Date Published: March 8, 2019
Publisher: Public Library of Science
Author(s): Linda Vesel, Kojo Nimako, Rachel M. Jones, Meghan Munson, Sarah Little, Henry Njogu, Irene Njuru, Teresa Ogolla, Grace Kimenju, Mary Nell Wegner, Sathyanath Rajasekharan, Nicholas Pearson, Ana Langer, Christine E East.
Perinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.
The study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making.
Facility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement.
The findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.
Despite progress made in reducing maternal and newborn mortality, large gaps remain. Currently, 2.6 million neonates die yearly worldwide, most from preventable causes . Fetal growth restriction, small-for-gestational age (SGA) and preterm birth (<37 weeks of gestation) are major risk factors for unfavorable fetal and neonatal outcomes; preterm birth complications remain the leading cause of death in the first month of life [2–5]. Many of these deaths can be prevented through quality antenatal and delivery care, namely the identification and management of high-risk pregnancies and births. Key components of this care include the use of standard ultrasound algorithms to date pregnancies and monitor fetal growth, newborn anthropometry to assess size at birth, the support of a trained workforce for early identification of complications and timely referral for advanced care [3, 6, 7]. Ultrasound guided assessment, used in combination with an indication of the last menstrual period (LMP), is the gold standard measurement for gestational age early in pregnancy; it has been shown to increase the accuracy of pregnancy dating and, consequently, influence outcomes [5, 8, 9]. Newborn anthropometry, based on an international standard of optimal growth, is instrumental in identifying SGA and low birth weight newborns (<2.5kg) and referring them for advanced care . However, utilization of growth standards requires supply and demand side inputs including training of staff, procurement of equipment, changes in community perceptions for care-seeking and early presentation for antenatal care (ANC) in the case of ultrasound standards . The feasibility and acceptability of implementing the INTERGROWTH-21st standards at Jacaranda Health were assessed through the examination of two broad dimensions: (1) facility-level support to introduce and integrate the standards into practice; and (2) use and integration of the standards to influence uptake of ultrasound and newborn size at birth standards, and clinical decision-making around pregnancy and delivery care. Facility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. Training and job aids were instrumental in the introduction and reinforcement of the standards. A literature review of clinical guideline implementation in a number of low resource settings also highlights the importance of introducing checklists and other job aids and making context-specific adjustments to foster integration . In their paper introducing the rationale of the INTERGROWTH-21st standards, Uauy and colleagues  stress the importance of training health providers and adapting clinical practices to facilitate successful implementation of the standards. Lack of or inadequate training on the provision of ultrasounds was discussed in a number of studies in low-and-middle income countries as one of the biggest challenges to the uptake of obstetric ultrasounds [9, 22–24]. Finding time for such training was a facility-level barrier experienced at Jacaranda Health as well as in other low resource settings; this was particularly difficult without disturbing clinical scheduling and interfering with the routine delivery of care while managing staff retention [22, 23]. This implementation study is timely as the INTERGROWTH-21st standards are being adopted in a number of countries around the world and are proving to be an instrumental tool for the improvement of the quality of routine maternal and perinatal care and emergency situations that affect pregnancy and perinatal outcomes, such as the zika epidemic . The standards integrate well with other aspects of ANC as recommended by the WHO and align with the WHO child growth standards . Additionally, 75% of the currently available ultrasound machines now have INTERGROWTH-21st standards built into them, thus making it more feasible to implement the standards on a larger scale. We hope that providers’ experiences and insights will be beneficial to facility managers who are considering, preparing for or in the process of implementing the INTERGROWTH-21st standards or other similar clinical initiatives. This paper highlights the need to engage health providers in understanding and addressing their needs; the time and resource investment required for training and capacity building; the flexibility and monitoring necessary to facilitate adaptations to clinical flow; and the recognition that changes in clinical practice take time, especially when they deviate greatly from existing care. More research is needed to evaluate the financial, political and health implications of introducing routine gestational dating in low resource settings and community-based approaches to increase demand for early initiation of ANC. Source: http://doi.org/10.1371/journal.pone.0213388