Stakeholders perceptions regarding implementing maternal and newborn health care programs in Rwanda

Background: While maternal and newborn deaths has been decreasing since 2008 in Rwanda, there is room for improvement to meet its sustainable development goals. The maternal and newborn health care program needs to be monitored to ensure its effective implementation. This study therefore aimed to explore stakeholder’s perceptions of the Rwandan maternal and newborn health care program to identify areas for improvement. Methods: The convergent, parallel, mixed method study used quantitative and qualitative data in a single phase. The quantitative data was obtained from 79 health care workers, ranging from maternal community health care workers to program supervisors. The 10 areas of the Project Implementation Profile (PIP) instrument checklist with a five-point Likert scale were used to indicate their perceptions (strongly disagree to strongly agree). The qualitative interviews of five nurse managers used a manifest inductive content analysis, directed approach that entailed using existing theory and prior research to develop the initial coding scheme before starting data analyse. Results: There was disagreement about the level of top management support, human resources was regarded as an area of concern, with 18.7% (n = 14/79) indicating that they did not agree that this was adequately provided for; urgent solutions for unexpected problems was regarded as an areas of concern by 46.8% (n = 36/79). Top management support weakness were inadequate support training, materials, money for home visits, supervision and leaderships, and training of newly recruited maternity health care workers. For human resources, there were insufficient trained staff to take care of mothers and newborns due to the shortages of health providers. The management of unexpected problems was also an area of concerns and related to getting patients to health facilities during pregnancy emergencies and the lack of qualified birth attendants at health facilities. Conclusion: The study identified three areas for improvement: top management support, human resources and urgent solutions for unexpected problems, as they may be affecting the provision of maternal and newborn health care program services. Using the PIP enable managers to improve the country’s maternal and newborn health care program, and to provide ongoing monitoring and evaluation of with respect to the desired outcomes of reducing maternal and neonatal mortality. This study entailed the use of quantitative and qualitative techniques within a convergent, parallel mixed method methodology that requires both quantitative and qualitative data to be collected during a single phase of research [24]. Mixed methods compensate for the weakness of each type, but with the different methods remaining autonomous, operating side-by-side. This approach prioritizes the two methods equally, keeping the data analysis independent but combining the results during the overall interpretation, using both to look for convergence, divergence, contradictions, or relationships from the two data sources using data triangulation [24]. The purpose of the convergent design is to obtain different but complementary data (quantitative and qualitative) on the same topic to best understand the research problem [24]. Holloway and Wheeler (2013) defined qualitative data collection as a form of social inquiry that focuses on the way people make sense of their experiences and the world in which they live [25]. In this study, the qualitative research approach focused on interviews [26], while the quantitative component entailed the participants completing the PIP questionnaire. The Rwandan public health system consist of four levels: community, health facilities, district hospitals and national level hospitals being the final referral point, with the health system being decentralized to the district level. Rwanda has five provinces, with three public sector districts hospitals being purposively selected from 30 within the three of the provinces of Kigali City, Eastern Province and Western Provinces, and two each of their urban, semi-urban and rural associated health facilities being selected for inclusion. The health facilities were select based on their accessibility, these being: Kigali City Province: Muhima District Hospital, Muhima and Butamwa Health facility (urban); Eastern Province: Nyamata District Hospital, Nyamata and Mayange health facilities (semi-urban); Western Province: Kibogora District Hospital, Kibogora and Nyamasheke Health facility (rural). The participants consisted of maternal community health workers (MCHWs) and all staff working in the maternal and newborn health care programs at health facilities and district hospitals, namely: nurses and data managers, the nurses and midwives in the maternity ward and immunization services, and the district-based community health worker supervisors. The nurse managers provide information about the implementation and integration of maternal and newborn health care program and are responsible for the MCHW training and overall supervision. The data managers are responsible for patient records kept and training the MCHWs to record and send data to the health facilities. The nurses and midwives provide PNC, delivery and ANC services to the women in their catchment communities. The district level supervisors MCHW supervisor are community coordinators who oversee the health facility-based MCHW supervisors. Non-probability convenience sampling was used to identify 100 individuals to participate in the quantitative PIP questionnaire. The staff at each of the six sites consisted of those working in the program (MCHWs, nurses and midwives, nurse and data