The impact of a nurse mentoring program on the quality of labour and delivery care at primary health care facilities in Bihar, India

Developing and validating a tool for assessing the confidence in the competence of midwifery tutors in India on WHO core competency domains

Negligible quantitative research evidence exists on standardisation and psychometric validation of questionnaires that measure midwifery educators' confidence in their competence. This study developed a self-assessment of confidence in competence questionnaire in India based on the WHO Midwifery Educator Core Competencies (2014) with an aim to develop and validate a self-assessment tool measuring midwifery tutors' confidence in competence in imparting quality midwifery education. The questionnaire was developed as part of a multi-centre study to identify confident midwifery tutors for further training as educators, supporting India's rollout of professional midwives. The questionnaire underwent rigorous psychometric testing among 2016 midwifery tutors in India. Following exploratory Principal Component Analyses (PCA), the nine core competencies outlined in the WHO document were analysed separately. The results indicate that the questionnaire is psychometrically valid, with an internal consistency range of 0.81-0.93 for the nine domains. This robust testing process ensures the reliability and validity of the questionnaire. The self-assessment questionnaire can potentially be a valuable tool in India and other high-, middle-, and low-income countries. From a programmatic perspective, it can help identify key gaps and prioritise training needs, particularly in low-resource settings, so that limited resources are best utilised to fill the most prominent gaps. Furthermore, it can provide a universal platform for comparing data from different settings, facilitating global collaboration and learning in midwifery education.

Novel on-site follow-up and enhancement program (FEP) improves knowledge, clinical skills and enabling environment of skilled birth attendants in Nepal

INTRODUCTION

Although great strides have been made in maternal and newborn health in Nepal, the maternal mortality ratio (MMR) is still high at 186 per 100,000 births. Many maternal deaths are preventable if there is access to a skilled birth attendant (SBA). The Ministry of Health and Population of Nepal launched the in-service SBA training program in 2007 and has trained over 10,000 SBAs to date. Evidence shows that one episode of training is not enough to retain skills. Therefore, the Nick Simons Institute (NSI) in collaboration with National Health Training Center (NHTC) devised a Follow-Up and Enhancement Program (FEP) in 2011 where the knowledge, clinical skills, and working environment of SBA graduates were assessed directly at their worksites. FEP allows on-site coaching and feedback so that graduates may continue to improve upon any gaps in their knowledge, skills, and working environment. This study aims to assess the effectiveness of FEP.

METHODS

We used a mixed-methods research design. A total of 73 SBAs who had a pre-FEP assessment in 2016 were followed up for a post-FEP assessment in 2017. We also collected data from 3 additional districts (115 SBAs) that had not previously had FEP, to compare SBAs in FEP versus non-FEP districts. Qualitative data was collected from 16 health facilities on the perceptions, motivation, and satisfaction of stakeholders.

RESULTS

Of the total 188 SBAs that were sampled, a one-time FEP increased knowledge scores by 9%, clinical skills scores by 29%, and enabling environment scores by 7%. The number of deliveries conducted improved with a one-time FEP, although this increase was not statistically significant. We found a trickle-down effect of working in a facility that has had prior FEP, with SBAs that have never had FEP improving their clinical skills. FEP was found to be a highly accepted program and is beneficial to SBAs, trainers, and the Hospital Management Committee (HFOMC). However, a one-time FEP is not sufficient in retaining clinical skills and knowledge.

CONCLUSION

FEP is a highly effective program by both quantitative and qualitative evaluation. Our study suggests that FEP should be frequent and continuous to retain the knowledge and clinical skills of SBAs, motivate them through on-site coaching, and improve their working environment through direct feedback to the Ministry of Health and Population.

The effect of catchment based mentorship on quality of maternal and newborn care in primary health care facilities in Tigray Region, Northern Ethiopia: A controlled quasi-experimental study

BACKGROUND

In Ethiopia, quality of maternal and newborn care is poor. This situation has persisted, despite the wide implementation of several capacity building-oriented interventions including clinical mentoring for skilled birth attendants that were anticipated to translate in to high-quality maternal and newborn care on each encounter. The effectiveness of mentoring programs is not yet well documented in the research literature. Therefore, we evaluated the effect of a catchment based clinical mentorship in improving the quality of maternal and newborn care in primary level facilities of Tigray, Northern Ethiopia.

