Table 1. QI implementation of three Puskesmas in Cianjur district from April 2016 to April 2017.
| PUSKESMAS A | PUSKESMAS B | PUSKESMAS C | ||
|---|---|---|---|---|
| Profile in 2015 | ||||
| Setting | Sub-urban | Sub-urban | Sub-urban | |
| Population in the catchment area | Total: 80,649 | Total: 70,152 | Total: 55,159 | |
| Male: 41,514 | Male: 36,293 | Male: 28,666 | ||
| Female: 38,955 | Female: 33,859 | Female: 26,493 | ||
| Maternal health human resources: | ||||
| Midwife coordinator | 1 | 1 | 1 | |
| Puskesmas midwife | 5 | 8 | 3 | |
| Village midwife | 16 | 18 | 13 | |
| Number of deliveries | 1,586 | 1,240 | 1,157 | |
| Maternal deaths | 5 (highest in the district) | 3 | 2 | |
| QI team | ||||
| Size | 3 people (Midwife coordinator & two Puskesmas midwives) | 10 people (Head of Puskesmas, midwife coordinator & eight Puskesmas midwives) | 7 people (Head of Puskesmas, midwife coordinator, three Puskesmas midwives & administration officer) | |
| Year of QI team formation | April 2016 | April 2016 | August 2016 | |
| Frequency of meeting | Once a month | Once a month | - First four months: once a month - The next four months: one time |
|
| QI implementation | ||||
| Context | Across the three Puskesmas, the main issue was the persistent occurrence of maternal deaths in the previous three years. Therefore, the primary goal was to prevent maternal deaths through QI in maternal health services | |||
| Problem identified | In 2015, one of 16 village midwives performed quality 10T ANC services. The most neglected service was performance of laboratory tests. Case management and health counselling were conducted but not according to the quality standard. This led to undetected risks and late management of dangers during pregnancy | In 2015, only 50% of the pregnant women utilised the KIA book (maternal and child health book) was believed to cause low knowledge and awareness of pregnant women about maternal health issues. In addition, less than 50% of the village midwives performed 10T ANC services | In 2015, two maternal death cases were caused by the non-compliance of one village midwife on the standard of delivery screening procedure, leading to high-risk cases not being referred from the village to the Puskesmas | |
| Note: 10T ANC services are ten activities that must be performed during antenatal care, those are 1) measure the weight and height of the pregnant women, 2) check the blood pressure, 3) measure the height of fundal uterus, 4) screen and give tetanus toxoid vaccination (minimum two times during pregnancy), 5) give iron tablet, 6) determine the nutrition status by measure the mid-upper arm circumference, 7) do laboratory test (haemoglobin, HIV, blood type and rhesus, malaria screening), 8) check the foetus’ presentation and heartbeat 9) case management, and 10) pregnancy health counselling | ||||
| Aim | To improve the quality of ANC services delivered by village midwives | To improve the knowledge of pregnant women about maternal health issues written in the KIA book | To improve the quality of ANC services delivered by village midwives | To improve the adherence of village midwives to the standard screening procedure for referral |
| PDSA cycle | ||||
| ◾ Number of cycles | One (1) | Two (2) | One (1) | |
| ◾ Plan | Cycle 1 | Cycle 1 | Cycle 2 | Cycle 1 |
| - Purpose | To develop change idea | To develop change idea | To develop change idea | To develop change idea |
| - Intervention plan | 1. Provision of haemoglobin digital test kit for the village midwives 2. Refresher training workshop on case management of high-risk pregnancy topics |
1. Raise the number of pregnancy classes so that more pregnant women could attend the class 2. Deliver the topics in the pregnancy class using the KIA book so the pregnant women can easily re-read the information at home |
1. Perform on-site supervision and direct feedback for village midwives in the village and during their Puskesmas shift 2. Conduct refresher training workshop on quality 10T ANC services and high-risk pregnancies (high blood pressure, anaemia, etc) |
1. Transfer the village midwife who did not comply with the standard of delivery screening procedure from village to Puskesmas 2. Conduct refresher training workshop and feedback on all topics of high-risk pregnancy to all village midwives |
| - Subject | 16 village midwives | 207 pregnant women | 18 village midwives | 16 village midwives |
| - Success indicators | Improved percentage of village midwife who perform quality 10T ANC services from 6% (n = 1) to 50% (n = 8) | Increased knowledge of pregnant women regarding maternal health issues | Improved 10T ANC services performed by village midwives | Improved the village midwives’ compliance on delivery screening procedure, assessed by: The knowledge on high risk pregnancy must score at least 75/100 and the skills to do 21 steps of delivery screening procedure must score at a minimum of 90/100 |
| ◾ Do | 1. The haemoglobin digital test kit was provided to the village midwives who did not have the kits in November 2016 2. Refresher training workshop was conducted for 16 village midwives in three different batches |
1. An additional pregnancy class was started in nine of twelve villages from one pregnancy class to two classes 2. Pre- and post-test on the maternal health issues were conducted to assess the knowledge of pregnant women |
1. QI team conducted an on-site observation to obtain data on the 10T ANC services performed by village midwives 2. A refresher training workshop on 10T ANC services was delivered by the QI team 3. On-site supportive supervision and feedback were performed by the supervisor of village midwives both in the village and at the Puskesmas 4. Endline data on 10T ANC services were collected |
1. Transfer the one village midwife who did not comply from village to the Puskesmas and provide her with close supervision and technical guidance 2. A series of refresher training workshop (seven workshops) on high-risk pregnancy was conducted for all village midwives 3. Role plays were conducted on how to do the 21 steps of delivery screening procedure 4. Pre- and post- tests of knowledge on and skills to do delivery screening procedure were conducted |
| ◾ Study | Data analysis revealed that 56% (n = 9) of village midwives performed quality 10T ANC services in 2016 (in comparison to 6% (n = 1) at baseline) | The mean score of pre- and post-test increased from 69.2/100 (n = 207) to 82.5/100 (n = 203) | - Baseline data revealed that only two of 18 village midwives performed 10T. Seven midwives complied with 9T and the other seven performed 8T. There were two midwives who only did 7T - After the QI, four village midwives performed 10T, and the number of midwives who performed 9T and 8T remained the same - There was improvement in compliance to do 10T ANC services by the village midwives - In this cycle, the QI team was able to identify the previous unidentified cases. They revealed that from January to June 2017 there were 224 cases of anaemia in pregnancy and 64 cases of protein-energy malnutrition (PEM) in pregnancy |
- The mean score on knowledge of high-risk pregnancy increased from 39.3/100 (in the pre-test) to 80.75/100 (in the post-test) - The mean score of role-play skills on 21 steps of delivery screening procedure was 70/100 meanwhile the goal was minimum 90/100 |
| ◾ Act | 1. To continue the provision of the haemoglobin test kit by Puskesmas 2. To perform the next PDSA cycle on supportive supervision |
To continue the existed class and to add the number of pregnancy classes in the remaining three villages to be at least two classes per village | 1. To continue the on-site supportive supervision 2. To conduct the cycle 3 based on the anaemia and PEM issues found in the cycle 2 |
1. To re-assess the roleplay intervention and develop an improved version 2. To perform the next PDSA cycle on supportive supervision |