Better data, better births, better outcomes

In most places in the world, frontline nurses and midwives are the first to identify emergent problems during childbirth and provide subsequent solutions. Unfortunately, there are not enough nurses and midwives in the world, particularly in low resource settings, even as nurses and midwives are responsible for delivering care to eight out of every 10 patients globally. Indeed, most pregnant women in the developing world receive most, if not all, of their care from a nurse or nurse-midwife. Making the job of nurses and midwives even more difficult is the lack of readily available accurate data on patient outcomes to show where quality of care needs to be improved.  

Despite global campaigns and continued calls for improvement, significant disparities between countries still exist in outcomes for mothers and babies, with those in sub-Saharan Africa (SSA) some of the most affected. Through concerted work more and more women in SSA have been giving birth in health facilities, helping to reduce rates of maternal and neonatal morbidity and mortality. However, facility births alone will not reduce complications and deaths for mothers and babies. Further changes in maternal and neonatal outcomes require improvements in the quality of care at the facility level. Yet advances towards this end area are hindered in two key areas mentioned in the previous paragraph, 1) the lack of trained nurses and midwives to provide the care, and 2) a lack of accurate and timely data on outcomes to guide the focus for those who are tasked with ensuring safe childbirth.

This project will specifically address one of the world’s greatest health priorities, improving outcomes for mothers and neonates during childbirth through direct interventions to improve quality of care in Liberia, Malawi, and Sierra Leone. The Global Action in Nursing (GAIN) Partnership is a woman-founded, nurse-midwife directed organization which began in 2017. Through strategic collaborations with Ministries of Health, NGOs, and academic institutions, GAIN has worked to support feasible, long-term solutions to locally-identified areas in need of improvement. GAIN aims to tackle the dearth of skilled nurses and midwives by utilizing a model of mentorship and scholarship for nurses and those wishing to become nurse-midwives to complement their training and/or upgrade their education. In each of the countries where the GAIN team works, the Millennium Development Goal of reducing maternal mortality has not been met. Sierra Leone is estimated to have the highest maternal mortality (MMR) with 1,360 deaths per 100,000 live births in 2015. The rates of Liberia (725 deaths) and Malawi (634) are among the highest as well. Further, Sierra Leone has the world’s second highest infant mortality rate with 83 infant deaths per 1,000 live births. Fortunately, there is a known solution to improve such numbers: properly educated nurses and nurse-midwives. In fact, The World Health Organization (WHO) agrees saying, “women need not die in childbirth...maternal deaths could be prevented if women had access to skilled care.”

To address the first issue, increasing the number of available nurses and midwives, GAIN has been working with the Ministries of Health and NGOs in Malawi, Sierra Leone, and Liberia to provide scholarships to support those seeking to become nurses and midwives, followed by longitudinal mentorship for graduates at rural health facilities. However, this proposal for the MIT Solve grant seeks to address the second issue—that of simplifying and integrating existing systems to provide accurate and timely data on patient outcomes—based on feedback from the very midwives and nurses practicing at GAIN partner facilities. This proposal seeks to pilot a data platform named BIRTH to integrate all data sources at GAIN partner sites in Maryland County, Liberia. This proposal is inspired by direct feedback from GAIN partner site nurse and midwifery colleagues, who have identified numerous challenges with regards to current systems and proposed the BIRTH solution.  

First, we will describe the current system for collecting and sharing data on patient outcomes at government health facilities in GAIN sites.  The most common reporting systems in place in Liberia, Sierra Leone, and Malawi—and elsewhere in sub-Saharan Africa—come from monthly aggregate summaries reported to and by the Ministries of Health. These are the end result of a long chain of data entry, beginning with nurses and midwives filling out patient charts, then the charge nurse updating patient registers, followed by the facility lead compiling them into aggregated monthly reports, and finally, data-entry clerks putting the monthly reports into the official government database. Peer-reviewed examinations of this process by GAIN midwifery teams have shown increased data-entry errors at each stage, leaving significant gaps in the information from which policy decisions are made and resources allocated. Further, these reports return to the facilities often after months-long lag times with numbers the local staff note are not accurate, but that they lack the ability to update or change. The midwives and nurses at GAIN partnering facilities have expressed that these challenges limit their ability to review and respond to changing patterns in patient outcomes in a timely basis and advocate for supplies to do so.  

