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Weerasingha TK, Ratnayake C, Abeyrathne R, Tennakoon SU. Evidence-based intrapartum care during vaginal births: Direct observations in a tertiary care hospital in Central Sri Lanka. Heliyon 2024; 10:e28517. [PMID: 38571647 PMCID: PMC10988013 DOI: 10.1016/j.heliyon.2024.e28517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/05/2024] Open
Abstract
Background Evidence-based practice (EBP) is an effective approach to improve maternal and newborn outcomes at birth. Objective This study aimed to assess the current intrapartum practices of a tertiary care hospital in Central Province, Sri Lanka, during vaginal births. The benchmark for this assessment was the World Health Organisation's (WHO) recommendations on intrapartum care for a positive childbirth experience. Methods An observational study was conducted at the delivery room of Teaching Hospital, Peradeniya with the participation of 196 labouring women who were selected using systematic random sampling. A non-participant observation checklist covering labour room admission procedures, management of the first, second, and third stages of labour, and immediate care of the newborn and postpartum mother was used for the data collection. The care interventions implemented throughout labour and childbirth were observed and recorded. The data analysis was done using SPSS version 22. Results WHO-recommended practices such as providing privacy (33.2%), offering oral fluids (39.3%), and opioids for pain relief (48.5%) were found to be infrequent. Encouraging correct pushing techniques (77.6%), early breastfeeding (83.2%), regular assessment of vaginal bleeding (91.3%), skin-to-skin contact (93.4%), and using prophylactic uterotonics (100.0%) were found to be frequent. However, labour companionship, use of upright positions during labour, women's choice of birth position, and use of manual or relaxation techniques for pain relief were not observed in hospital intrapartum care. Conclusion The findings of the study indicate that additional attention and monitoring are required to align the current intrapartum care practices with the WHO recommendations. Moreover, the adoption of evidence-based intrapartum care should be encouraged by conveying the standard evidence-based intrapartum care guidelines to the grassroots level healthcare workers to avoid intrapartum interventions.
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Affiliation(s)
| | - Chathura Ratnayake
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | - R.M. Abeyrathne
- Department of Sociology, Faculty of Arts, University of Peradeniya, Sri Lanka
| | - Sampath U.B. Tennakoon
- Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
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Gagnon J, Breton M, Gaboury I. Decision-maker roles in healthcare quality improvement projects: a scoping review. BMJ Open Qual 2024; 13:e002522. [PMID: 38176953 PMCID: PMC10773379 DOI: 10.1136/bmjoq-2023-002522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/17/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Evidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking. We conducted a scoping review to identify QI projects involving decision-makers published in the literature and to describe the roles decision-makers played. METHODS Following the Joanna Briggs Institute framework for scoping reviews, we systematically searched for all types of studies in English or French between 2002 and 2023 in: EMBASE, MEDLINE via PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. Criteria for inclusion consisted of literature describing health sector QI projects that involved local, regional or system-level decision-makers. Descriptive analysis was performed. Drawing on QI and participatory research literature, the research team developed an inductive data extraction grid to provide a portrait of QI project characteristics, decision-makers' contributions, and advantages and challenges associated with their involvement. RESULTS After screening and review, we retained 29 references. 18 references described multi-site projects and 11 were conducted in single sites. Local decision-makers' contributions were documented in 27 of the 29 references and regional decision-makers' contributions were documented in 12. Local decision-makers were more often active participants in QI processes, contributing toward planning, implementation, change management and capacity building. Regional decision-makers more often served as initiators and supporters of QI projects, contributing toward strategic planning, recruitment, delegation, coordination of local teams, as well as assessment and capacity building. Advantages of decision-maker involvement described in the retained references include mutual learning, frontline staff buy-in, accountability, resource allocation, effective leadership and improved implementation feasibility. Considerations regarding their involvement included time constraints, variable supervisory expertise, issues concerning centralised leadership, relationship strengthening among stakeholders, and strategic alignment of frontline staff and managerial priorities CONCLUSIONS: This scoping review provides important insights into the various roles played by decision-makers, the benefits and challenges associated with their involvement, and identifies opportunities for strengthening their engagement. The results of this review highlight the need for practical collaboration and communication strategies that foster partnership between frontline staff and decision-makers at all levels.
