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Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)

Summary document of the experiences from the Maternal and Newborn Health in Ethiopia Partnership

MaNHEP LEarNiNg SESSioNS

May 2013

MaNHEP Learning SessionsSummary document of the experiences from the

Maternal and Newborn Health in Ethiopia Partnership

Kim Ethier Stover, Ma, University research Co., LLC

Solomon Tesfaye, MD, MPh, University research Co., LLC

ContributorsNigel Livesley, Lynn Sibley, Kenneth Hepburn

acknowledgementsThe authors gratefully acknowledge and thank the Bill and Melinda gates Foundation, the Ethiopia

Federal Ministry of Health and amhara and oromiya regional Health Bureaus, and the Degem, Kuyu, Warajarso, North achefer, South achefer, and Mecha Woreda Health offices for their support of the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP). We also thank MaNHEP partners

University research Co., LLC, Emory University, and John Snow research and Training institute, who participated in and facilitated the work contained in this document on Learning Session report,

and the coaches, frontline health workers, women and families who participated in the quality improvement activities. The views expressed in this report are solely those of the authors.

Table of Contents

acronyms .................................................................................................................... vi

Introduction............................................................................................................. 1

What.are.Learning.Sessions?................................................................................... 2

How.are.Learning.Sessions.facilitated?................................................................... 3

Sharing experiences .................................................................................................. 3

Panel discussion ..................................................................................................... 3

Poster presentations ............................................................................................... 3

Small group Discussions ........................................................................................ 5

Story telling ............................................................................................................ 5

Knowledge café ...................................................................................................... 6

action plans .............................................................................................................. 7

MaNHEP.Learning.Session.Objectives.and.Agendas.............................................. 8

regional Learning Session 1 ..................................................................................... 8



regional Learning Session 4 (Joint) ........................................................................ 10

regional Learning Session 5 ................................................................................... 10

Woreda Learning Session 1 ..................................................................................... 11



Maternal and newborn HealtH in etHiopia partnersHipvi

acronymns

aNC antenatal care

BCC Behavior change communications

CMNH Community Maternal and Newborn Health

HCW Health care workers

HEW Health Extension Workers

LS Learning Session

MaNHEP Maternal and Newborn Health in Ethiopia Partnership

MNH Maternal and Newborn Health

PDSa Plan Do Study act

PNC Postnatal care

Qi Quality improvement

MaNHEP LEarNiNg SESSioNS 1

introduction

The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), funded by the Bill

and Melinda gates Foundation, was designed to support communities in 2 regions of Ethiopia to provide care to mothers and babies in the birth to 48 hours after birth period. a quality improvement approach was one of the key components of supporting communities together with training in the Community Maternal and Newborn Health (CMNH) Package and a behavior change communications (BCC) strategy.1 The improvement strategy centered on quality improvement (Qi) teams of family members, health care workers (HCWs), and community members developing and testing changes to the way they provide care to mothers and babies. They were supported by

MaNHEP staff and coaches from health centers and Woreda (district) Health offices. improvement areas included identification of pregnant women, registration at antenatal care (aNC), attendance at CMNH family meetings, notification of labor and birth and postnatal care (PNC) within 2 days. Every four to six months, MaNHEP and the regional Health Bureau would bring together the community level teams for an interactive workshop called a “Learning Session” (LS). This document outlines briefly how these sessions were organized and facilitated with a focus on approaches to sharing experiences. The design and facilitation of learning sessions draws heavily from the experience of the USaiD Health Care improvement project’s work on knowledge management.

1 additional information on the project activities can be found at www.MaNHEP.org.

Maternal and newborn HealtH in etHiopia partnersHip2

What are Learning Sessions?

Learning Sessions are workshops conducted with representatives of community teams

and coaches from project sites to review their progress and data and share experiences; to present aggregated progress; to initially teach and later reinforce basic improvement skills; to introduce new improvement areas; and to plan next steps at the community level.