A key issue is the use of aggregate numbers cannot examine aspects of quality of care, whether the right action or medication came at the right time, a critical step in improving outcomes at a facility level. When such data is available, facility leads can engage in targeted trainings and quality-improvement activities to address gaps in care and help empower their staff. As improvements in the quality of nursing and midwifery care becomes a primary driver of maternal and neonatal survival, it is essential that indicators sensitive to quality of care are included in data systems. While the data for this already exist in patient charts, current data collection approaches omit this critical information from any regular reporting approaches. This is not surprising as assessing quality of care requires both significant time and a level of clinical competency to determine whether care was appropriate or not, and thus often draws nurses and midwives away from patients for data-entry purposes.  

Current systems are also hindered by a lack of linkages to other reporting mechanisms for components critical to patient care. These components include facility supplies of medicines and materials. While pharmacists may know when a facility is running low of a given drug or if central repositories are facing similar shortages, this information often does not reach nurses and midwives so that they can plan accordingly. Similarly, pharmacists often lack information as to what is missing in patient wards when it may be in a storeroom. While local GAIN nurses and midwives have often taken the initiative to source vital supplies on their own, this occurs at a site-by-site basis and is not sustainable.  

The most challenging and ripe for change issue, and the one that is the primary focus of this proposal, is tackling the siloed nature of facility level data. At every partner facility, GAIN nurses and midwives inquire about patient care, outcomes, and solutions at other sites both in their country and outside, searching for novel solutions which could be locally adapted. For example, at a recent cross-site meeting of GAIN leaders, Sierra Leonian midwives noted with interest that kitchen timers were present in rural facilities in Neno District, Malawi.  They saw the impact that timers were having as a simple, yet profoundly effective quality improvement device, helping staff be timely in tracking patient vitals in their busy wards. Upon returning home, the Sierra Leonian midwives acquired their own timers, and saw a roughly 50% reduction in rates of neonatal asphyxia in the facilities where they were implemented.  They now work with the site’s supply staff to ensure that the timers (and batteries for them) are included as part of standard supplies. This simple solution would have been a well-kept secret if nurses and midwives from GAIN sites had not gathered in person to share idea. A simple and clear system to collect and disseminate this type of information to those who need it the most, including policy makers, is the key for improving patient outcomes.  

Overall, our work has shown us that the nurses and midwives providing the majority of care for birthing parents and their newborns are collecting a great deal of data as part of their standard practice. These data could be instrumental in identifying areas of success and those areas needing improvement, but the majority will never be seen or shared. This is primarily due to the “clunkiness” of the current data collection and dissemination system. While nurses and midwives are constantly innovating to ensure their patients have safe birth outcomes, many of the easily scalable innovations rarely leave individual facilities.  To date, nurses and midwives lack an easy way to look beyond -or even within- their own walls and connect with others.

While GAIN supports monitoring and evaluation (M&E) staff at facilities and provides clinical training and mentorship to nurses and midwives at partner sites, a critical gap is leveraging the existing systems in a way that seamlessly integrates the two.

The proposed solution is the BIRTH data platform, a simple streamlined approach to the existing data collection process into a single accessible platform. While we hope to expand this to GAIN sites in Malawi and Sierra Leone, we wish to pilot this approach in Liberia as a demonstration of its potential and proof that such an approach is cost-effective based on improved patient outcomes. We are confident once success is demonstrated, Liberian, Malawian, and Sierra Leonean Ministries of Health will recognize and support further expansion. Our goal is not to permanently fund staff or build out a new costly data system, but to integrate the current systems already used by those in the field as part of their work, thus increasing the scalability of the project.

We will begin the process by digitizing all applicable facility records (e.g. de-identified patient register data, supplies checklists, medicine inventories, and staffing) into a single dashboard that is accessible in real time to all GAIN nurses and midwives in partner facilities. After the digitization of registers, local nurses and midwives will design a comprehensive quality of care checklist. The work will be led by a nurse midwife who brings the clinical expertise coupled with an M&E background to ensure information from patient charts is abstracted correctly. The blend of skills enables this individual to engage with both clinical staff and facility M&E staff to identify issues in data collection and analyses, and perhaps most importantly, integrate the two.

Quality of care indicators will then be added to the monthly data collection in facility registers. Those data, along with currently collected data on supplies availability and staffing levels, will be uploaded directly into the BIRTH data platform, circumventing issues of data-entry errors in the current approaches.