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Affiliation(s)
- Justin Gagnon
- Department of Community Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mylaine Breton
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Gaboury
- Department of Community Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Litorp H, Målqvist M, Sunny AK, Gurung A, Gurung R, Kc A. Improved obstetric management after implementation of a scaled-up quality improvement intervention: A nested before-after study in three public hospitals in Nepal. Birth 2023; 50:616-626. [PMID: 36774588 DOI: 10.1111/birt.12709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/28/2021] [Accepted: 01/12/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND We assessed the change in obstetric management after implementation of a quality improvement intervention, the Nepal Perinatal Quality Improvement Package (NePeriQIP). METHODS The Nepal Perinatal Quality Improvement Package was a stepped-wedge cluster-randomized controlled trial conducted in 12 public hospitals in Nepal between April 2017 and October 2018. In this study, three hospitals allocated at different time points to the intervention were selected for a nested before-after analysis. We used bivariate and multivariate analyses to compare obstetric management in the control vs intervention group. RESULTS There were 25 977 deliveries in the three hospitals during the study period: 10 207 (39%) in the control and 15 770 (61%) in the intervention group. After adjusting for maternal age, ethnicity, education, gestational age, stage of labor at admission, complications during labor, and birthweight, the intervention group had a higher proportion of fetal heart rate monitoring performed as per protocol (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.12-1.27), shorter time intervals between each fetal heart rate monitoring (aOR 2.09, 95% CI 1.96-2.23), a higher likelihood of abnormal fetal heart rate being detected (aOR 1.53, 95% CI 1.25-1.68), progress of labor more often being recorded immediately after per vaginal examination (aOR 2.73, 95% CI 2.55-2.93), and partograph filled as per standards (aOR 3.18, 95% CI 2.98-3.50). The cesarean birth rate was 2.5% in the control group and 8.2% in the intervention group (aOR 3.12, 95% CI 2.64-3.68). CONCLUSIONS The NePeriQIP intervention has potential to improve obstetric care, especially intrapartum fetal surveillance, in similar low-resource settings.
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Affiliation(s)
- Helena Litorp
- Department of Women's and Children's´ Health, Uppsala University, Uppsala, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mats Målqvist
- Department of Women's and Children's´ Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Ashish Kc
- Department of Women's and Children's´ Health, Uppsala University, Uppsala, Sweden
- Society of Public Health Physicians Nepal, Kathmandu, Nepal
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Singh S, Kannuri NK, Mishra A, Gaikwad L, Shukla R, Tyagi M, Chamarty S. Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys. Arch Public Health 2023; 81:57. [PMID: 37072820 PMCID: PMC10111820 DOI: 10.1186/s13690-023-01028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability. METHODS Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner. RESULTS Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers. CONCLUSION The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.
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Affiliation(s)
- Samiksha Singh
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi, India.
| | - Nanda Kishore Kannuri
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Aparajita Mishra
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi, India
| | - Leena Gaikwad
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Rajan Shukla
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Mukta Tyagi
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Swecha Chamarty
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
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Evidence-based intrapartum care practice and associated factors among obstetric care providers working in hospitals of the four Wollega Zones, Oromia, Ethiopia. PLoS One 2023; 18:e0275506. [PMID: 36701302 PMCID: PMC9879444 DOI: 10.1371/journal.pone.0275506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/27/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Even though Evidence-Based Practice (EBP) is a key component of quality of Intrapartum care and links to improved health care outcomes, consistent application of EBP in patient care remains a challenge for health care providers. In the study area, there are no previous studies conducted on evidence-based Intrapartum care practice among obstetric care providers. Therefore, this study was aimed to assess the magnitude of evidence based intra-partum care practice and its associated factors among obstetric care providers working in hospitals of Wollega zones, Oromia Region, West Ethiopia, 2022. METHOD An institution-based cross-sectional study using quantitative method was conducted from January to April/2022 in 11 hospitals of the four Wollega zones. All obstetric care providers (278) who were practicing intrapartum care in the selected hospitals were included. The data was collected using structured self-administered questionnaire and observational checklist. Data was entered via Epi-Data version 3.1 and analyzed by SPSS version 25 statistical software. To see the association between the independent variables and evidence based Intrapartum care practice, multivariable logistic regression analysis was done. The statistical significance of association was declared at p-value ≤ 0.05. Tables, figures and charts were also used in descriptive statistics. RESULT The overall magnitude of evidence-based Intrapartum care practice was found to be 63.7% [95% CI (59.7, 67.7)]. There was a statistically significant association between evidence-based Intrapartum care practice and having good knowledge about Intrapartum care practice [AOR = 2.95; 95% CI (1.52,5.73)], positive attitude towards Intrapartum care practice [AOR = 3.13; 95% CI (1.59,6.16)], availability of updated Intrapartum care guideline [AOR = 2.88; 95% CI (1.46,5.70)], number of obstetric care providers per a shift (≥5 care providers) [AOR = 2.31; 95% CI (1.01,5.29)], number of deliveries within a day (<10 deliveries) [AOR = 4.61; 95% CI (2.28,9.31)], educational level (MSc and above) [AOR = 5.75; 95% CI (2.23,14.84)] at p-value ≤ 0.05. CONCLUSION Our study revealed that, magnitude of evidence-based Intrapartum care practice was found to be low according to the WHO recommendation. These findings indicate that additional attention and monitoring is required to implement current Intrapartum care practices with the WHO guidelines.
