Did a quality improvement intervention improve quality of maternal health care? Implementation evaluation from a cluster-randomized controlled study

Objective: To test the success of a maternal healthcare quality improvement intervention in actually improving quality. Design: Cluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls. Setting: Four districts in rural Tanzania. Participants: Health facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline). Interventions: In-service training, mentorship and supportive supervision and infrastructure support. Main outcome measures: We measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis. Results: Quality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0-75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators. Conclusions: A multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.