METHODS

We conducted a controlled quasi-experimental pre-post study among 19 primary health care facilities, with 10 facilities assigned to the group where the catchment based clinical mentorship program was implemented (intervention group), and 9 facilities to the control group. We assigned the group based on administrative criteria, number of deliveries in each facility, accessibility, and ease of implementation of the intervention. A sample of 1320 women(662 at baseline; 658 at post intervention) and 233 skilled birth attendants(121 at baseline and 112 at end line) were included. We collected data from mothers, skilled birth attendants and facilities. The first round of data collection (baseline) took place two weeks prior the inauguration of the intervention, 05 October to 04 November 2019. The end line data collection occurred from 22 May to 03 July 2020. The primary Outcome was "receipt quality of maternal/newborn care". We analyzed the data using difference in differences (DiD) and logistic regression with Generalized Estimating Equation. The level of significance of predictors was declared at p-value less than 0.05in the multivariable analysis.

INTERVENTION

We deployed a team of local clinical mentors working at primary hospitals to provide clinical mentorship, and direct feedback in routine and emergency obstetrical and newborn care to the mentees (all skilled birth attendants performing maternal and newborn health services) functioning in their catchment rural health centers for duration of six months. While visiting a facility, mentors remain at the facility each lasting at least five to seven days per month, over the course of intervention period.

RESULTS

A significantly higher proportion of women at intervention facilities received quality of care services, compared with women at comparison facilities. (DiD = 18.4%, p<0.001). Moreover, following the implementation of the intervention we detected a difference in the occurrences of maternal complication outcome during delivery and immediately after birth. This was decreased by 4.5%, with significant differences between intervention and comparison sites (DiD = 4.5%, p = 0.013). We also found a favorable difference in occurrences of neonatal obstetric complications, with a decrease of 4.8% in the intervention site and almost no change in the comparison site (DiD = 4.8%, p = 0.002). Among the determinants of quality of care, we found that providers' job satisfaction (AoR = 2.95, 95%CI: 1.26 to 6.91), and making case presentation at regular basis(AoR = 1.89, 95%CI: 1.05 to 3.39) were significantly associated to improve the quality of care. However, delivery load(AoR = 0.95, 95%CI: 0.93 to 0.98) was negatively associated with quality of care.

CONCLUSIONS

We conclude that the catchment based clinical mentorship intervention is effective to improve quality of care and reduce childbirth complications in northern Ethiopia. This finding further elaborated that incorporating maternal and newborn health catchment based clinical mentorship activities into the existing health system strengthening strategies can catalyze improvement processes to quality practice and health systems. This is seen as a necessary step to achieve the effective quality universal health care required to meet the health-related Sustainable Development Goals. Besides, more attention needs to be given to develop interventions and strategies that directly enhance providers' job satisfaction and reduce delivery work load.

The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India

INTRODUCTION

Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings.

METHODS

We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015-2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India.

RESULTS

We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant.

CONCLUSION

Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.

Leverage the power of ritual to improve community health worker efficacy and public health outcomes: Lessons from Bihar, India

Biomedical health interventions now have global reach and interact in complex and often poorly understood ways with traditional medical rituals that precede biomedicine. People often experience biomedical practices and treatments as rituals because they are very similar from an experiential perspective.1 Yet the global public health community often views ritual practices of communities as obstacles to adopting new health-promoting behaviors. The lack of engagement with the biomedical and traditional medical rituals of local populations has obscured understanding the critical functions of these behaviors, limited the potential to leverage ritualization to increase behavioral uptake, and stymied social and behavioral change efforts. Our large-scale, mixed methods research with Community Health Workers (CHW) in Bihar, India, has shown that understanding the rituals of a community provides critical insight into their identities, norms, values, and goals. We propose that health interventions should be informed by, and build upon, knowledge of health rituals. A deep understanding of existing beliefs and behaviors will allow local health "influencers" such as CHW to encourage new and modified rituals that integrate the best of biomedical and traditional health practices in ways that preserve their meaning and shared purpose.

Funding

Grants INV-008582 and INV-016014 to C.L. from The Bill & Melinda Gates Foundation funded this manuscript.

In-service nurse mentoring in 2020, the year of the nurse and the midwife: learning from Bihar, India

In-service nurse mentoring is increasingly seen as a way to strengthen the quality of health care in rural areas, where healthworkers are scarce. Despite this, the evidence base for designing large-scale programs remains relatively thin. In this capacity-building article, we reflect on the limited evidence that exists and introduce features of the world's largest program, run by CARE-India since 2015. Detail on the mechanics of large-scale programs is often missing from empirical research studies, but is a crucial aspect of organizational learning and development. Moreover, by focusing on the complex ways in which capacity-building is being institutionalized through an embedded model of in-service mentorship, this article bridges research and practice. We point to a number of areas that require further research as well as considerations for program managers designing comparable workforce strengthening programs. With careful planning and cross-national policy learning, we propose that in-service nurse mentoring may offer a cost-effective and appropriate workforce development approach in a variety of settings.