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Gross G, Ling R, Richardson B. Improving curriculum delivery: Using a results informed quality improvement model for teen behavioral health education. Front Public Health 2022; 10:965534. [PMID: 36466477 PMCID: PMC9709193 DOI: 10.3389/fpubh.2022.965534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/12/2022] [Indexed: 11/18/2022] Open
Abstract
Adolescence is a critical developmental stage to establish healthy decision-making processes and behavior patterns. Many interventions such as evidence-based curricula have been implemented to guide adolescents to avoid risk-taking behaviors and improve health and medical knowledge and outcomes. This study presents a participatory approach informed by the three-stage (3S) quality improvement process model to improve the quality of curriculum delivery, based on the results indicating outcomes achieved, needs for improvement, and quality assurance for maintaining the expected outcomes of an evidence-based curricula. Tests were conducted before and after the intervention. Using threshold levels and measures of change in the tests, instructors participated in guided discussion and analysis of the data to identify where and how instructional improvements should be made and where outcomes were being achieved as expected. This method was used to diagnose variation in the results and delivery and identify root causes informing actions to improve curriculum delivery and outcomes. After the facilitated discussions, pre- and post-tests from subsequent classes were analyzed. The results showed improved test item scores ranging from 2 to 69.5% and seven of 18 items obtained statistical significance following the implementation of the model described. Overall, an increase in the mean percent correct of 17.1% was found.
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Affiliation(s)
- Gregory Gross
- National Resource Center for Family Centered Practice, University of Iowa School of Social Work, Des Moines, IA, United States,Brown School, Washington University, St. Louis, MO, United States
| | - Rui Ling
- National Resource Center for Family Centered Practice, University of Iowa School of Social Work, Des Moines, IA, United States
| | - Brad Richardson
- National Resource Center for Family Centered Practice, University of Iowa School of Social Work, Des Moines, IA, United States,*Correspondence: Brad Richardson
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Vedam S, Titoria R, Niles P, Stoll K, Kumar V, Baswal D, Mayra K, Kaur I, Hardtman P. Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration. Health Policy Plan 2022; 37:1042-1063. [PMID: 35428886 PMCID: PMC9469892 DOI: 10.1093/heapol/czac032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/30/2022] [Accepted: 04/15/2022] [Indexed: 11/12/2022] Open
Abstract
India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.
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Affiliation(s)
- Saraswathi Vedam
- Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada
| | - Reena Titoria
- Population Health Observatory, Fraser Health Authority, Suite 400, Central City Tower 13450 – 102nd Avenue, Surrey, BC V3T 0H1, Canada
| | - Paulomi Niles
- Rory Meyers College of Nursing, New York University, 433 1st Avenue, New York, NY 10010, USA
| | - Kathrin Stoll
- Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada
| | - Vishwajeet Kumar
- Community Empowerment Lab, 26/11 Wazir Hasan Road, Gokhale Marg, Lucknow, UP 226001, India
| | - Dinesh Baswal
- MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave-II, New Delhi 110048, India
| | - Kaveri Mayra
- Global Health Research Institute, Faculty of Social Sciences, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - Inderjeet Kaur
- Fernandez Foundation, Fernandez Hospital, 4-1-120, Bogulkunta, Hyderabad 500001, India
| | - Pandora Hardtman
- Johns Hopkins Program for International Education in Gynecology and Obstetrics, John Hopkins University, 1615 Thames Street, Baltimore, MD 21231, USA
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Debeb Sendekie A, Belay MA, Ayalew Yimer S, Degu Ayele A. Evidence-Based Intrapartum Practice and Associated Factors Among Obstetric Care Providers Working in Public Hospitals of South Wollo Zone North-Central Ethiopia: An Institutional-Based Cross-Sectional Study. Int J Womens Health 2022; 14:719-730. [PMID: 35615384 PMCID: PMC9126653 DOI: 10.2147/ijwh.s351795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Even though recent progress, Ethiopia continues to be one of the most significant contributors to the worldwide burden of maternal mortality. Evidence-based intrapartum practices have significant value to improve the health outcome of the mother and the neonate. However, in Ethiopia, it is not exercised according to the standard. Assessing the proportion of evidence-based intrapartum practice and predictors is essential and vital to providing better-quality care to laboring mothers. Hence, this study was aimed to assess the magnitude of evidence-based intrapartum practice and predictors among obstetric care providers working in public hospitals in South Wollo zone, North-central Ethiopia. Patient and Methods An institutional-based cross-sectional study was employed among 398 obstetric care providers from February 1 to April 30, 2021. Study participants were selected using a simple random sampling technique. Both a structured questionnaire and an observational checklist were used to collect the data. Bivariate and multivariable logistic regression was done to determine predictors associated with evidence-based intrapartum practice and P-value <0.05 at 95% CI was declared as statistically significant. Results The overall magnitude of evidence-based intrapartum care was 54.7% [95% CI (49.6-59.7%)]. Knowledge [AOR = 2.1; 95% CI (1.30-3.38)], computer access [AOR = 2.04; 95% CI (1.27-3.27)], work experience [AOR= 2.13; 95% CI (1.21-3.73)] and training [AOR = 1.81; 95% CI (1.12-2.93)] were found to be statistically significant with evidence-based intrapartum practice. Conclusion We found that only half of the obstetric care providers applied evidence-based intrapartum practice. Increasing knowledge of intrapartum care, providing continuous training, making the working environment safe to handle experienced providers, and easily access computers in the workplace will be needed to maximize the practice of evidence-based intrapartum care and scale up the quality of care.
