Did a quality improvement intervention improve quality of maternal health care? Implementation evaluation from a cluster-randomized controlled study

Int J Qual Health Care. 2020 Apr 21;32(1):54-63. doi: 10.1093/intqhc/mzz126.


Objective: To test the success of a maternal healthcare quality improvement intervention in actually improving quality.

Design: Cluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls.

Setting: Four districts in rural Tanzania.

Participants: Health facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline).

Interventions: In-service training, mentorship and supportive supervision and infrastructure support.

Main outcome measures: We measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis.

Results: Quality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0-75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators.

Conclusions: A multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.

Keywords: Tanzania; cluster-randomized controlled study; implementation science; maternal health; quality improvement; quality measurement.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Adult
  • Delivery, Obstetric / standards
  • Female
  • Humans
  • Infant, Newborn
  • Inservice Training
  • Male
  • Maternal Health Services / organization & administration*
  • Maternal Health Services / standards
  • Patient Satisfaction / statistics & numerical data
  • Pregnancy
  • Primary Health Care / methods
  • Primary Health Care / organization & administration
  • Quality Improvement / organization & administration*
  • Quality of Health Care / organization & administration*
  • Quality of Health Care / standards
  • Rural Population
  • Surveys and Questionnaires
  • Tanzania