Implementation strategies for supporting maternal and perinatal death surveillance and response (MPDSR)

PROJECT SUMMARY/ ABSTRACT The AMANI (Accelerating Maternal And Newborn survIval) study aims to address persistently high rates of maternal and neonatal mortality in Kenya by improving maternal and infant death auditing and response. Maternal and Perinatal Death Surveillance and Response (MPDSR) is a structured quality improvement (QI) process for health workers to identify, report, review, and respond to maternal and/or perinatal deaths at a facility level. The WHO developed MPDSR global technical guidelines and they were adopted by the Kenyan government as national policy nearly a decade ago. However, MPDSR is rarely conducted with fidelity, in part due to lack of health worker clarity about MPDSR steps, lack of familiarity with QI including how to identify concrete response actions, and cultures of blame surrounding maternal or perinatal deaths. The AMANI study builds on our team’s prior research identifying critical issues contributing to neonatal deaths during facility delivery and identifying factors influencing guideline adherence. Through structured interrogation of these findings with Kenyan policy makers and health workers, we co-developed a multi-component practice facilitation package that includes audit and feedback (AF) and enhanced mentorship (EM). We will conduct a cluster randomized trial across 20 health facilities to test the practice facilitation package using the RE-AIM framework. In Aim 1, we assess participation in practice facilitation components in intervention facilities (Reach) and evaluate the effectiveness of the AMANI intervention on maternal and perinatal mortality, adoption of MPDSR following a maternal or perinatal death, and implementation of MPDSR with partial or full fidelity (primary outcome). We will also identify determinants of implementation fidelity and track adaptations to MPDSR implementation. A 24-month implementation phase will be followed by a 12-month maintenance phase, during which no external practice facilitation will take place. We will evaluate if the strategy has an enduring impact on fidelity during the maintenance phase. We will also track if AF and EM activities continue to be implemented in intervention facilities. In Aim 2 we will investigate the primary mechanisms through which the practice facilitation package influences MPDSR implementation fidelity. Leveraging the Information-Motivation-Behavioral skills (IMB) model, the study team will conduct mediation analyses to determine if the strategy activates hypothesized mechanisms of provider knowledge, social support, attitudes, and self-efficacy. Other mechanisms investigated include psychological safety and provider burnout. By leveraging routine data sources and political support, this study has the potential to dramatically influence progress towards achieving Sustainable Development Goals 3.1 and 3.2 by improving the implementation of the WHO-endorsed MPDSR tool. Moreover, it contributes to the collaborative testing of a pragmatic strategy to enhance the adoption, integration, and sustainability of an evidence-based intervention, potentially reducing preventable deaths in high mortality settings.