managers, community supervisors) with 30% of the MCHWs being included out of a total of 224 in the three selected districts. The team in charge of the maternal and newborn health care program was purposively selected from each health facility or district hospital according to their availability during working hours. These consisted of 30% of the MCHWs, one nurse manager, one data manager, and two nurses and/or midwives in the maternity wards, and one district hospital level community supervisor. All those who provided informed consent completed the PIP questionnaire. Qualitative research typically involves purposeful sampling to enhance the understanding of the information–rich case [27]. It is oriented toward the development of ideographic knowledge from generalizations about individual cases. The six health facility nurse managers were invited to participate in the semi-structured interviews, as they could provide rich information regarding the implementation of the maternal and newborn health care program based on their educational background, management and supervisory experience in the various clinical settings. However, one nurse manager was unavailable, which resulted in five participants. A meeting was held with the selected staff at each of the six health facilities to outline the project, establish their willingness to participate and complete a written informed consent form, which they were given a copy of for their records, with standard ethical considerations being observed throughout the study. Those who provided consent were asked to complete the questionnaires, which took approximately 30 min, and were provided with assistance where required. Three data collection tools were used, the first being to obtain their demographic details on a standardized questionnaire, the second being the Project Implementation Profile (PIP) instrument to monitor the current perceived state of each of the 10 successes areas with all the participants (Appendix, Supplementary file 1, point 4). They were asked to indicate the extent to which they agreed with statements about factors affecting the implementation of the maternal and newborn health care program using a five-point Likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’. The third was a question schedule to obtain qualitative data from semi-structured interviews with the five nurse manager participants who had completed the questionnaires, the interviews being audio-recorded and transcribed for interpretation using a manifest content analysis directed approach (Appendix, Supplementary file 2). The directed content analysis used prior research and the PIP areas of interest to develop the coding scheme. The quantitative cross-sectional descriptive and qualitative methods entailed establishing the extent to which the stakeholders perceived the 10 statements to accurately reflect the status of the maternal and newborn health program: Validity is linked to the question of quality, with the value and wholeness of the work being key elements of validity judgements that ensure that the data can be trusted [28]. The instrument or procedures used in the research must be trusted to measure what they supposed to measure [29]. For the quantitative aspect of the study, a pilot study was conducted using 10 participants to test the data collection instruments for internal validation and reliability to ensure that the researcher obtains the appropriate data, with feedback being used to modify the questions. Some questions were adapted from the literature review and the Rwanda Health Sector Strategic Plan 4 to specifically address the maternal, neonatal and child mortality. In addition, the study included the 10 areas of the Project Implementation Profile (PIP), with permission to use the instrument being given by the Project Management Institute (PMI). The PIP instrument was initially validated as a useful diagnostic tool for practicing manager and adapted according to the program under investigation in this study [30]. In the current study (Appendix, Supplementary file 1), the Cronbach’s Alpha was .76, which was an acceptable internal consistency as it was above the 0.70 indicated by Polite and Beck (2012), was considered to be acceptable [31]. The trustworthiness of a qualitative study can be increased by maintaining high credibility and objectivity [25]. This was addressed by issues of credibility, which relates to the notion of internal validity, and entailed ensuring that the participants’ responses were accurately reflected. Through prolonged engagement in the setting, the researcher reflected on how she may have influence data collection, analysis, interpretation and write up. The researcher has completed a Masters in Nursing (Community Health specialisation), experience in the settings that was researched, and in the field of the maternal and newborn health care program performed by MCHWs in the community. The participants are experienced in the field of maternal and newborn health and gave their opinions about their experiences, with the researcher‘s findings being a reflection of the perceptions of the population under study [25]. The participants provided demographic data from a questionnaire and indicated their opinions about the critical success factor of the Maternal and Newborn health care program through the PIP questionnaire. The quantitative data was analysed using various statistical measures that included a needs assessments and empowerment analysis. It provided an opportunity for a mixed methods study to contribute to learning about what worked regarding the implementation of the program as well as to explore its effectiveness in achieving the desired maternal and newborn health outcome [24]. The participants were asked to indicate