title: Improving service uptake and quality of care of integrated maternal health services: the Kenya Kwale District improvement collaborative.
abstract: BACKGROUND
  Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack of progress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother.
  
  
  METHODS
  Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office.
  
  
  RESULTS
  The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012).
  
  
  CONCLUSIONS
  Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries.
authors.affiliation: University Research Co,, LLC (URC), 7200 Wisconsin Avenue, Ste, 600, Bethesda 20814, MD, USA. michael.kivkiv@gmail.com.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Mwaniki
authors.forename: Sonali
authors.initials: S
authors.lastname: Vaid
authors.forename: Isaac Mwamuye
authors.initials: IM
authors.lastname: Chome
authors.forename: Dorcas
authors.initials: D
authors.lastname: Amolo
authors.forename: Youssef
authors.initials: Y
authors.lastname: Tawfik
mesh_terms: D003299:Cooperative Behavior; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D005260:Female; D006801:Humans; D007630:Kenya; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data*; D011247:Pregnancy; D058996:Quality Improvement; D012017:Referral and Consultation; D012042:Registries