Stillbirth disproportionately affects those in low-resource settings, with 10-fold higher stillbirth rates in low-income countries compared to high-income countries. This disparity is due in part to gaps in health care delivery; even facilities that are equipped to provide comprehensive emergency obstetric and newborn care (CEmONC) often fail to deliver care quickly and effectively. A third of intrapartum stillbirths (those occurring after the onset of labor) could be prevented through improved labor and delivery management and use of interventions that are known to be efficacious (e.g. cesarean sections). The Every Newborn Action Plan (ENAP) has set a global target stillbirth rate of 12 per 1000 births by 2030. At Coast Provincial General Hospital (CPGH), a large CEmONC facility in Mombasa, Kenya, the intrapartum stillbirth rate is substantially higher than this target, at 21.2 per 1000 births. To address this problem, the Mombasa County Ministry of Health wishes to conduct an audit and feedback quality improvement project within the Labor and Delivery Ward of CPGH. In this proposal, our objectives are to identify factors associated with stillbirth at CPGH to inform the development of this project, and to evaluate the effectiveness of this intervention in reducing intrapartum stillbirth.
The aims of this proposal are: 1) to identify factors associated with intrapartum stillbirth that could be addressed by modifying provider behavior; 2) to conduct a pre-post study using interrupted time series analysis to determine if rates of stillbirth are reduced after implementation of an audit and feedback intervention; and 3) to determine the incremental cost and budget impact of the audit and feedback intervention. The proposed research will use quantitative and qualitative methods to assess change in both process indicators (e.g. time to cesarean section) and intrapartum stillbirth rates before and after the audit and feedback intervention. Demonstrating how effective the intervention is at both changing targeted provider behavior and reducing stillbirth rates is critical to determining its public health impact. Audit and feedback is a flexible approach that allows for context-specific factors to be considered and addressed. If found to be effective and low-cost, this approach could be expanded to other CEmONC facilities in sub-Saharan Africa as a cost-effective means of lowering stillbirth rates. To conduct this work, the candidate will receive training at the University of Washington, which is a world leader in implementation research. Her training plan will include field experience, coursework, supplementary training, and mentorship in implementation science, interrupted time series analysis, and cost analysis. The fellowship will also provide ample opportunities for the candidate to publish original research, present work at international conferences, develop a professional network, and gain experience with grant writing. This set of skills will put her on a path toward a career as an independent investigator.
There is an urgent need for action to reduce the global rate of stillbirths, particularly intrapartum stillbirths, which can be prevented through improved delivery of comprehensive obstetrical care. This study will assess the impact of an audit and feedback quality improvement intervention on process indicators of obstetrical care and rates of stillbirth at a large public hospital in Mombasa, Kenya. This research, which includes cost analysis to evaluate the budget impact of the intervention, could inform expansion of the audit and feedback approach to similar facilities in other low-resource settings with high rates of stillbirth.