The project conducted five regional level Learning Sessions, and the focus for each session differed depending on the stage of improvement and competency of the improvement teams. Learning Session 1 focused on training Qi team

representatives and coaches on improvement skills.2 Learning Sessions 2 – 5 were focused on sharing experiences between sites, synthesizing learning across sites, reinforcing improvement skills, and preparing plans for the next cycle of testing changes.

During the implementation periods between regional level Learning Sessions, MaNHEP also facilitated day-long woreda level Learning Sessions for coaches and Qi teams. These woreda level workshops included almost all Qi team members, providing a chance for all members to share and learn from others. These Learning Sessions created an ideal opportunity to synthesize change ideas across teams and determine which were most effective.

2 The training approach and materials are presented in a separate document.


How are Learning Sessions facilitated?

Sharing experiencesMaNHEP used several different methods in combination to promote sharing experiences between team members. These included panel discussions, poster presentations, storytelling, small group discussions and knowledge cafes; each method is more fully described below.

Panel.discussionThe objective of a panel discussion was to learn from high performing sites. Coaches and staff chose teams with exceptional results and conducted an interview-style panel discussion to highlight their work and what other sites could learn from them. We used the panel discussion as simple way of sharing and at the same time reviewing improvement skills in the early stage of improvement at LS 2.

The panel discussion lasted for 1 to 1.5 hours. Each team was given 5 minutes to present on their work, guided by questions prepared by the facilitator, a MaNHEP staff member. The facilitator was prepared with information on what these teams had accomplished by other staff and coaches in order to be able to ask pertinent questions. The other LS participants were given the chance to ask some clarifying questions of the panel. We followed the panel discussion with small group work to discuss how other teams could learn from what they heard.

Poster.presentationsPoster presentations provided participants with a chance to share what they have done in a semi-structured way with guidance on content provided by MaNHEP. The content and presentation style progressed over time, beginning with individual team’s simple changes and moved to more analysis and aggregation of learning. By the last two learning sessions, Qi teams had enough data points to analyze their level of improvement.

Posters served as the basis of an oral presentation, were clear enough for others to read on their own and provided a reference document for small group discussions. Participants were given between 1 and 1.5 hours to prepare a poster based on information they have been asked to bring regarding the changes they have tried, what has worked, what has not worked and the data which supports these claims. it was useful to give participants time during the learning session to prepare their posters. First, participants often did not have the materials (flip chart paper and markers) in their communities to create posters. Second, it provided a chance for coaches to work with teams to ensure that the information provided was clear, useful and relatively standard across teams.

Depending on the learning session, teams either prepared one poster on their best achievement or a short poster for each of the key care steps. Dividing team representatives into groups and limiting the number of oral presentations based on the

MaNHEP’s Experience – Example of instructions for panel facilitator

The facilitator might ask “Please tell us about how you identified pregnant women. What is working well? What is difficult? Why is it helpful?” and similar questions to prompt the team to speak on-point. if they talk about their activities without specifically mentioning their “good” area, the facilitator needs to ensure that they follow up with a question on what this team has done well.

For the remaining 30 minutes, hold a debrief plenary discussion:

• What was useful in how they explained what they did? How is this similar/different from what you’ve experienced?

• What did you learn from listening to these kebeles?

• Pick one or two examples of kebeles describing changes as examples, ask the participants how well they described what they did. Could you repeat this process based on what they told you? What was helpful to know? We want to use this final question as an opportunity to get them to think about what they should include in their poster and presentation.


poster allowed each team to hear all of the other experiences without the complication of ensuring that every person hears every presentation.

Facilitation of poster presentations was done in different ways from completely unstructured such as allowing participants to wander and ask questions to structured facilitation such as dividing participants into groups and assigning them specific presentations to attend. We often used a combination of approaches by dividing team representatives into groups and later providing some unstructured time for participants to read posters on their own. given that some of the audience was illiterate, an oral presentation explaining what was on the posters was necessary.

