AFRO-NETS> Better Births Initiative (BBI)

[James Irlam <james@rmh.uct.ac.za>]

Better Births Initiative (BBI)
------------------------------
Source: Reproductive Health List <repro-l@healthlink.org.za>


A global initiative to promote humane, evidence based childbirth care
News and update: Feb. 2001

How was the Better Births Initiative conceived?

Women using state maternity services in resource-poor settings are 
often subjected to uncomfortable and degrading procedures for which 
there is no evidence of benefit. Busy health professionals frequently 
fail to treat them with respect. 

People living in resource-poor settings are more likely to develop 
complications during labour and suffer the adverse consequences from 
these problems. They cannot afford private care. They will avoid ser-
vices where unpleasant things happen to them, where staff are not 
welcoming and where there is a community perception of poor quality 
obstetric care. 

Therefore there is a need to address the quality of obstetric care in 
government facilities to improve the access and outcomes in poorer 
groups.

Care should be humane and comfortable for women. An added advantage 
is that this will enhance the reputation of the service, encourage 
women to attend, and contribute to better health in the mother and 
baby. Greater use of services is a key step in reducing the half a 
million maternal deaths in developing countries each year.

Initial discussions 

The International Association of Maternal and Neonatal Health 
(IAMANEH) conference in Stellenbosch, April 2000, provided the oppor-
tunity to present the Better Births Initiative concept document for 
discussion among delegates. Using breakaway discussion groups during 
the session, we sought comments and suggestions about the content and 
direction of the BBI. Consensus statements were fed back to the core 
collaborative group; the principles were modified, and the focus re-
fined.

Principles

HUMANITY: women treated with respect 
EVIDENCE: care that is based on the best available evidence 
COMMITMENT: health professionals committed to improving care 
ACTION: effective strategies to change current practices.

The BBI strategy

Using baseline studies, (conducted at government hospitals in China, 
South Africa and Zimbabwe), we documented the use of selected proce-
dures during labour, and sought provider's and women's views about 
the care received during childbirth (see website for more detail 
about these studies):
http://www.liv.ac.uk/lstm/bbimainpage.html

In addition to this observational data, we compiled evidence from 
clinical trials (and systematic reviews) to determine the benefits 
and harms of commonly used childbirth interventions. 

We then identified changes that can be easily implemented in low-
income labour wards. These changes will make care more evidence-based 
and humane, and in addition will save time and money:

1. Encouraging obstetric practices for which there is good evidence 
of benefit. For example, companionship during labour, mobility during 
labour, and non-supine position for birth.

2. Discouraging the routine use of procedures for which there is no 
evidence of benefit. This includes routine episiotomy, and routine 
enema.

3. Discontinuing procedures for which there is evidence of potential 
harm. For example, pubic shaving.

4. Implementing practices for which there is evidence of effective-
ness. This includes steroids for pre-term birth, and magnesium sul-
phate for eclampsia.

Implementing change

Few studies of methods of changing practice have been conducted in 
under-resourced settings, where large infrastructure and financial 
barriers to change exist. The Better Births Initiative aims to ad-
dress this by developing and testing innovative change mechanisms ap-
plied to primary obstetric care in the African region.

An educational package is being developed by the BBI. It focuses on a 
few key areas of midwifery and obstetric care, and comprises core ma-
terials to raise the demand for change, and innovative management 
strategies that involve providers in the process of change.

Materials include a workshop for labour ward staff with a workbook, 
posters, video material, a presentation of best evidence for proce-
dures during labour, a reference booklet, and a self-audit mechanism.

The workbook is used during the workshop to guide discussion around 
the benefits and harms of different procedures, and the opportunities 
and barriers to change. Posters show the principles of the Initia-
tive, and can be displayed in labour wards to signify the hospital's 
commitment to Better Births. The Powerpoint presentation provides an 
introduction to evidence-based practice, and focuses on the benefits 
and harms associated with commonly used procedures. It can be used by 
labour ward staff to introduce concepts of evidence-based practice 
for childbirth care to colleagues. The self-audit is a simple process 
that can be carried out periodically by staff to chart their progress 
towards Better Births. The video programme uses real experiences of 
women and providers in South Africa, and explains how companionship 
can be successfully introduced using minimum resources in labour 
wards in low-income countries.

Pilot study

A pilot implementation trial is in progress to test the BBI educa-
tional package.

The study is a cluster randomised design and is being conducted at 10 
purposively selected maternity units in Gauteng province, South Af-
rica. Sites were matched according to number of beds available. All 
sites received the workshop and associated materials, and one of each 
pair was randomly allocated to receive the self-audit mechanism in 
addition.

Baseline exit interviews with postnatal women were used to document 
use of procedures and women's experiences during childbirth. Work-
shops were conducted during September - November 2000, and the fol-
low-up phase is now in progress (February - March 2001).

Helen Smith (LSTM, UK) and Heather Brown (RHRU, Johannesburg) are co-
ordinating the follow-up and evaluation phase. Evaluation comprises 
four main components: a) determining whether the desired changes to 
practice were initiated; b) documenting the impact of the package on 
provider attitude towards change and knowledge of best practice; c) 
determining whether the package was used, and the self-audit imple-
mented; and d) if not, what were the barriers that prevented imple-
mentation. Methods used during follow-up include exit interviews with 
women, and focus group discussions and in -depth interviews with la-
bour ward staff who attended the initial workshops.

Future directions

The pilot study will be complete by April, and the materials modified 
to according to the evaluation findings. There is interest, from the 
Department of Health in South Africa and others internationally, to 
adapt and use the BBI package in other primary obstetric units.

We aim to make all the (modified) materials available on the BBI web-
site, so that any health professional working in a maternity unit can 
download the package and use it in his/her own setting. 

A BBI background document, plus the powerpoint presentation of best 
evidence have recently been added to the WHO Reproductive Health Li-
brary (look out for it on the 2001 edition). Other materials from the 
package will be added to future editions.

For more information

Visit the BBI website at: 
http://www.liv.ac.uk/lstm/bbimainpage.html

Contact for electronic mailing list:

Helen J Smith 
Research Assistant 
International Health Division 
Liverpool School of Tropical Medicine 
Tel: +44-151-708-9393 Ext. 2214 
Fax: +44-151-707-1702
mailto:cjdhel@liv.ac.uk 

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