their perceptions about the 10 key performance areas of the PIP regarded as important in maternal and newborn health care programs. The five-point Likert scale answers ranged from 1 = strongly disagree [SD], to 5 = strongly agree [SA]. The mean of each statement was out of 5, with the scales being grouped into three categories of (1) disagree, (2) Neutral (3) and agree. The data was analysed using the statistical package for Social Sciences (SPSS 25.0), with a mean value of four being required to be regarded as an indicator [32].. The questionnaires were numbered and coded to facilitate data capturing and auditing, and to ensure data confidentiality. The qualitative analysis entailed content analysis, which required identifying codes, with the initial categories being revised and refined with ongoing analysis. A directed approach was used for the 10 PIP areas in the context of study, hence that used for qualitative data being directed content analysis [33]. This process of analysis goes through various stages: transcribing interviews and sorting field notes; organising, ordering and storing the data; listening to and reading or viewing the material collected repeatedly [25]. In this study, the computer-aided programme 12 Nvivo was used to organise and analyse the qualitative data. The qualitative analysis entailed the following analysis processes: (1) Transcribing interviews and sorting field notes: a combination of audio-taping of participants responses and field notes for observations were used during the individual interviews. (2) Ordering and organising the data: the recorded material was cross checked and labelled for final analysis, with the material being stored in appropriate files for later retrieval. (3) Analytical steps: this entailed a variety of analysis measures, such as listening to, viewing and gaining a holistic view of the data, as well as dividing them into units or segments of meaning. The analysis steps were: reflect on each transcript and search for significant statements; record all relevant statements; delete repetitive and overlapping statements; leave only invariant constituents of the phenomenon; organise, link and relate these into themes, including verbatim quotes from the data; integrate the themes into a description of the texture of the experience as told by the participants; reflect on this and their own experiences; and develop a description of the meanings of the experience [25]. (4) After obtaining written meaning of their experiences, the researcher returned to the supervisor for a review of the analysis process. The point of interface for the mixed methods entailed the convergent parallel design collecting and analysing two independent strands of quantitative and qualitative data at the same time in a single phase. It prioritizes the methods equally, keeps the data analysis independent, combines the results during the overall interpretation in an effort to find convergence, divergence, contradictions, or relationships of the two sources of data [24]. Triangulation, which can combine quantitative and qualitative methods, was used as some of the participants who completed the questionnaire were interviewed, with the answers from the two data sets being compared [25]. Data triangulation was used to ensure that the inherent bias of one method was countered-balanced by the strengths of other. Using mixed methods is useful to establish if the results converge or corroborate one another, strengthening the validity of the findings. Triangulation seek convergence, corroboration and correspondence of results from different methods [25]. Ethical considerations, which are related to the protection of the rights, dignity, safety and well-being of human subjects, underpinned this study. According to Brink (2006), a researcher is responsible for conducting research in an ethical manner and must have paid attention to all requirements [30]. The mayors of the Bugesera, Nyamasheke, Nyarugenge Districts provided gatekeeper permission, and confirmed that were in support that the health facilities being used should the university ethics committee approve the study. Approval for the study was obtained from the Biomedical Research Ethics Committee (BREC) at the University of KwaZulu-Natal (BREC Ref No: BE029/18), South Africa, and the Rwanda National Ethics committee (RNEC) (No.182/RNEC/2018). According to Emmanuel, Wendler, Killen and Grady (2016), it is important to subscribe to ethical standards [34], with the following issues being addressed: The anonymity of the target population was ensured by not having any personal identification attached to the data collection responses. Participants only agreed to volunteer if sensitive information was held in confidence. For the questionnaire, confidentiality was guaranteed by using coding and storing the completed forms in a locked cupboard in a locked room at the School of Nursing at the University of KwaZulu-Natal, which will be kept for a period of 5 years before being shredded. Only the researcher and the research supervisor have access to the data collected and copies of relevant review documents. The participants need to understand their contribution to the study and what the researcher is asking them to do. Thus, participation in this study was voluntary and details about the aims, research methods (what was done to collect data), objectives and the potential outcomes were explained. All participants completed a written informed consent form and each was given a signed copy for their personal records. During the research process, the participants were informed that participation was voluntary, they had the right to withdraw at any stage and not to answer any questions without this affecting their employment in any way [34].