Each group rotated through its assigned poster presentations, stopping at each for 10 to 15 minutes, for instance with 5 minutes to present and 5 minutes of Q&a. The groups were each assigned a facilitator (project staff or coach) to help keep time and organize the discussion. Participants were told to think about the following questions as they rotated through presentations:

• How do you know the changes tested were successful?

• are these changes similar or different to what you have done in your kebele?

• are there any ideas which you have heard that you want to try in your kebele?

For some learning sessions, we focused on synthesizing the ideas at the project level. For this activity, we asked woredas to summarize common changes across their woreda based on the woreda-level learning sessions and present aggregated data. Discussions around these posters focused on developing a list of successful changes from across the project regions. Participants were told to think about questions such as the ones below:

• What similarities do you observe among woredas?

• What differences do you observe among woredas?

• Did you observe significant improvement in any of the care steps? Which steps? Which woreda? What do you think are the reasons for those improvements? Do you think that this improvement will be sustained?

• What lessons will you draw from each of the woredas?

• What challenges have you heard from each of the woredas?

• What recommendations/suggestions will you give for each of the woreda?

The poster presentations generally serve as preparation and information gathering for later small group discussions. often, the poster presentation session was followed up by a short report out from each group of key themes around similarities, successes, failures and lessons learned.

MaNHEP’s Experience – Example of poster presentation guide

a. Choose one step in the process for which you feel that you had good success (pregnancy identification, registration at aNC, labor/birth notification) and you will prepare a poster on that area. Please choose only one so we can get some more focused information and learn from you. You will have the chance to discuss other things you did in small group work.

B. Create a poster which has the following information:

• Care.Step:.(only oNE) Pregnancy identification, registration at aNC, labor/birth notification).

• Challenges: List what some of the major challenges were to implementing that care step.

• Changes.tested: List all of the things you have tried to overcome these challenges and/or create a clear process for the care step. (Note: Do not only list who did the change, but what they did. For instance, “Used model households to go house to house and explain the importance of telling the HEW that a women is pregnant.

• Successful: Describe briefly what changes work and give the data you have which shows that it was successful. (Note: if the teams have more than one month of data, facilitators could assist them in plotting a graph for the related indicator.)

• Unsuccessful: Describe briefly what changes you tried that did not work and give the reasons for how you know it was unsuccessful.


Small.Group.DiscussionsSmall group discussions provided opportunities for participants to discuss in depth what they had done, what they had heard and what they had learned. Keeping the small groups under 15 people and ideally around 10 people allowed for better discussion and interaction. a guide was provided to each group; the guide listed discussion questions and was expected to provide a short report out following the group discussion. Depending on topic and number of questions, these discussions might range from 30 minutes to 2 hours.

Story.tellingStorytelling is a simple way of facilitating sharing by having participants recount a story that is particularly meaningful to them and do so in 2 or 3 minutes in a small group. This gives participants a chance to learn from real stories of what has happened in other places and encourages group interaction. We often used this approach to begin a learning session and get people engaged. Storytelling is also an important part of the CMNH training approach and was widely used during coaching sessions with teams.

MaNHEP’s Experience – Example of small group discussion

following poster presentation

give teams 1 hour to discuss the following questions for pregnancy identification, registration at aNC and labor/birth notification:

• open discussion for around 30 minutes on the following questions:– What good ideas did they hear from the poster

presentation discussions and how do they know these ideas worked (What does the data tell us?)? Did they do something similar?

– What did participants from your group do for these areas? Did the changes work well? How do you know?

• Discussion for an additional 30 minutes to think about the commonalities and differences they are hearing:– What were the common successful changes

you heard across sites? How do you know these worked?

– What were some of the changes that didn’t work?

• What are new changes you’ve heard which you might try in your kebeles?