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Affiliation(s)
| | - Mengistu Abate Belay
- College of Medicine and Health Sciences, School of Nursing, Wollo University, Dessie, Ethiopia
| | - Sindu Ayalew Yimer
- College of Medicine and Health Sciences, School of Nursing, Wollo University, Dessie, Ethiopia
| | - Alemu Degu Ayele
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Iyengar K, Gupta M, Pal S, Kaur K, Singla N, Verma M, Dhiman A, Singla R, Rohilla M, Suri V, Aggarwal N, Singh T, Goel P, Goel NK, Pant R, Gaur KL, Gehlot H, Bhati I, Verma M, Agarwal S, Acharya R, Singh K, Chauhan M, Rastogi R, Bedi R, Pancholi P, Nayak B, Modi B, Nakum K, Trivedi A, Aggarwal S, Patel S. Baseline Assessment of Evidence-Based Intrapartum Care Practices in Medical Schools in 3 States in India: A Mixed-Methods Study. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100590. [PMID: 35487543 PMCID: PMC9053154 DOI: 10.9745/ghsp-d-21-00590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Implementation research with pre- and post-comparison was planned to improve the quality of evidence-based intrapartum care services in Indian medical schools. We present the baseline study results to assess the status of adherence to intrapartum evidence-based practices (IP-EBP) in study schools in 3 states in India and the perception of the faculty. METHODS A concurrent mixed-methods approach was used to conduct the baseline assessment in 9 medical schools in Rajasthan, Gujarat, and Union Territory from October 2018 to June 2019. IP-EBP among pregnant women in uncomplicated first (n=135), second (n=120), and third stage (n=120) of labor were observed using a predesigned, pretested checklist quantitatively. We conducted in-depth interviews with 33 obstetrics and gynecology faculty to understand their perceptions of intrapartum practices. Quantitative data were analyzed using SPSS (version 22). COM-B (Capability, Opportunity, and Motivation Behavior) model was used to understand the behaviors, and thematic analysis was done for the qualitative data. FINDINGS Unindicated augmentation of labor was done in 64.4%, fundal pressure applied in 50.8%, episiotomy done in 58.3%, and delivery in lithotomy position was performed in 86.7% of women in labor. CONCLUSIONS Intrapartum practices that are not recommended were routinely practiced in the study medical schools due to a lack of staff awareness of evidence-based practices and incorrect beliefs about their impact.
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Affiliation(s)
| | - Madhu Gupta
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Swarnika Pal
- Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Kiranjit Kaur
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Neena Singla
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Madhur Verma
- All India Institute Medical Science, Bathinda, Punjab, India
| | - Anchal Dhiman
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rimpi Singla
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Minakshi Rohilla
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vanita Suri
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Neelam Aggarwal
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Tarundeep Singh
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Poonam Goel
- Government Medical College and Hospital, Chandigarh, India
| | - N K Goel
- Government Medical College and Hospital, Chandigarh, India
| | - Reena Pant
- Swai Maan Singh Medical College, Jaipur, Rajasthan, India
| | | | - Hanslata Gehlot
- Dr. Sampurnanand Medical College and Hospital, Jodhpur, Rajasthan, India
| | - Indra Bhati
- Dr. Sampurnanand Medical College and Hospital, Jodhpur, Rajasthan, India
| | - Manoj Verma
- Dr. Sampurnanand Medical College and Hospital, Jodhpur, Rajasthan, India
| | - Sudesh Agarwal
- Sardar Patel Medical College and PBM Hospital, Bikaner Rajasthan, India
| | - Rekha Acharya
- Sardar Patel Medical College and PBM Hospital, Bikaner Rajasthan, India
| | - Keerti Singh
- Rabindranath Tagore Medical College and Hospital, Udaipur, Rajasthan, India
| | - Madhubala Chauhan
- Rabindranath Tagore Medical College and Hospital, Udaipur, Rajasthan, India
| | - Radha Rastogi
- Rabindranath Tagore Medical College and Hospital, Udaipur, Rajasthan, India
| | - Renu Bedi
- Jawaharlal Nehru Medical College and Hospital, Ajmer Rajasthan, India
| | - Poornima Pancholi
- Jawaharlal Nehru Medical College and Hospital, Ajmer Rajasthan, India
| | - Bipin Nayak
- GMERS Medical College and Hospital, Gandhinagar, Gujarat, India
| | - Bhavesh Modi
- GMERS Medical College and Hospital, Gandhinagar, Gujarat, India
| | - Kanaklata Nakum
- Government Medical College and Hospital, Bhavnagar, Gujarat, India
| | - Atul Trivedi
- Government Medical College and Hospital, Bhavnagar, Gujarat, India
| | | | - Sangita Patel
- Government Medical College and Hospital, Baroda, Gujarat, India
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Das P, Ramani S, Newton-Lewis T, Nagpal P, Khalil K, Gharai D, Das S, Kammowanee R. "We are nurses - what can we say?": power asymmetries and Auxiliary Nurse Midwives in an Indian state. Sex Reprod Health Matters 2022; 29:2031598. [PMID: 35171082 PMCID: PMC8856050 DOI: 10.1080/26410397.2022.2031598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
