Patient-experience during delivery in public health facilities in Uttar Pradesh, India

Knowledge of gendered needs among the planners and policy makers for prevention of NCDs in Bangladesh: a qualitative exploration

BACKGROUND

Globally, non-communicable diseases (NCDs) are increasingly the primary cause of mortality and morbidity among women. Like many developing countries, Bangladesh also faces a growing burden of NCDs. The "Multisectoral Action Plan for Prevention and Control of Non-communicable Diseases, 2018-2025" signifies Bangladesh's commitment to comprehensively combating the rising burden of NCDs. This study investigates the perceptions of those involved in developing the action plan and if/how a gender lens was incorporated into its implementation.

METHODS

In-depth interviews were conducted with 25 key individuals involved in a high-level committee to develop and implement Bangladesh's multisectoral action plan to address the burden of NCDs. Data were collected between July and November 2021, and thematic analysis was conducted.

RESULTS

The findings revealed that interviewees believed the multisectoral action plan adopted a population-wide approach without considering gender-specific needs. This study presents the explanations for this inattention under five themes: (1) A population-level approach to NCD prevention; (2) Understanding women's health beyond reproductive health; (3) Absence of gender-specific programs; (4) Lack of consideration of gender constraints on physical activity; and (5) Lack of collaborative efforts to address NCDs beyond the health ministry.

CONCLUSION

In conclusion, governments in countries like Bangladesh can develop more effective strategies to reduce the disease burden of NCDs among women by recognizing and addressing the gendered nature of preventive health. This can be achieved by promoting gender-responsive research, programs, and policy initiatives that consider women's specific health concerns, ultimately leading to better health outcomes for all.

Self-reported symptom burden among patients attending public health care facilities in India: Looking through ICPC-3 lens

INTRODUCTION

The objectives of this study were: 1) to describe the socio-demographics and classify the chief complaints and reasons to encounter facilities of patients presenting to public healthcare facilities; 2) to explore differences in these complaints and: International Classification of Primary Care-3 (ICPC-3) groups across socio-demographic and health system levels.

METHODS

This is a cross-sectional study conducted in three districts of Odisha, India. Within each district, the district hospital (DH), one Sub-district hospital (SDH) (if available), two Community health centers (CHCs), and two Primary health care centers (PHCs) were selected. Thus, a total of three DHs, three SDHs, six CHCs, and six PHCs were covered. Two tertiary healthcare facilities were also included. Patients aged 18 years and older, attending the Outpatient Departments (OPD) of sampled health facilities were chosen as study participants through systematic random sampling.

RESULTS

A total of 3044 patients were interviewed. In general, 65% of the sample reported symptoms as their chief complaint for reason of encounter, whereas 35% reported disease and diagnosis. The most common reasons to encounter health facilities were fever, hypertension, abdominal pain, chest pain, arthritis, skin disease, cough, diabetes, and injury. Among the symptoms, the highest number of patients reported the general category (29%), followed by the digestive system (16%). In the disease category, the circulatory system has the highest proportion, followed by the musculatory system. In symptom categories, general, digestive, and musculatory systems were the key systems for the reasons of encounter in outpatient departments irrespective of different groups of the population. In terms of different tiers of health systems, the top three reasons to visit OPD were dominated by the circulatory system, respiratory system, and musculatory system.

CONCLUSION

This is the first Indian study using the ICPC-3 classification for all three levels of health care. Irrespective of age, socio-economic variables, and tiers of healthcare, the top three groups to visit public health facilities according to the ICPC-3 classification were consistent i.e., general, digestive, and circulatory. Implementation of standard management and referral guidelines for common diseases under these groups will improve the quality and burden at public health facilities in India.

Mixed methods evaluation of the Caring for Providers to Improve Patient Experience intervention

OBJECTIVE

To assess the impact of the Caring for Providers to Improve Patient Experience (CPIPE) intervention, which sought to improve person-centered maternal care (PCMC) by addressing two key drivers: provider stress and bias.

METHODS

CPIPE was successfully piloted over 6 months in two health facilities in Migori County, Kenya, in 2022. The evaluation employed a mixed-methods pretest-posttest nonequivalent control group design. Data are from surveys with 80 providers (40 intervention, 40 control) at baseline and endline and in-depth interviews with 20 intervention providers. We conducted bivariate, multivariate, and difference-in-difference analysis of quantitative data and thematic analysis of qualitative data.

RESULTS

In the intervention group, average knowledge scores increased from 7.8 (SD = 2.4) at baseline to 9.5 (standard deviation [SD] = 1.8) at endline for stress (P = 0.001) and from 8.9 (SD = 1.9) to 10.7 (SD = 1.7) for bias (P = 0.001). In addition, perceived stress scores decreased from 20.9 (SD = 3.9) to 18.6 (SD = 5.3) (P = 0.019) and burnout from 3.6 (SD = 1.0) to 3.0 (SD = 1.0) (P = 0.001), with no significant change in the control group. Qualitative data indicated that CPIPE had an impact at multiple levels. At the individual level, it improved provider knowledge, skills, self-efficacy, attitudes, behaviors, and experiences. At the interpersonal level, it improved provider-provider and patient-provider relationships, leading to a supportive work environment and improved PCMC. At the institutional level, it created a system of accountability for providing PCMC and nondiscriminatory care, and collective action and advocacy to address sources of stress.