Based on our experience, minimal facilitation works best to promote sharing. We encouraged participants to stand up and find 3 additional people who were not from their team. in the first round, these groups of 4 took turns with each person telling a 2-3 minute story on the given topic. a facilitator

MaNHEP’s Experience – Examples of small group discussions

at woreda learning session

Example 1Discussion guide on pregnancy identification, registration/aNC 1 and labor/birth notification:

1. What are your achievements so far, including stories? reflect on individual (kebele) level charts.

2. How did you achieve this? What kinds of change ideas are being tested?

3. How do you know this change idea worked? How can you relate your results to this effort?

4. What obstacles did you face and how did you overcome them?

5. What would you do to improve this care step?

Example 2Start with a few questions on what the problems are:

• What are the reasons for mothers and babies not to have care by a trained provider immediately after birth?

• What needs to happen for the mother and baby to receive care by trained provider immediately after birth?

• is it possible to improve visit of mother and babies immediately after birth by trained provider? How?

Then discuss opportunities for improvement:

• Share the ideas tested so far and results at woreda level (notification and PNC visit). relate this also with CMNH meetings.

• Share results/experiences from two successful kebeles in these areas. invite participants from these two kebeles to talk about their experiences.

• Discuss common issues/challenges across all the sites in improving PNC visit.

• Discuss areas to look on developing and testing new ideas; related this with the discussion the team had on process mapping around labor and birth during last mini learning session.

• Could each of the team plan for 70% PNC coverage in the next three to four months?


announced when a certain amount of time had gone by to ensure that each person had a chance to speak, for instance by saying “Next story” every 3 minutes. once the first round ended, they formed new groups of 4 and told the same story to new people. Each round took approximately 15 minutes to form the group and tell stories. The number of rounds conducted varied depending on the available time. Following the rounds, we encouraged a few volunteers to tell us in plenary about a story they heard (not their own) which they felt was powerful to wrap up the exercise.

MaNHEP’s Experience – Example of storytelling topics

• Most successful change you have made in your kebele.

• Story of a life saved because of the new way of working.

Knowledge.café.Knowledge café is an approach to facilitating small group discussions to encourage in depth discussion of a topic in order to learn as much as possible. This is done by having groups rotate through discussion topics, building on the discussion of the previous group. We used this approach to review progress on improvement areas and give participants a chance to have discussions around the successes, failures and challenges of their improvement work.

We began by breaking the participants into smaller groups and running three or four parallel sessions in which each group had subgroups focusing on 3 or 4 questions. Each table was dedicated to a specific question and was assigned two to three facilitators responsible for guiding the conversation and taking notes on one specific questions. The subgroups would spend 30 to 45 minutes addressing the question at their table, then rotate to the next question. During the second round, the facilitators would summarize the key conversation points from the first subgroup, and the second subgroup would then pick up and add to the conversation. The subgroups continue to rotate through the questions until all the subgroups have discussed all of the questions.

MaNHEP’s Experience – Example of knowledge café questions

Discussion.guide.on.labor/birth.notification.and.PNC.visit.within.48.hrs

1. reflect on achievements of kebeles so far in relation to the grouping? What is common for each group? What do you learn from each group? Try to briefly review individual (kebele) level chart.

2. What do you learn from those kebeles with variable or sustained improvement? What processes are being used in these kebeles, processes that are common or different?

3. What kinds of change ideas are being tested in each kebele? How do you know this change idea works? How does each kebele review/relate result with the change idea being tested?

Discussion.guide.on.CMNH.meeting

1. What do you learn from those kebeles with organized effort and signs of improvement? What processes are in use in these kebeles, processes that are common or different? What does the detail tell us?

2. How do you make sure that the PW completes all four CMNH meetings before delivery?

3. What changes did you observe from the mother going through the CMNH meeting?

4. Which areas need to be focused on for improving percent of mothers/families completing CMNH meetings in the next period? Do you suggest any idea to test?

There were multiple tables of the same question which necessitated summarizing the information. all of the facilitators who were focused on a specific question took time to combine the lessons learned. Some of the guiding questions for reporting back included:

• What changes were tested? How did teams make improvements? What is different from before?

– What changes are common across teams?