In India, nurses and midwives are key to the provision of public sexual and reproductive health services. Research on impediments to their performance has primarily focused on their individual capability and systemic resource constraints. Despite emerging evidence on gender-based discrimination and low professional acceptance faced by these cadres, little has been done to link these constraints to power asymmetries within the health system. We analysed data from an ethnography conducted in two primary healthcare facilities in an eastern state in India, using Veneklasen and Miller's expressions of power framework, to explore how power and gender asymmetries constrain performance and quality of care provided by Auxiliary Nurse Midwives (ANMs). We find that ANMs' low position within the official hierarchy allows managers and doctors to exercise "power over" them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways. Our findings contribute to the empirical evidence, advancing the understanding of gender as a structurally embedded dimension of power. We illustrate how the weak positioning of ANMs reflects their lack of representation in policymaking positions, a virtual absence of gender-sensitive policies, and ultimately organisational power structures embedded in patriarchy. By deepening the understanding of empowerment, the paper suggests implementable pathways to empower ANMs for improved performance. This requires addressing entrenched gender inequities through structural and organisational changes that realign power relations, facilitate more collaborative ways of exercising power, and create the antecedents to individual empowerment.
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Affiliation(s)
- Priya Das
- Consultant, Oxford Policy Management Limited, New Delhi, India. Correspondence:
| | - Sudha Ramani
- Senior Consultant, Oxford Policy Management Limited, New Delhi, India
| | | | - Phalasha Nagpal
- Assistant Consultant, Oxford Policy Management Limited, New Delhi, India
| | - Karima Khalil
- Senior Consultant, Oxford Policy Management Limited, New Delhi, India
| | - Dipanwita Gharai
- Nurse Researcher, Oxford Policy Management Limited, New Delhi, India
| | - Shamayita Das
- Nurse Researcher, Oxford Policy Management Limited, New Delhi, India
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Stierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health 2021; 6:e006698. [PMID: 34610906 PMCID: PMC8493923 DOI: 10.1136/bmjgh-2021-006698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards. METHODS We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume. RESULTS Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices. CONCLUSION SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.
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Affiliation(s)
- Elizabeth K Stierman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Saifuddin Ahmed
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Oromia, Ethiopia
| | - Linnea A Zimmerman
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Catalytic Support for Improving Clinical Care in Special Newborn Care Units (SNCU) Through Composite SNCU Quality of Care Index (SQCI). Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2192-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Singh A, Vellakkal S. Impact of public health programs on maternal and child health services and health outcomes in India: A systematic review. Soc Sci Med 2021; 274:113795. [PMID: 33667744 DOI: 10.1016/j.socscimed.2021.113795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes. OBJECTIVES AND METHODS This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings. FINDINGS AND CONCLUSION We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care.
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Affiliation(s)
- Abinash Singh
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India
| | - Sukumar Vellakkal
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India; Department of Economic Sciences, Indian Institute of Technology Kanpur, Uttar Pradesh, India.
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Ledo BC, Góes FGB, Santos ASTD, Pereira-Ávila FMV, Silva ACSSD, Bastos MPDC. Fatores associados às práticas assistenciais ao recém-nascido na sala de parto. ESCOLA ANNA NERY 2021. [DOI: 10.1590/2177-9465-ean-2020-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo identificar os fatores associados às práticas assistenciais ao recém-nascido adotadas na sala de parto de uma maternidade na baixada litorânea do Rio de Janeiro. Método estudo transversal, realizado em instituição pública no estado Rio de Janeiro, mediante coleta de dados em prontuários de nascimentos entre 2015 e 2017. Na associação entre variáveis, adotou-se o Teste Qui-Quadrado e a regressão logística. Resultados entre 351 (100,0%) prontuários, constituíram-se como práticas realizadas na sala de parto: contato pele a pele e aleitamento materno precoce (28,0%); secagem (92,3%); aspiração oronasofaríngea (82,1%); aspiração gástrica (52,7%); aspiração traqueal (12,2%); oxigênio inalatório (7,7%); e encaminhamento ao Alojamento Conjunto (91,1%). O contato precoce com o seio materno esteve associado ao tipo de parto (p=0,043) e às alterações no exame físico (p=0,001). Possuir alterações no exame físico ao nascimento diminuiu significativamente as chances de o bebê ser colocado nessa posição ainda na sala de parto (p=0,001) assim como os recém-nascidos de parto cesáreo (p=0,045). Nascer de cesárea aumentou duas vezes as chances de o recém-nascido ser submetido à aspiração gástrica (p=0,002). Conclusão e implicações para a prática é premente organizar as rotinas dos serviços, de modo a evitar intervenções desnecessárias visando uma atenção obstétrica e neonatal humanizada e de qualidade.
