and birth

The midwives allow laboring mothers to have a birth companion of their choice. Mothers were informed of this change idea during monthly PWCs and ANC visits. The identified birth companion is informed on her/his role ahead of time.

Making the facility clean and attractive

Cleaning the health facility, wards and birth couch. Creating attractive environment by making the compound green with signage for different service points.

Tour Labor and Birthing ward

During fourth ANC visit, tour of labor and birthing ward is organized to help women get familiar with setting before labor. During highest turnout of ANC attendees (usually on market day), head of facility and midwife in charge host a tour to labor and birthing ward for those on the fourth visit. This usually lasts for 10–20 min where questions and comments are addressed. Names and numbers of attendees are registered in a designated template.

Maternity waiting home (MWH)^a- Creating home like environment: cultural coffee ceremony, allowing prayers

During their stay pre-birth, they are looked after daily, vital signs checked and provision of structured lesson plans for health education. The health center provides supplies for coffee ceremony. Prayers and cultural celebrations allowed.

Organize community contribution to equip and supply MWH on a regular basis.

Growing cereals within health facility compound, used to support running costs for MWH.

^aUse screen during labor & birth process

Make bed screen available and use it during examination in labor ward.

Use clean screen in the labor room to provide privacy for women receiving care in birthing ward.

^aUse of reminder

Posting the SCC on the wall of the labor ward which prompts to check for danger signs, to wash hands and use gloves during exams, to encourage birth companion be present and maintain privacy during labor and birth.

Midwife in charge of birth room will make SCC available. When a laboring woman is admitted, the duty midwife files SCC in the women’s folder and uses SCC as a reminder of care to be given. As she gives care per SCC reminder, she ticks SCC to confirm care provision.

^aUse of Spot Checks to Reduce Variation

Daily retrospective monitoring of SCC use for every birth. Duty midwife reviews daily birth cards. She checks if SCC was used and discuss with the team areas for improvement.

Onsite coaching of duty midwife by Medical director and MNCH head. Medical director coaches nurse/midwife on the job once per week randomly to ensure SCCs are filled according to standards and existing scenario. They provide real-time feedback to nurse/midwives.

Postnatal care home-like environment: arrange coffee ceremony and provide porridge to women

It is customary to celebrate with coffee and eat porridge following birth. Hence, utensils and supplies for coffee ceremony and making porridge are provided to birth companion and other family members to celebrate together.

Transporting mothers and newborns back home by ambulance

Pregnant women in labor and newly delivered mothers with their newborns are transported back to their home by ambulance so that they are encouraged to give birth in health facilities for future births.