– Provide an example of a change, how many teams have tried it and a few specific examples of implementation.

– Were there examples of changes that didn’t work at all or were minimally effective?

• What are some NEW and different ideas that the team has to address challenges in this area?


action plansThe final session in any Learning Session was the development of formatted action plans and next steps for Qi teams. Since only a few representatives attended a given Learning Session, these plans focused on their recommendations to the entire team based on what they had learned and heard. Qi team representatives would sit together and would be supported by coaches.

MaNHEP’s Experience – Action plan format

Kebele.name

Report.to.team

Note what you would like to share with the team about this Learning Session. What ideas did you hear that you think you might try? What was important from what you heard?

Plan.first.test.

1. What are you trying to accomplish?

2. What idea do you want to test? Why do you think it will work?

3. Plan your test. (Who is responsible for what action? When will they do it? What do they need to know to be able to implement the test?)

4. What is your measure? How will you know whether your test worked?

5. Plan your measure. (What data is needed? Where will it come from? Who will collect it? When will they collect it? Who will summarize the data and plot it on a graph?)

remember that this is a proposed plan. You need to share it with your team and get their input before you implement.


MaNHEP Learning Session objectives and Sample agendas

This section provides examples of the objectives and sample agendas from the regional level and

woreda level learning sessions including the time spent on specific activities. These general agendas would be modified for the specific region or woreda but the same major components were common for all groups.

regional Learning Session 1The objectives for Learning Session 1 included that participants to be able to:

• articulate the key concepts of quality improvement

• Develop a plan for the first Plan-Do-Study-act (PDSa) cycle together with the Qi team

• Understand how to collect and analyze data and begin ongoing measurement

The participants at the first learning sessions discussed major MNH care steps and decided to work (as a collaborative) on three improvement areas for the first activity period. The improvement areas for the first activity period are: pregnancy identification, pregnancy registration and labor/birth notification to HEWs. The specific information on how this training was conducted can be found in a separate document.

regional Learning Session 2The objectives of Learning Session Two were to:

• Update/refresh skills of Qi teams on improvement approaches

• Provide a forum for kebele Qi teams to discuss their progress in improving maternal and neonatal health around the time of birth

• Facilitate sharing between kebele Qi teams on best practices

Time Activity

Day.1

Session 1 40 minutes overview of MaNHEP

Session 2 1 hour What is the problem?

Session 3 2 hours How do we solve problems?

Session 4 1 hour What are we trying to accomplish?

Session 5 1:30 hours How do we know the change is an improvement?

Day.2

Session 6.1 2 hours What changes can make an improvement? Part 1 – Process

Session 6.2 1 hour What change can make an improvement? Part 2 – Teamwork

Session 6.3 2:30 hours What change can make an improvement? Part 3 – Developing changes

Section 7 40 minutes PDSa

Day.3

Section 8 1:30 hours Selected indicators and data collection tools

Section 9 1:30 hours analysis of data

Section 10 30 minutes Sharing Experiences/Collaborative improvement

Section 11 50 minutes introduction to action Plan

Sample Agenda: Regional Learning Session 1


• introduce the CMNH meeting as new care step for improvement and plan for next activity period

The focus improvement areas for the first activity period were pregnancy identification, pregnancy registration and labor/birth notification to HEWs. Trained coaches from health centers and woreda offices together with project staff (MNH specialist) provided on-site support for each kebele level team. on average each site was visited three times in the

Time Activity

Day.1

Session 1 1 hour Drama3; Understanding improvement

Session 2 1:30 hour Panel discussion on creating and testing changes

Session 3 1:15 hour Creating poster presentations on best changes

Session 4 1 hour Poster presentation in small groups

Session 5 2:15 hour Small group discussion of best changes and sharing experiences

Day.2

Session 6 1:15 hour introduction of new care steps – CMNH meetings

Session 7 30 minutes overview of data collection tools

Session 8 1:30 hours Kebele team planning


3 See MaNHEP basic quality improvement training for teams and coaches for details on the drama.

time between Learning Sessions one and Two. in addition, CMNH meetings were introduced as an area for improvement in the second learning session.