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Litorp H, Gurung R, Målqvist M, Kc A. Disclosing suboptimal indications for emergency caesarean sections due to fetal distress and prolonged labor: a multicenter cross-sectional study at 12 public hospitals in Nepal. Reprod Health 2020; 17:197. [PMID: 33334355 PMCID: PMC7745386 DOI: 10.1186/s12978-020-01039-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Global caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings. We sought to assess management and outcomes of deliveries with emergency CSs due to fetal distress and prolonged labor at 12 public hospitals in Nepal and determine factors associated with suboptimal CS indications. METHODS We conducted a cross-sectional study on all deliveries between the 14th of April 2017 and the 17th of October 2018 at 12 public hospitals in Nepal and included all emergency CSs due to fetal distress and prolonged labor. Analysis was conducted using Pearson chi-square test and bivariate and multivariate logistic regression. RESULTS The total cohort included 104,322 deliveries of which 18,964 (18%) were CSs (13,095 [13%] emergency CSs and 5230 [5.0%] elective CSs). We identified 1806 emergency CSs due to fetal distress and 1322 emergency CSs due to prolonged labor. Among CSs due to fetal distress, only 36% had fetal heart rate monitoring performed according to protocol, and among CSs due to prolonged labor, the partograph was completely filled in only 8.6%. Gestational age < 37 weeks and birth weight < 2500 g were associated with more suboptimal CS indications due to fetal distress (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.1-1.8 and aOR 1.7, 95% CI 1.3-2.2 respectively) than those with gestational age > 37 weeks and birth weight > 2500 g. We found no association between suboptimal CS indications and maternal ethnicity or education level. CONCLUSIONS As fetal heart rate monitoring and partograph are fundamental to diagnose fetal distress and prolonged labor, the inappropriate monitoring proceeding CS decisions disclosed in our study indicate that CSs were performed on suboptimal indications. We call for improved quality of intrapartum monitoring, enhanced documentation in medical records, and structured auditing of CS indications in order to curb the potentially harmful CS trend.
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Affiliation(s)
- Helena Litorp
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. .,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Mats Målqvist
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Society of Public Health Physician's Nepal, Kathmandu, Nepal
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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020; 10:021008. [PMID: 33425332 PMCID: PMC7759019 DOI: 10.7189/jogh.10.021008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017. METHODS We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using χ2 tests. RESULTS Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P < 0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P < 0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P < 0.05). CONCLUSION Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sanjiv Daulatrao
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Rohini Durbha
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Peven K, Bick D, Purssell E, Rotevatn TA, Nielsen JH, Taylor C. Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review. Health Policy Plan 2020; 35:ii47-ii65. [PMID: 33156939 PMCID: PMC7646733 DOI: 10.1093/heapol/czaa122] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 01/02/2023] Open
Abstract
Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.
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Affiliation(s)
- Kimberly Peven
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, 57 Waterloo Road, London SE1 8WA, UK
| | - Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - Edward Purssell
- School of Health Sciences, City, University of London, London, UK
| | - Torill Alise Rotevatn
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jane Hyldgaard Nielsen
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Midwifery, University College of Northern Denmark, Aalborg, Denmark
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, UK
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Palo SK, Kripalini P, Sanghamitra P. Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India - A SWOT analysis. J Family Med Prim Care 2020; 9:3308-3314. [PMID: 33102288 PMCID: PMC7567242 DOI: 10.4103/jfmpc.jfmpc_376_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/25/2020] [Accepted: 05/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Poor documentation practices in labour rooms have been a challenge especially in resource limited countries. This hinders the efforts towards improving quality of maternal healthcare services. Little effort has been made on this regard in many countries including India. SWOT analysis on labour room documentation would be the first step in understanding the situation, barriers and to formulate strategies for improvement. Materials and Methods: Facility based cross-sectional study was carried out in five secondary health facilities of Cuttack district, Odisha, India. A qualitative method using in-depth interviews among 26 healthcare providers was adopted for data collection and inductive content analysis approach for analysis. Strategies like pioneering, positive, conservative and resistive were formulated under each of the three major components identified. Results: Three major components emerged were i) Adherence and completeness of labour room records and reports, ii) Status of the monitoring and supervision and iii) Utilization of labour room data. Improving knowledge and skill through training and supportive supervision, adopting computer-based application for data management, better coordination among supervisors and labour room staff, infrastructural strengthening for documentation and its security, making documentation a priority, more accountability would improve the documentation. Ensuring data analysis and interpretation, discussion in review meetings and regular monitoring and supervision will improve performance. Conclusion: Ensuring documentation of labour room records, regular quality monitoring and supervision, and analysis and interpretation of data are critical to improve labour room performance. Making it a priority and adopting the strategies will achieve the same, thereby better labour outcome.
