Wash hands? Check. Monitor heart rate? Check. Prepare essential supplies? Check. These might seem like obvious steps for medical professionals to take while delivering a child, but lapses remain one of the leading causes of preventable patient deaths in low- and middle-income countries, and initiatives aimed at addressing the problem are not working.
One such initiative focuses on creating a checklist for birth attendants to consult. But in a multiyear, multimillion-dollar randomised controlled trial in northern India in 2017, the use of the World Health Organisation’s Safe Childbirth Checklist, together with coaching on its implementation, did not improve outcomes for babies or their mothers.
Even if a childbirth checklist has some potential benefits, it amounts to an insufficient basis for efforts to address high infant and maternal mortality. Yet, as a report in British medical journal The Lancet shows, such micro-level interventions — including direct mentoring — constitute 72% of all strategies for improving the quality of primary care globally.
Although such micro-level interventions can help to improve commitment to quality, “people tend to revert to entrenched ways of doing things, especially when surrounding systems do not support transformation”. The focus on micro-level interventions alone can even be detrimental, as such measures consume limited time and resources.
To improve quality of care before, during and after childbirth, the global health community must develop new, evidence-backed interventions that address the underlying — often hidden — reasons healthcare providers fail to take the necessary steps. The first step is to identify what those reasons are.
One answer that can immediately be ruled out is that more training is all providers need. Survey data indicates that, in general, transferring relevant knowledge and skills to nurses and other healthcare providers is not enough. Even when more nurses become aware that they must monitor blood pressure or refer a complicated case to a better-equipped hospital, for example, they don’t always do it, or the effects do not last.
The imperative, then, is to explain the gap between providers’ knowledge and behaviour. That is what my colleagues and I have aimed to do in Uttar Pradesh, one of India’s poorest states, where mothers and newborns are 10 times more likely to die during or shortly after childbirth than in the United States.
After observing more than 20 clinics and conducting in-depth interviews with dozens of nurses and other staff, we developed several hypotheses to explain health professionals’ failure to take the necessary actions. We then tested those hypotheses using a series of novel decision-making games designed to elucidate the factors driving nurses’ choices.
The factors we identified fall into two categories: perceptual drivers (health workers’ fears, beliefs, motivations, biases and perceptions) and contextual drivers (demands from patients and their families, the attitudes of doctors, hospital infrastructure, and the processes). The two categories are closely interconnected.
Nurses in Uttar Pradesh, our research showed, have little support from the doctors with whom they work, but tend to be blamed — and punished — when something goes wrong.
Moreover, families do not always respect nurses, and often will resist a nurse’s recommendation to refer a woman to a bigger hospital.
As a result, nurses are under constant stress and live in fear of risks to themselves, which end up taking precedence over the risks faced by patients. Given this, many nurses focus on those tasks for which they are solely responsible, such as the delivery itself, while letting less acute tasks related to that process fall by the wayside.
The point is not to cast more blame on nurses; on the contrary, our research makes clear that nurses need better working conditions to do their jobs well. To this end, hospitals should offer supportive, rather than punitive, supervision. A culture of collaboration and team problem-solving should be fostered. Hospital managers should be held accountable for health outcomes. Efforts to manage patients and their families expectations of what to expect and how to interact with providers, would also help. What will not help is another checklist.
Of course, the main factors that drive healthcare providers’ decision-making are not exactly the same everywhere. More localised research is needed to enable people to tailor solutions to each context. But, by asking why health providers behave as they do, global health programmes can save millions of dollars — and many more lives. — © Project Syndicate
Sema Sgaier, an assistant professor at the Harvard TH Chan School of Public Health, is co-founder and executive director of the Surgo Foundation