regional Learning Session 3The objectives of Learning Session 3 were to:

• review progress in improving MNH around the time of birth

• Share the best experiences in implementing MNH care at the community level

Time Activity

Day.1

Session 1 1:30 hours Story telling in a group of three to four people; reflection (story telling)

Session 2 45 minutes reviewing the regional Performance – Presentation

Session 3 30 minutes CMNH meeting – Presentation

Session 4.1 3 hours Small group discussion

Day.2

Session 4.2 1 hourreport back (summary presentation) of small group discussion; reflection on small group discussion

Session 5 45 minutes Poster presentation

Session 6 2 hoursrecording, reporting and plotting data; Small group discussion on data management; report back

Session 7 1:30 hours Focus for the next activity period

Session 8 1 hour Planning for the next activity period



• Discuss recording, reporting and plotting data for monitoring improvements in MNH care

regional Learning Session 4 (Joint) The objectives of Learning Session 4 were to:

• Share lessons from the implementation of MNH care at the community level across all project sites in two regions

• Discuss and plan how to implement/integrate successful ideas into community activities permanently

• Discuss challenging care steps and identify ideas for improvement

• introduce new improvement areas of misoprostol use and referral

regional Learning Session 5The objectives for Learning Session 5 were to:

• Share successful changes and lessons learned in the implementation of CMNH care package

• Collect information on new, successful changes implemented since May 2012 in order to update the change package

Time Activity

Day.1

Session 1 1 hour reviewing overall Performance in all improvement areas

Session 2 3:30 hoursWoreda poster presentation; report back - summary presentation; reflection/discussion

Session 3 20 minutes Update on BCC activities

Session 4 20 minutes implementation cycle

Session 5.1 2 hours Small group discussion

Day.2

Session 5.2 1 hourreport back of small group discussion; reflection on small group discussion

Session 6 30 minutesimproving recording and reporting data and related activities (audit, autopsy)

Session 7 30 minutesintroduction of new improvement areas & focus for next activity period


Time Activity

Day.1

Session 1 1:30 hours Survey

Session 2 2 hours group work – 1

Session 3 1:30 hours Poster presentation – woreda level; Discussion

Session 4.1 1:30 hours group work – 2

Day.2

Session 4.2 1 hours (group work – 2 continue): report back and discussion

Session 5 30 minutes regional level performance – presentation

Session 6 2:30 hours group work – 3



Woreda Learning Session 1The objectives for Woreda Learning Session 1 were to:

• Share successful experiences implementing MNH care at the community level

• review the progress of improving MNH care around the time of birth

Woreda Learning Session 2 The objectives of Woreda Learning Session 2 were to:

• review and synthesize ideas which worked well for pregnancy identification, registration and CMNH meeting enrollment.

Time Activity

Day.1

Session 1 40 minutes review and discussion

Session 2 30 minutes Performance review

Session 3 3 hours Small group discussion; report back and discussion

Session 4 1 hourSection 4a: Kebele team discussion Section 4b: Health center/woreda coaches discussion

Sample Agenda: Woreda Learning Session 1

Time Activity

Day.1

Session 1 1 hour Performance review

Session 2 3:30 hours Small group discussion; report back and discussion

Session 3 1 hour Kebele team discussion


Time Activity

Day.1

Session 1 1:30 hours review and Discussion

Session 2 1 hour Share experiences

Session 3 2 hours group discussion; report back and discussion

Session 4 1 hour Kebele level planning session


• review successful ideas, challenges and potential solutions for labor/birth notification

• Share experiences between kebeles

Woreda Learning Session 3The objectives of woreda Learning Session 3 were to:

• Focus participants on efforts to improve PNC visit by HEWs within 48 hours and brainstorm new ideas

• review successful ideas labor/birth notification, discuss challenges and possible solutions

• Share experiences between different kebeles

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