CONCLUSION

CPIPE impacted multiple outcomes in the theory of change, leading to improvements in both provider and patient experience, including for the most vulnerable patients. These findings will contribute to global efforts to prevent burnout and promote PCMC and equity.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana

BACKGROUND

Person-centered maternity care (PCMC) has become a priority in the global health discourse on quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequitable PCMC based on SES.

METHODS

Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers' perceptions of women's expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women's SES characteristics and providers' perceptions of women as 'difficult' or 'good'. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression.

RESULTS

The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger negative explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. Providers in private facilities had higher IAT scores than those in government hospitals.

CONCLUSIONS

The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.

Associations between self-reported obstetric complications and experience of care: a secondary analysis of survey data from Ghana, Kenya, and India

BACKGROUND

Although several indicators have been proposed to measure women's experience of care in health facilities during the intrapartum period, it is unknown if these indicators perform differently in the context of obstetric emergencies. We examined the relationship between experience of care indicators from the Person-Centered Maternity Care (PCMC) scale and obstetric complications.

METHODS

We used data from four cross-sectional surveys conducted in Kenya (rural: N = 873; urban: N = 531), Ghana (N = 531), and India (N = 2018) between August 2016 and October 2017. The pooled sample included 3953 women aged 15-49 years who gave birth within 9 weeks prior to the survey. Experience of care was measured using the PCMC scale. Univariate, bivariate, and multivariable analyses were conducted to examine the associations between the composite and 31 individual PCMC indicators with (1) obstetric complications; (2) severity of complications; and (3) delivery by cesarean section (c-section).

RESULTS

16% (632) of women in the pooled sample reported obstetric complications; and 4% (132) reported having given birth via c-Sect. (10.5% among those with complications). The average standardized PCMC scores (range 0-100) were 63.5 (SD = 14.1) for the full scale, 43.2 (SD = 20.6) for communication and autonomy, 67.8 (SD = 14.1) for supportive care, and 80.1 (SD = 18.2) for dignity and respect sub-scales. Women with complications had higher communication and autonomy scores (45.6 [SD = 20.2]) on average compared to those without complications (42.7 [SD = 20.6]) (p < 0.001), but lower supportive care scores, and about the same scores for dignity and respect and for the overall PCMC. 18 out of 31 experience of care indicators showed statistically significant differences by complications, but the magnitudes of the differences were generally small, and the direction of the associations were inconsistent. In general, women who delivered by c-section reported better experiences.

CONCLUSIONS

There is insufficient evidence based on our analysis to suggest that women with obstetric complications report consistently better or worse experiences of care than women without. Women with complications appear to experience better care on some indicators and worse care on others. More studies are needed to understand the relationship between obstetric complications and women's experience of care and to explore why women who deliver by c-section may report better experience of care.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Self-reported provision of person-centred maternity care among providers in Kenya and Ghana: scale validation and examination of associated factors

INTRODUCTION

Person-centred maternity care (PCMC), which refers to care that is respectful and responsive to women's preferences needs, and values, is core to high-quality maternal and child health. Provider-reported PCMC provision is a potentially valid means of assessing the extent of PCMC and contributing factors. Our objectives are to assess the psychometric properties of a provider-reported PCMC scale, and to examine levels and factors associated with PCMC provision.

METHODS

We used data from two cross-sectional surveys with 236 maternity care providers from Ghana (n=150) and Kenya (n=86). Analysis included factor analysis to assess construct validity and Cronbach's alpha to assess internal consistency of the scale; descriptive analysis to assess extent of PCMC and bivariate and multivariable linear regression to examine factors associated with PCMC.

FINDINGS

The 9-item provider-reported PCMC scale has high construct validity and reliability representing a unidimensional scale with a Cronbach's alpha of 0.72. The average standardised PCMC score for the combined sample was 66.8 (SD: 14.7). PCMC decreased with increasing report of stress and burnout. Compared with providers with no burnout, providers with burnout had lower average PCMC scores (β: -7.30, 95% CI:-11.19 to -3.40 for low burnout and β: -10.86, 95% CI: -17.21 to -4.51 for high burnout). Burnout accounted for over half of the effect of perceived stress on PCMC.

CONCLUSION

The provider PCMC scale is a valid and reliable measure of provider self-reported PCMC and highlights inadequate provision of PCMC in Kenya and Ghana. Provider burnout is a key driver of poor PCMC that needs to be addressed to improve PCMC.

