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ObjectivesTo describe the feeding profile of low birthweight (LBW) infants in the first half of infancy; and to examine growth patterns and early risk factors of poor 6-month growth outcomes.DesignProspective observational cohort study.Setting and participantsStable, moderately LBW (1.50 to Variables of interestKey variables of interest included birth weight, LBW type (combination of preterm/term status and size-for-gestational age at birth), lactation practices and support, feeding profile, birthweight regain by 2 weeks of age and poor 6-month growth outcomes.ResultsBetween 13 September 2019 and 27 January 2021, 1114 infants were enrolled, comprising 4 LBW types. 363 (37.3%) infants initiated early breast feeding and 425 (43.8%) were exclusively breastfed to 6 months. 231 (22.3%) did not regain birthweight by 2 weeks; at 6 months, 280 (32.6%) were stunted, 222 (25.8%) underweight and 88 (10.2%) wasted. Preterm-small-for-gestational age (SGA) infants had 1.89 (95% CI 1.37 to 2.62) and 2.32 (95% CI 1.48 to 3.62) times greater risks of being stunted and underweight at 6 months compared with preterm-appropriate-for-gestational age (AGA) infants. Term-SGA infants had 2.33 (95% CI 1.77 to 3.08), 2.89 (95% CI 1.97 to 4.24) and 1.99 (95% CI 1.13 to 3.51) times higher risks of being stunted, underweight and wasted compared with preterm-AGA infants. Those not regaining their birthweight by 2 weeks had 1.51 (95% CI 1.23 to 1.85) and 1.55 (95% CI 1.21 to 1.99) times greater risks of being stunted and underweight compared with infants regaining.ConclusionLBW type, particularly SGA regardless of preterm or term status, and lack of birthweight regain by 2 weeks are important risk identification parameters. Early interventions are needed that include optimal feeding support, action-oriented growth monitoring and understanding of the needs and growth patterns of SGA infants to enable appropriate weight gain and proactive management of vulnerable infants.Trial registration numberNCT04002908.

TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery.We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth.A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P lt; 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures.Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

Overall, the Saving Mothers, Giving Life partnership was praised as a successful model for interagency coordination. Key strengths included diversity in partner expertise, high-quality monitoring and evaluation, strong leadership, and country ownership. Uncertainty about partner roles and responsibilities, perceived power inequities between partners, bureaucratic processes, and limited Ministry of Health representation in the governance structure were some challenges that, if addressed by similar public-private partnerships under development, may improve long-term partnership success., Background: Public-private partnerships (PPPs) have garnered appeal among governments around the world, making impressive contributions to health resource mobilization and improved health outcomes. Saving Mothers, Giving Life (SMGL), a PPP aimed at reducing maternal deaths, was born out of the need to mobilize new actors, capitalize on diverse strengths, and marshal additional resources. A qualitative study was initiated to examine how the SMGL partnership functioned to achieve mortality reduction goals and foster country ownership and sustainability. Methods: We purposively selected 57 individuals from U.S. and global public and private partner organizations engaged in SMGL in Uganda and Zambia for qualitative in-depth interviews. Representative selection was based on participant knowledge of partner activities and engagement with the partnership at various points in time. Of those invited, 46 agreed to participate. Transcripts were double-coded, and discordant codes were resolved by consensus. Results: Several recurring themes emerged from our study. Perceived strengths of the partnership included goal alignment; diversity in partner expertise; high-quality monitoring, evaluation, and learning; and strong leadership and country ownership. These strengths helped SMGL achieve its goals in reducing maternal and newborn mortality. However, uncertainty in roles and responsibilities, perceived power inequities between partners, bureaucratic processes, a compressed timeline, and limited representation from ministries of health in the SMGL governance structure were reported impediments. Conclusion: While SMGL faced many of the same challenges experienced by other PPPs, local counterparts and the SMGL partners were able to address many of these issues and the partnership was ultimately praised for being a successful model of interagency coordination. Efforts to facilitate country ownership and short-term financial sustainability have been put in place for many elements of the SMGL approach; however, long-term financing is still a challenge for SMGL as well as other global health PPPs. Addressing key impediments outlined in this study may improve long-term sustainability of similar PPPs.

A multi-partner effort in Uganda and Zambia employed a districtwide health systems strengthening approach, with supply- and demand-side interventions, to address timely use of appropriate, quality maternity care. Between 2012 and 2016, maternal mortality declined by approximately 40% in both partnership-supported facilities and districts in each country. This experience has useful lessons for other low-resource settings., Background: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public–private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. Implementation: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. Results: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (−13% in Uganda and −36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. Conclusion: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.