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Affiliation(s)
- Subrata Kumar Palo
- Department of Community Medicine, Scientist-D, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
| | - Patel Kripalini
- Senior Research Fellow, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
| | - Pati Sanghamitra
- Director, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
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Esteves Mills J, Flynn E, Cumming O, Dreibelbis R. Determinants of clean birthing practices in low- and middle-income countries: a scoping review. BMC Public Health 2020; 20:602. [PMID: 32357872 PMCID: PMC7195776 DOI: 10.1186/s12889-020-8431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Infection is a leading cause of maternal and newborn mortality in low- and middle-income countries (LMIC). Clean birthing practices are fundamental to infection prevention efforts, but these are inadequate in LMIC. This scoping study reviews the literature on studies that describe determinants of clean birthing practices of healthcare workers or mothers during the perinatal period in LMIC. Methods We reviewed literature published between January 2000 and February 2018 providing information on behaviour change interventions, behaviours or behavioural determinants during the perinatal period in LMIC. Following a multi-stage screening process, we extracted key data manually from studies. We mapped identified determinants according to the COM-B behavioural framework, which posits that behaviour is shaped by three categories of determinants – capability, opportunity and motivation. Results Seventy-eight studies were included in the review: 47 observational studies and 31 studies evaluating an intervention. 51% had a household or community focus, 28% had a healthcare facility focus and 21% focused on both. We identified 31 determinants of clean birthing practices. Determinants related to clean birthing practices as a generalised set of behaviours featured in 50 studies; determinants related specifically to one or more of six predefined behaviours – commonly referred to as “the six cleans” – featured in 31 studies. Determinants of hand hygiene (n = 13) and clean cord care (n = 11) were most commonly reported. Reported determinants across all studies clustered around psychological capability (knowledge) and physical opportunity (access to resources). However, greater heterogeneity in reported behavioural determinants was found across studies investigating specific clean birthing practices compared to those studying clean birthing as a generalised set of behaviours. Conclusions Efforts to combine clean birthing practices into a single suite of behaviours – such as the “six cleans”– may simplify policy and advocacy efforts. However, each clean practice has a unique set of determinants and understanding what drives or hinders the adoption of these individual practices is critical to designing more effective interventions to improve hygiene behaviours and neonatal and maternal health outcomes in LMIC. Current understanding in this regard remains limited. More theory-grounded formative research is required to understand motivators and social influences across different contexts.
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Affiliation(s)
- Joanna Esteves Mills
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Erin Flynn
- Infection & Immunity, South Australian Health and Medical Research Institute, North Terrace, Adelaide, 5000, Australia
| | - Oliver Cumming
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Ahmed S, Srivastava S, Warren N, Mayra K, Misra M, Mahapatra T, Rao KD. The impact of a nurse mentoring program on the quality of labour and delivery care at primary health care facilities in Bihar, India. BMJ Glob Health 2020; 4:e001767. [PMID: 31908856 PMCID: PMC6936590 DOI: 10.1136/bmjgh-2019-001767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/04/2019] [Accepted: 11/10/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Although the number of women who deliver with a skilled birth attendant in India has almost doubled between 2006 and 2016, the country still has the second highest number of maternal deaths and the highest number of neonatal deaths globally. This study examines the impact of a nurse mentoring programme intended to improve the quality of intrapartum care at primary healthcare centre (PHC) facilities in Bihar, India. Method We conducted an evaluation study in 319 public PHCs in Bihar, where nurses participated in a mentoring programme. Using a quasi-experimental trial design, we compared the intrapartum quality of care between the mentored (n=179) and non-mentored PHCs (n=80). Based on direct observation of 847 women, we examined percent differences in 39 labour, delivery and postpartum care-related recommended tasks on five domains: vital sign and labour progress monitoring after admission, second and third stages of labour management, postpartum counselling, infection prevention and essential newborn care practices. Results A significantly higher proportion of women at mentored PHCs received the recommended clinical care, compared with women at non-mentored PHCs. The overall total score of quality of care, expressed in percent of tasks performed, was 30.2% (95% CI: 28.3 to 32.2) in the control PHCs, suggesting that less than one-third of the expected tasks during labour and delivery were performed by nurses in these facilities; the score was 44.2% (95% CI: 42.1 to 46.4) among the facilities where the nurses were trained within last 3 months. The task completion score was slightly attenuated when observed 1 year after mentoring (score 39.1% [37.7–40.5]). Conclusion Mentoring improved intrapartum care by nurses at PHCs in Bihar. However, less than half of the recommended normal delivery intrapartum tasks were completed by the nurse providers. This suggests the need for further improvement in the provision of quality of intrapartum care when risks to maternal and perinatal mortality are highest.
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Affiliation(s)
- Saifuddin Ahmed
- Population, Family and Reproductive Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Swati Srivastava
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | | | | | | | - K D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dodd R, Palagyi A, Jan S, Abdel-All M, Nambiar D, Madhira P, Balane C, Tian M, Joshi R, Abimbola S, Peiris D. Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region. BMJ Glob Health 2019; 4:e001487. [PMID: 31478026 PMCID: PMC6703302 DOI: 10.1136/bmjgh-2019-001487] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/15/2019] [Accepted: 06/23/2019] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. METHODS We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. RESULTS From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. CONCLUSION Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.