Understanding disparities in person-centred maternity care: the potential role of provider implicit and explicit bias

Studies in low-resource settings have highlighted disparities in person-centred maternity care (PCMC)-respectful and responsive care during childbirth-based on women's socioeconomic status (SES) and other characteristics. Yet few studies have explored factors that may underlie these disparities. In this study, we examined implicit and explicit SES bias in providers' perceptions of women's expectations and behaviours, as well as providers' general views regarding factors influencing differential treatment of women. We conducted a convergent mixed-methods study with 101 maternity providers in western Kenya. Implicit SES bias was measured using an adaptation of the Implicit Association Test (IAT) and explicit SES bias assessed using situationally specific vignettes. Qualitative data provided additional details on the factors contributing to disparities. Results provide evidence for the presence of both implicit and explicit bias related to SES that might influence PCMC. Differential treatment was linked to women's appearance, providers' perceptions of women's attitudes, assumptions about who is more likely to understand or be cooperative, women's ability to advocate for themselves or hold providers accountable, ability to pay for services in a timely manner, as well as situational factors related to stress and burnout. These factors interact in complex ways to produce PCMC disparities, and providing better care to certain groups does not necessarily indicate preference for those groups or a desire to provide better care to them. The findings imply the need for multilevel approaches to addressing disparities in maternity care. This should include provider training on PCMC and their biases, advocacy for women of low SES, accountability mechanisms, and structural and policy changes within health care settings.

Institutional deliveries in India's nine low performing states: levels, determinants and accessibility

Background

Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality.

Objective

This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities.

Methods

A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings.

Results

Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility.

Conclusions

The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.

Do you need to pay for quality care? Associations between bribes and out-of-pocket expenditures on quality of care during childbirth in India

While it is mandated that reproductive and child health services be provided for free at public facilities in India, qualitative evidence suggests it is common for facilities to request bribes and other informal payments for medicines, medical tests or equipment. This article examines the prevalence of bribe requests, total out-of-pocket expenditures (OOPEs) and associations between bribe requests and total OOPEs on the experience of quality of care and maternal complications during childbirth. Women who delivered in public facilities in Uttar Pradesh, India were administered a survey on sociodemographic characteristics, bribe requests, total OOPEs, types of health checks received and experience of maternal complications. Data were analysed using descriptive, bivariate and multivariate statistics. Among the 2018 women who completed the survey, 43% were asked to pay a bribe and 73% incurred OOPEs. Bribe requests were associated with lower odds of receiving all health checks upon arrival to the facility (aOR = 0.49; 95% CI: 0.24-0.98) and during labour and delivery (aOR = 0.44; 95% CI: 0.25-0.76), lower odds of receiving most or all health checks after delivery (aOR = 0.44; 95% CI: 0.31-0.62) and higher odds of experiencing maternal complications (aOR = 1.45; 95% CI: 1.13-1.87). Although it is mandated that maternity care be provided for free in public facilities in India, these findings suggest that OOPEs are high, and bribes/tips contribute significantly. Interventions centred on improving person-centred care (particularly guidelines around bribes), health system conditions and women's expectations of care are needed.

Results of a person-centered maternal health quality improvement intervention in Uttar Pradesh, India

Background

Poor patient experiences during delivery in Uttar Pradesh, India is a common problem. It delays presentation at facilities after the onset of labor and contributes to poor maternal health outcomes. Patient-centered maternity care (PCMC) is recognized by the World Health Organization as critical to overall quality. Changing PCMC requires changing the process of care, and is therefore especially challenging.

Methods

We used a matched case-control design to evaluate a quality improvement process directed at PCMC and based on widely established team-based methods used in many OECD countries. The intervention was introduced into three government facilities and teams supported to brainstorm and test improvements over 12 months. Progress was measured through pre-post interviews with new mothers, scored using a validated PCMC scale. Analysis included chi-squared and difference-in-difference tests.

Findings

On a scale to 100, the PCMC score of the intervention group increased 22.9 points compared to controls. Deliveries attended by midwives, dais, ASHAs or non-skilled providers resulted in significantly higher PCMC scores than those attended to by nurses or doctors. The intervention was associated with one additional visit from a doctor and over two additional visits from nurses per day, compared to the control group.

Interpretation

This study has demonstrated the effectiveness of a team-based quality improvement intervention to ameliorate women’s childbirth experiences. These improvements were locally designed and led, and offer a model for potential replication.

Providing respectful maternity care in northern Ghana: A mixed-methods study with maternity care providers

OBJECTIVE

This study explored providers' perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices.

DESIGN

Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities SETTING: Government health facilities in rural northern Ghana PARTICIPANTS: 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care.

MEASUREMENTS AND FINDINGS

We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions.

KEY CONCLUSIONS

Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present.

IMPLICATIONS FOR PRACTICE

Further research and programmatic efforts are needed to address the gap between knowledge and behavior.