Currently the sites in Liberia are using tablets programmed with CommCare for supplies and staffing tracking. Aggregated patient-level data is compiled by nurse-midwives and input into Ministry tracking forms by M&E clerks. These data, plus the newly added quality of care indicators, will be easily integrated into systems that are already available. For this project, we would choose the system that is most feasible and adaptable for the multi-country teams, such as PowerBI which is already being used at the proposed site. The goal of BIRTH is to use information already collected and add quality of care indicators to a full-integrated and easy to use data platform. Once the platform is designed, nurses and midwives will be able to view the data in real-time on their phones or in the clinical setting on tablets fixed at the nurses’ station. For more remote facilities with intermittent power and/or technological availability, hard copies will be made available on a rolling basis. This will include poster-sized charts for critical indicators as well as more comprehensive booklets of cross-site data.

The approach benefits greatly from the simple fact that it leverages existing processes, workflows, and systems in a way that is both low-cost and scalable. Most importantly, the whole approach is designed to be accessible in real time to frontline midwives and nurses who not only have a concerted stake in its outcome but also will take the lead in the development and continued refinement of the system.

The solution primarily serves the patient population of approximately 10,000 birthing women and their neonates in the catchment area where the work will take place. It will impact their lives by making sure the best quality of care is available at the health facilities where they give birth. In addition, nurses and midwives working at GAIN sites (JJ Dossen Hospital, Karloken Health Center, and Pleebo Health Center in Maryland County, Liberia) will benefit by having immediate access to information on patient outcomes, critical supplies availability, and complication and death rates. Currently nurses and midwives working at the project sites do not have access to information to guide their decision-making and clinical growth. To solve the most intractable problems in maternal and neonatal health, providers must first know where the greatest problems lie in their facilities and how others have solved such problems. 

Global Action In Nursing (GAIN) is a nurse and midwife-led organization of global health experts from around the world. GAIN has been working in Malawi since 2017 and Liberia and Sierra Leone since 2020. Under the leadership of our Co-Director Daniel Maweu, each country is led by GAIN Lead Mentors, who are experts in maternal and neonatal health. Lead Mentors rotate among peripheral facilities to support and embed best clinical practices. GAIN Lead Mentors also work with facility-based mentors to ensure a robust reporting network driven by local knowledge. Crucially, in each country we have also developed a strong relationship with both the local and national Ministry of Health officials. This ensures a bi-directional relationship whereby GAIN can be responsive to district and national priorities and where our team can share their innovations.

Backing the local country-based teams, GAIN has a nimble implementation science team situated in the Institute for Global Health Sciences at the University of California, San Francisco (UCSF). This branch of GAIN supports Co-Director Maweu and the individual country teams through identifying and developing data collection systems, data analysis and reporting, and linkages to other experts such as the UCSF School of Nursing which has one of the country’s premiere midwifery programs. The team blends experts not only in their respective research fields, but also those with a history of teaching, who lead both short- and long-course trainings for the in-country staff based on their expressed needs. The epidemiological research capabilities of the team have contributed to the success of our projects as they draw upon qualitative and quantitative approaches to ground advocacy in clear data that incorporates local understandings. The use of this data, both peer-reviewed and robust, has proven a critical component in advocacy efforts towards policy change.

The GAIN Partnership approach has a proven history of success in similar fields. In Malawi, we worked with mobile clinic providers to identify tools to improve diagnostics for non-malarial fevers, resulting in a 50% reduction in unnecessary antibiotic prescriptions. We helped improve cancer treatment for patients in Tanzania by offering providing tools and tracking for oncology nurses working at the bedside.  In each case, the solutions were derived from on-the-ground input from frontline healthcare workers and implemented in tandem with partners at the associated Ministries of Health. Currently, the Malawian government is engaging a national rollout of an adapted WHO Safe Childbirth Checklist (SCC) designed and piloted by GAIN midwives at facilities in Neno District.

Importantly, our team is composed of scientists with a strong track record of designing interventions, evaluating outcomes, and disseminating findings. We have published on some of the issues nurses and midwives face in some of the least resourced places on the planet.

Over the next month, approximately 700 women in the three countries listed above will die giving birth. Recent funding in this area has been directed towards “quick fixes” such as new drugs and tools. However, without adequately trained healthcare providers who have access to data, the likelihood of sustainable success of other solutions is limited. Further, women play a critical role in helping poor and emerging countries build community, resulting in better welfare for all. If basic needs of women are not met (health and mothering), the power of women to advance communities is compromised. This project addresses the heart of the problem: providing critical resources to nurses and midwives to improve outcomes.

