Table 1 A summary of PTBi intrapartum package intervention, contextual modifications, and key insights

Data strengthening

GA estimation and indicator definition review. Data quality/completeness monitoring and feedback

5 data specialists in Kenya, and 2 in Uganda

Continuous support rather than a single training

Continuous support rather than a single training

• Staff shortages, inconsistent supply of appropriate resources/reporting tools, and data storage infrastructure affected implementation

• Challenge to identify and select key people to participate in data trainings, which affected reach

• Facility staff’s lack of internet access to view Data Dashboard limited its utility at study sites

• Bottom up approach could be better complemented by MoH engagement for sustainability prospects

Modified WHO Safe Childbirth Checklist

A modified checklist with 5 pause points and a focus on identification and care of preterm/low birthweight babies

2 clinical staff team and 2 data specialists in Uganda, 4 clinical staff team in Kenya

Split up per pause points and integrated in the maternity patient chart to make it user friendly and for consistency

Integrated into the maternity inpatient chart by being attached either at the back or in front of the patient chart. A small monetary incentive implemented

• Modification of mSCC raised profile of preterm babies

• Duplicative nature between patient chart and mSCC created unnecessary documentation and burden for personnel

• Financial incentive in Kenya threatened sustainability of tool

• Continued use of mSCC is reliant on administration and policymakers

PRONTO simulation training and mentorship

Simulation-based training and mentorship focusing on intrapartum and immediate newborn care. Complemented by clinical bedside mentoring

10 mentors (2 nurses and 8 clinicians) in Uganda and, 5 nurses in Kenya

• Curriculum adjusted to reflect Ugandan MOH protocols and guidelines

• Curriculum revised to focus on newborn care, particularly preterm care

• The duration of mentorship was increased from one to two days to enable bedside mentorship

• Additional clinical mentorship visits included for 2-day bedside mentorship

• Facility mentorship days reduced from 5 to 4 days per week to give room for adequate debrief and preparation for the next facility/ week work.

• Curriculum aligned with the existing Kenya MOH protocols

• Additional adjustments made to address (a) Birth preparedness for preterms; (b) referral management; and (c) immediate management and transfer of a preterm in a warm environment (skin-skin, KMC, warming blankets, referral systems)

• PRONTO approach and onsite mentorship enhanced the learning experience

• High staff turnover/rotation affected consistency of PRONTO participation and dosages in training across curriculum

• Contextual suitability and sustainability of PRONTO warrants further attention, such as training cascades (e.g., expert and resident mentors)

Quality improvement Collaborative

Model for Improvement approach: QI teams conduct PDSA cycles and share experiences in learning sessions. Indicators to track progress included: GA estimation, ACS to eligible mothers, and KMC care

1 QI coach and 10 PRONTO mentors in Uganda, 2 QI coaches in Kenya

Included process indicators of mSCC, partograph, and monitoring of sick and small newborn babies

Included process indicators mSCC, partograph monitoring, and referrals

• QI was closely linked to the 3 other interventions leading to perceived improvements in teamwork, communication and self-efficacy

• Adherence to QI meeting frequency and attendance varied, underscoring importance of facilitation and management

• Alignment with county and other ongoing implementation/QI efforts was critical to ensure complementarity in activities and resources