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Table 1 Highly ranked change ideas recommended by the collaborative for implementation in similar settings

From: Improving service uptake and quality of care of integrated maternal health services: the Kenya kwale district improvement collaborative

Focus area Change idea implemented
Utilization of ANC and skilled delivery services and health facility-community linkages. i. The facility staffs engaged traditional birth attendants (TBAs) in dialogue and redefined their roles to those of birth companions who would help trace women for missed appointments and accompany women to the health facility for skilled deliveries.
ii. All facilities introduced the routine practice of asking all women of reproductive age coming to the health facility for other health services (general outpatient visits, immunization visits) or their last menstrual period to identify pregnant women.
iii. Health workers gave their phone numbers to TBAs and community health workers (CHWs) to ease communication anytime they were bringing clients to the health facility. A dedicated health facility phone was also used to follow up on ANC clients and remind them of their appointments.
iv. After discussion with the community, mothers who could not afford to pay for ANC laboratory tests at once were allowed to pay in installments.
Quality of care at the health facility i. All facilities drastically reduced client waiting time by process mapping their services, eliminating unnecessary steps, and providing integrated ANC care in one room.
ii. Some health facilities took the initiative to submit proposals for financial support from local donors, such as residents’ associations, local banks and traders’ groups, to overcome resource constraints and also lobbied local politicians and other stakeholders for the provision of items such as microscopes to equip laboratories. Three new laboratories were started due to these efforts.
iii. Due to the unreliable government supply of iron and folate, facilities reallocated their funds and purchased these items locally since they were cheap and critical components of ANC.
iv. Almost all healthcare staff in the district are trained in providing services. However Antiretroviral drugs (ARVs) were only available at the district’s central pharmacy. The health management team reviewed this protocol/policy such that that all health facilities were allowed to stock a limited number of ARVs for better implementation of PMTCT services across the entire district.
v. Clean water and cups were provided in the ANC room so that the ANC clients could take sulphadoxine-pyrimethamine for malaria prophylaxis under direct observation of the health worker. This way they did not have to queue again at the pharmacy for these drugs.
vi. Staff in all the facilities initiated regular structured dialogues with various community groups (women groups, traditional birth attendants and opinion leaders) and also used general community meetings to get open criticism on services and their attitudes.
vii. Privacy during delivery was enhanced by designating rooms for delivery, having curtains in place, and restricting entrance to the delivery rooms.