Table 4 Important lessons from the Umbi9 implementation study
Lesson | Implications for further scale-up |
|---|---|
1. Stakeholder involvement and continuous communication | • Ensure that all key stakeholders are engaged in the planning and rollout of the intervention, including the use of community platforms (e.g. community leaders, hospital groups, church groups, local support groups, MomConnect), pamphlets and radio • Assists with acceptance and better integration, especially in the early stages of implementation • Encourages and strengthens facility engagements and communication between management and facility staff |
2. Recruiting and screening at PHC clinic level | • Clinic healthcare providers feel empowered • Enhanced staff responsiveness to monitoring foetal growth and assessing for placental insufficiency • Heightened awareness of importance of recognizing pregnancy at risk – staff more inclined to consult with each other about patients with complications |
3. Integrating CWDU screening into routine work | • Staff should be trained and accept the intervention • Staffing, resources and arrangement of staff duties should be considered and reorganized • Daily screening is needed to ensure the coverage of all pregnant women • Outreach doctors could evaluate placental function at the clinic if pulsed-wave ultrasound is available at PHC clinics • Effective data collection and monitoring tools are essential to reduce the burden on staff and assist with swift adoption in the health system |
4. Training and learning when CWDU screening is introduced | • There is a fast learning curve, with nursing teams able to use the probe after a short period of training • Reassurance can be given that other staff would be able to use the Umbiflow™ device • Peer learning occurs through observation of others performing the examination • Onsite training allows for better learning • Greater staff awareness of antenatal and postpartum needs in the screened women is created |
5. Communication | • Continuous communication with the study and implementation teams allows for timeous solutions and planning of next steps • Virtual communication allows for real-time access to data and information and allows for troubleshooting issues to be solved timeously • Good rapport between the referring nurse and patients may contribute to better follow-up rates at the high-risk clinic – advanced midwives are familiar with antenatal care and medium and high-risk obstetric care and would be able to reassure women and help them prepare for the pregnancy journey and experience |
6. Site support visits | • Continuous stakeholder engagement is enabled • Data collection, data entry, recruiting and screening challenges can be addressed and timeous solutions can be found • Reassurance is given that implementation progresses as planned |
7. Referral after CWDU screening | • Improvement of the referral pathways and communication between the different levels of care could be facilitated • Available patient transport facilitates women’s attendance of the high-risk antenatal clinic • Open communication pathways, a functional referral system and transport assist screening and the further management of women identified with abnormal RIs • Outreach needs and possibilities should be considered • Continuum of care could be enhanced in urban areas with mobile populations by ensuring that pregnant women who move from one area to another or who ask to be referred to a different hospital receive a detailed referral letter (including the Doppler findings) to enable the next health team to manage these women appropriately |
8. Acceptance of patients at the referral hospitals | • Because referral hospitals see the importance of screening, acceptance of patients at the high-risk hospital clinics is perhaps not as big a factor as previously thought • Each referral hospital must establish a high-risk antenatal clinic for women with abnormal RIs, or reorganize ANC to incorporate women identified with abnormal RIs in the current high-risk clinic(s) at the hospital • Neonatal services should be prepared for challenges related to admissions of CWDU-screened neonates |
9. Robust and durable equipment | • Umbiflow™ equipment set could be moved daily from clinic to clinic – able to withstand a lot of handling and proved to be low on maintenance • Only two high-volume sites required replacement of the probe cord – new upgraded probes are cordless and allow for even better mobility and accessibility • The small thermal printers did not need any ink and did not require frequent paper changes |