@article{fdi:010073508,
  title = {{T}oward communities as systems : a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in {N}ampula {P}rovince, {M}ozambique},
  author = {{C}ole, {C}.{B}. and {P}acca, {J}. and {M}ehl, {A}. and {T}omasulo, {A}. and {V}an {D}er {V}eken, {L}. and {V}iola, {A}. and {R}idde, {V}al{\'e}ry},
  editor = {},
  language = {{ENG}},
  abstract = {{B}ackground: {S}killed birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. {I}n {M}ozambique, the government has prioritized improved service delivery and demand for these practices, alongside 'humanization of the birth process'. {A}n intervention implemented in {N}ampula province beginning in 2009 saw marked improvement in institutional delivery rates. {T}his study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries.
{M}ethods: {A} descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of {N}ampula province. {S}ite selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. {U}sing a modified {D}elphi technique, two expert panels - each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels - were convened to formulate the ?story? of the implementation and to identify contextual factors to use in developing semi-structured interview guides. {T}hirty-four key informant interviews with facility {MCH} nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the {C}onsolidated {F}ramework for {I}mplementation {R}esearch through inductive and deductive coding. {R}esults: {T}he two sites' skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. {E}ight contextual and human factors were found as dominant themes. {T}hough both sites achieved increases,
implementation context differed significantly with compelling examples of both respectful and disrespectful care. {I}n one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. {I}n the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts.{C}onclusion: {F}indings support global health recommendations for combined health system and community interventions for improved {MNH} outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.},
  keywords = {{MOZAMBIQUE}},
  booktitle = {},
  journal = {{R}eproductive {H}ealth},
  volume = {15},
  numero = {},
  pages = {art. no 132 [19 ]},
  ISSN = {1742-4755},
  year = {2018},
  DOI = {10.1186/s12978-018-0574-8},
  URL = {https://www.documentation.ird.fr/hor/fdi:010073508},
}