Shared decision-making (SDM) may improve communication, teamwork, patient experience, respectful maternity care, and safety during childbirth. Despite these benefits, SDM is not widely implemented, and strategies for implementing SDM interventions are not well described. We assessed the acceptability and feasibility of TeamBirth, an SDM solution that centers the birthing person in decision-making through simple tools that structure communication among the care team. We identified and described implementation strategies that bridge the gap between knowledge and practice.We conducted a qualitative study among four hospitals in the United States to understand the acceptability and feasibility of TeamBirth. We interviewed 103 clinicians and conducted 16 focus group discussions with 52 implementers between June 2018 and October 2019. We drew on the Consolidated Framework for Implementation Research to understand acceptability and feasibility, and to identify and describe the underlying contextual factors that affected implementation.We found that clinicians and implementers valued TeamBirth for promoting clarity about care plans among the direct care team and for centering the birthing person in decision-making. Contextual factors that affected implementation included strength of leadership, physician practice models, and quality improvement culture. Effective implementation strategies included regular data feedback and adapting "flexible" components of TeamBirth to the local context.By identifying and describing TeamBirth's contextual factors and implementation strategies, our findings can help bridge the implementation gap of SDM interventions. Our in-depth analysis offers tangible lessons for other labor and delivery unit leaders as they seek to integrate SDM practices in their own settings.

Costa Rica is a bright spot of primary healthcare (PHC) performance, providing first-contact accessibility and continuous, comprehensive, coordinated, and patient-centered care to its citizens. Previous research hypothesized that strong data collection and use for quality improvement are central to Costa Rica’s success. Using qualitative data from 40 interviews with stakeholders across the Costa Rican healthcare system, this paper maps the various data streams at the PHC level and delineates how these data are used to make decisions around insuring and improving the quality of PHC delivery. We describe four main types of PHC data: individual patient data, population health data, national healthcare delivery data, and local supplementary healthcare delivery data. In particular, we find that the Healthcare Delivery Performance Index—a ranking of the nation’s 106 Health Areas using 15 quality indicators—is utilized by Health Area Directors to create quality improvement initiatives, ranging from education and coaching to optimization of care delivery and coordination. By ranking Health Areas, the Index harnesses providers’ intrinsic motivation to stimulate improvement without financial incentives. We detail how a strong culture of valuing data as a tool for improving population health and robust training for personnel have enabled effective data collection and use. However, we also find that the country’s complex data systems create unnecessary duplication and can inhibit efficient data use. Costa Rica’s experience with data collection, analysis, and use for quality improvement hold important lessons for PHC in other public sector systems.

IntroductionEnding preventable deaths of newborns and children under 5 will not be possible without evidence-based strategies addressing the health and care of low birthweight (LBW, Methods and analysisLIFE is a formative, multisite, observational cohort study involving 12 study facilities in India, Malawi and Tanzania, and using a convergent parallel, mixed-methods design. We assess feeding patterns, growth indicators, morbidity, mortality, child development and health system inputs that facilitate or hinder care and survival of LBW infants.Ethics and disseminationThis study was approved by 11 ethics committees in India, Malawi, Tanzania and the USA. The results will be disseminated through peer-reviewed publications and presentations targeting the global and local research, clinical, programme implementation and policy communities.Trial registration numbersNCT04002908and CTRI/2019/02/017475.

As the world strives to achieve universal health coverage by 2030, countries must build robust healthcare systems founded on strong primary healthcare (PHC). In order to strengthen PHC, country governments need actionable guidance about how to implement health reform. Costa Rica is an example of a country that has taken concrete steps towards successfully improving PHC over the last two decades. In the 1990s, Costa Rica implemented three key reforms: governance restructuring, geographic empanelment, and multidisciplinary teams. To understand how Costa Rica implemented these reforms, we conducted a process evaluation based on a validated implementation science framework. We interviewed 39 key informants from across Costa Rica’s healthcare system in order to understand how these reforms were implemented. Using the Exploration Preparation Implementation Sustainment (EPIS) framework, we coded the results to identify Costa Rica’s key implementation strategies and explore underlying reasons for Costa Rica’s success as well as ongoing challenges. We found that Costa Rica implemented PHC reforms through strong leadership, a compelling vision and deliberate implementation strategies such as building on existing knowledge, resources and infrastructure; bringing together key stakeholders and engaging deeply with communities. These reforms have led to dramatic improvements in health outcomes in the past 25 years. Our in-depth analysis of Costa Rica’s specific implementation strategies offers tangible lessons and examples for other countries as they navigate the important but difficult work of strengthening PHC.