To be frank, systems development and the refinement of data-collection systems, even when they directly benefit patient care, are not high priority funding areas. They are neither flashy projects that catch the eye of major philanthropic donors, nor are they high-priority areas for major government agencies such as the National Institutes of Health. As noted in our introduction, there simply are not enough nurses and midwives currently practicing in the world, and so funders often prioritize projects that train and build capacity of health providers. If one has a choice between hiring someone at the bedside versus someone to help that provider collect, track, and report on quality data, the right decision is to place a skilled provider at the bedside. This is the backbone of the work currently done by GAIN.  

However, as we continue to develop the frontline workforce, these providers need tools and support if we are to take the next step in reducing maternal and neonatal outcomes. Feedback from each of the countries where we operate, whether from our lead midwifery mentors, focus group discussions with our scholars, or from our partners in the Ministries of Health, all note a desire to ‘know what is going on’ before it becomes an issue. They have asked for better and integrated data frameworks across their healthcare systems to enable them to make better clinical decisions as far ahead of emergent issues as they can.

Our solution is innovative in two major ways. First, our ultimate goal is to improve patient outcomes, but the current tracking systems are not accurate or effective. Right now patient data are aggregated, which does not help providers at the bedside understand where problems lie. The use of aggregated data by the Ministry to make resource allocation decisions may miss major priorities in patient care. Further, rarely is the information relayed to the front-line nurses and midwives providing care. By focusing on collecting patient-level data and including quality-of-care indicators and making it directly accessible to nurses and midwives providing care, we can actually allow front-line providers to respond in real time to the needs of their patients. This will also allow the Ministry and policymakers to have better data from which to make decisions. Second, this approach synchronizes data available in facilities (e.g. supplies, medications, etc) that are critical to patient care, but currently are not shared outside of their current siloed structures.

The primary indicators that we are looking to tackle over the next five years are the SDG 3.1 and 3.2, to reduce maternal and neonatal morbidity and mortality. Specifically, these will be addressed through quality-of-care indicators identified by nurses and midwives at participating facilities. These relate to the myriad of complications and outcomes experienced by birthing parents and their babies at the facilities including the following priority areas:

• Neonatal asphyxia
• Sepsis
• Post-Partum Hemorrhage
• Emergency preparedness (completeness of supplies for emergency care)
• Prolonged labor

To address these indicators, nurses and midwives have requested better information on their quality of care, patient outcomes, supplies, and a streamlined way to access it. They have noted that while M&E teams are making detailed charts on the data they are receiving, they do not have access to the data they need to implement positive change. Thus, we also seek to improve the quality of data as it relates to the actual practice of care.

Change does not occur immediately, and indeed research has shown that while short-course interventions may move the needle, practice often reverts back to familiar trends if not supported. This fact has been instrumental in GAIN's approach of situating longitudinal mentorship alongside any intervention. Therefore, we seek to measure progress over time with a keen eye to this possibility. In developing a combined data-system, we will be able to track key indicators listed as priority areas by both our Ministry of Health partners and the providers at the facilities where we work. Recognizing that there are many influencing factors that can impact goals, and that some are not always present in raw data, we propose a mixed-methods approach to measuring progress. This would incorporate in-depth interview and focus-group discussions with quantitative mixed-effect modeling that can track changes over time while accounting for other potential confounders.  

As it relates to the indicators, we believe our approach will result in:

• A simple to use data platform that will be accessed at least 2 times per clinical shift at each site
• All participating nurses and midwives will share a positive experience and an example of how practice was influenced based on the new platform
• A meeting with the Ministry of Health to collaborate on how to expand the platform across all districts.

Please see the attached image for a visualization of the GAIN Theory of Change

The success of our solution is by leveraging existing digital technology, specifically CommCare and PowerPI, that is current used at proposed sites via tablets, computers, and data entry systems. The knowledge and experience of midwives and nurses in remote settings of the world are also part of the core 'technology' of our solution. They are the ones on the ground seeing changes in patient trends and adjusting as needed, well ahead of aggregated reports that often appear months later and with incorrect data. This blend of innate knowledge, experience, and digital solutions will provide the much needed support structure to impact real change in real time.

