Caring for Providers to Improve Patient Experience (CPIPE) Study

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PROJECT SUMMARY: An estimated 800 pregnancy-related deaths occur daily. Most of these deaths occur in low- and middle-income countries (LMICs), with about two-thirds in sub-Saharan Africa (SSA) alone. Skilled care in health facilities is critical to improving maternal and neonatal outcomes. Yet, only about two-thirds of births in SSA occur in health facilities—with wide disparities, especially by socioeconomic status (SES). Poor person-centered maternal care (PCMC) is a key driver of both the low rates of facility-based deliveries and disparities. Further, where facility-based childbirth rates have increased, poor PCMC leads to morbidity and mortality due to delayed, inadequate, unnecessary, or harmful care. Yet, there is limited research on interventions to improve PCMC in LMICs; and existing interventions do not explicitly address inequities in PCMC experiences. To address this gap, we designed the “Caring for Providers to Improve Patient Experience” (CPIPE) intervention to address drivers of poor PCMC and center the unique needs of vulnerable women in LMICs. CPIPE is a theory and evidence-based intervention with 5 components: provider training, peer support, mentorship, embedded champions, and leadership engagement. The training is a simulation-based curriculum that integrates content on PCMC, stress, burnout, and bias into emergency obstetric and neonatal care drills. We target provider stress and bias because they are mutually reenforcing factors driving poor and inequitable PCMC. The other intervention components create an enabling environment for behavior change. Our pilot studies show high feasibility, acceptability, and preliminary effectiveness. We therefore propose a cluster randomized-controlled trial, in 40 high-volume delivery health facilities in Kenya and Ghana, to assess the impact of CPIPE on PCMC and intermediate and distal outcomes in our conceptual model. We will accomplish this through 3 aims. Aim 1: to assess the effectiveness of the CPIPE intervention on PCMC in Kenya and Ghana. We hypothesize that CPIPE will improve PCMC for all women, and especially for low SES women. Our primary outcome is PCMC measured with the PCMC scale through multiple cross-sectional surveys of mothers who gave birth in the preceding 9 weeks in study facilities at baseline (prior to intervention), midline (6 months post-baseline), and endline (12 months post-baseline) (N=2000 at each time point). A sub-aim 1 will assess the cost-effectiveness of CPIPE. Aim 2: to examine the mechanisms of impact of CPIPE on PCMC. We will assess the effect of CPIPE on intermediate outcomes such as provider knowledge, self-efficacy, stress, burnout, and bias levels; and conduct mediation analysis to assess if changes in these outcomes account for the effect of CPIPE on PCMC. Aim 3: to assess impact of the CPIPE intervention on distal outcomes including maternal health seeking behavior and maternal and neonatal health; and examine if changes in PCMC account for these effects.