The success of our solution is by leveraging existing digital technology, specifically CommCare and PowerBI, that is current used at proposed sites via tablets, computers, and data entry systems. The knowledge and experience of midwives and nurses in remote settings of the world are also part of the core 'technology' of our solution. They are the ones on the ground seeing changes in patient trends and adjusting as needed, well ahead of aggregated reports that often appear months later and with incorrect data. This blend of innate knowledge, experience, and digital solutions will provide the much needed support structure to impact real change in real time.

The data collected as part of our solution is currently collected in two streams: 1) clinical data collected by nurses and midwives and 2) facilities data collected by M&E staff.

The midwives and nurses for whom this project is designed currently collect the majority of the health care data that will be used for the solution. They do so as part of their regular standard-of-care for their patients and scope of their job. This begins with keeping information on patients' individual detailed charts, from which they then take key indicators for reporting in the patient registers. Their primary incentive to collect this data is its necessity in order to provide high-quality and successful care. While they are the primary collectors of this data in its individual form, they have reported significant challenges in receiving benefit from it longitudinally due to current reporting systems. This can be from immediately knowing which patients are 'high risk' when coming onto a shift, to tracking their improvement in care over time, to even knowing rates of key indicators for their facility. Such limitation can result in limited motivation to devote time to data collection over other duties. This is the prime driver behind our solution, as the successful implementation of our program - giving them simplified, real time access to uncluttered data around key indicators - will increase their incentive to collect the data in the future.

The second team, the M&E staff currently collect data related to summary scores from the clinicians and facility-level indicators. They do so primarily driven by the scope of their jobs, but have similarly reported limited engagement with the overall data itself due to the current limitations around its use and value in improving provider practice and care. Thus, similar to the nurses and midwives, our solution will help incentivize them towards keeping data to the highest quality.

GAIN is committed to upholding a culture of diversity, equity, and inclusion and embodies these values by empowering in-country staff with the responsibility of identifying key priorities of focus and directing the priority areas in which investment is directed. We recognize the colonial nature of global health and actively work to dismantle the suppression of low- and middle-income countries by employing lead mentors from the countries where GAIN is present and having their active participation in the programs that occur on their soil. They are the ones who need to be making the decision and we elicit that insight from the leadership of our Co-Director Daniel Maweu in Liberia.

To complete this project, the following components of our business model are critical:

Key Resources: A clinical leader onsite to lead activities, a clinical team to provide feedback in real time, funding for tablets and airtime, transportation services

Partners: Liberian Ministry of Health, Partners in Health M & E team in Liberia, human subjects approval from the Liberian IRB

Cost Structure: Clinical staff, Project lead, M & E support

Intervention: Introduction of a revised data platform that includes patient outcomes as well as quality of care activities. Viewable on a smart phone, tablet, computer, or hard copy as needed.

Channels: All “customers” (nurses, midwives, M & E teams, pharmacy) will be reached via SMS (WhatsApp) and during in-person meetings at all sites

Beneficiaries: all patients seeking maternity care at partner sites

Customer: Ministry of Health and Partners In Health

Impact Measures: a reduction in maternal and neonatal morbidity and mortality

The overarching goal of this project is to create a simple, easy-to-use data platform that contains all important data about how patients giving birth are faring  at partner sites. The technology for this platform exists, therefore, if it is successful, it will be sustained within the current data collection system. In fact, it may be even more cost-effective than the current disjointed system of data collection. The input for our solution is largely a one-time improvement that can be replicated at other locations. As with our work with the Safe Childbirth Checklist in Malawi, we have proven that our partner organizations and Ministries of Health are interested in, and willing to scale using their own funds, solutions that improve patient care and outcomes. The GAIN Partnership provides all its tools and resources as 'open source' via our website and on request, and do not seek to gain revenue streams from projects that improve maternal and child health.

In Liberia, a GAIN fellowship model proved successful in increasing the nurse to neonate ratio in the NICU and reducing maternal and neonatal mortality rates. In acknowledgment of the success, the Board of Nursing and Midwifery has requested GAIN lead the development of a new one-year upgrading curriculum for nurses to become midwives. While GAIN has invested financial support for the fellowship program, its success in producing better health outcomes is the impetus for the development of a new program to expand the nurse-midwife workforce in Liberia. Moving forward, the fellowship program will be sustained by way of the new upgrading curriculum and supported by the Ministry of Health. The success of GAIN lies in the sustainability of the mentorship and capacity building model.  In Malawi, GAIN’s model of nurse and midwifery training is now fully embedded in the Ministry of Health activities without support by GAIN.