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Affiliation(s)
- Rebecca Dodd
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Marwa Abdel-All
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
| | | | - Christine Balane
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Beijing, China
| | - Rohina Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
- The George Institute for Global Health, New Delhi, India
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Rao KD, Srivastava S, Warren N, Mayra K, Gore A, Das A, Ahmed S. Where there is no nurse: an observational study of large-scale mentoring of auxiliary nurses to improve quality of care during childbirth at primary health centres in India. BMJ Open 2019; 9:e027147. [PMID: 31289071 PMCID: PMC6615817 DOI: 10.1136/bmjopen-2018-027147] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Clinician scarcity in Low and Middle-Income Countries (LMIC) often results in de facto task shifting; this raises concerns about the quality of care. This study examines if a long-term mentoring programme improved the ability of auxiliary nurse-midwives (ANMs), who function as paramedical community health workers, to provide quality care during childbirth, and how they compared with staff nurses. DESIGN Quasi-experimental post-test with matched comparison group. SETTING Primary health centres (PHC) in the state of Bihar, India; a total of 239 PHCs surveyed and matched analysis based on 190 (134 intervention and 56 comparison) facilities. PARTICIPANTS Analysis based on 335 ANMs (237 mentored and 98 comparison) and 42 staff nurses (28 mentored and 14 comparison). INTERVENTION Mentoring for a duration of 6-9 months focused on nurses at PHCs to improve the quality of basic emergency obstetric and newborn care. PRIMARY OUTCOME MEASURES Nurse ability to provide correct actions in managing cases of normal delivery, postpartum haemorrhage and neonatal resuscitation assessed using a combination of clinical vignettes and Objective Structured Clinical Examinations. RESULTS Mentoring increased correct actions taken by ANMs to manage normal deliveries by 17.5 (95% CI 14.8 to 20.2), postpartum haemorrhage by 25.9 (95% CI 22.4 to 29.4) and neonatal resuscitation 28.4 (95% CI 23.2 to 33.7) percentage points. There was no significant difference between the average ability of mentored ANMs and staff nurses. However, they provided only half the required correct actions. There was substantial variation in ability; 41% of nurses for normal delivery, 60% for postpartum haemorrhage and 45% for neonatal resuscitation provided less than half the correct actions. Ability declined with time after mentoring was completed. DISCUSSION Mentoring improved the ability of ANMs to levels comparable with trained nurses. However, only some mentored nurses have the ability to conduct quality deliveries. Continuing education programmes are critical to sustain quality gains.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Swati Srivastava
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division Health Economics Health Financing, Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, India
| | - Saifuddin Ahmed
- Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Tholandi M, Sethi R, Pedrana A, Qomariyah SN, Amelia D, Kaslam P, Sudirman S, Apriatni MS, Rahmanto A, Emerson M, Ahmed S. The effect of Expanding Maternal and Neonatal Survival interventions on improving the coverage of labor monitoring and complication prevention practices in hospitals in Indonesia: A difference‐in‐difference analysis. Int J Gynaecol Obstet 2019; 144 Suppl 1:21-29. [PMID: 30815869 DOI: 10.1002/ijgo.12732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | - Alisa Pedrana
- Disease Elimination Program Burnet Institute Melbourne Victoria Australia
| | | | | | | | | | | | | | - Mark Emerson
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD USA
| | - Saifuddin Ahmed
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD USA
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Saxena M, Srivastava A, Dwivedi P, Bhattacharyya S. Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India. PLoS One 2018; 13:e0204607. [PMID: 30261044 PMCID: PMC6160099 DOI: 10.1371/journal.pone.0204607] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022] Open
Abstract
Background Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.
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Affiliation(s)
- Malvika Saxena
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Aradhana Srivastava
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Pravesh Dwivedi
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Sanghita Bhattacharyya
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
- * E-mail:
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Singh S, Kashyap JA, Chandhiok N, Kumar V, Singh V, Goel R. Labour & delivery monitoring patterns in facility births across five districts of India: A cross-sectional observational study. Indian J Med Res 2018; 148:309-316. [PMID: 30425221 PMCID: PMC6251267 DOI: 10.4103/ijmr.ijmr_103_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND & OBJECTIVES India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India. METHODS A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets. RESULTS A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases. INTERPRETATION & CONCLUSIONS The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.
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Affiliation(s)
- Shalini Singh
- Division of Reproductive Biology, Maternal & Child Health, Indian Council of Medical Research, New Delhi, India
| | - Jyotika A. Kashyap
- Department of Obstetrics & Gynaecology, Sir Sayajirao General Hospital, Medical College, Vadodara, India
| | - Nomita Chandhiok
- Division of Reproductive Biology, Maternal & Child Health, Indian Council of Medical Research, New Delhi, India
| | - Vipin Kumar
- Division of Clinical Oncology, ICMR-National Institute of Cancer Prevention & Research, Noida, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Spindler H, Dyer J, Bagchi K, Ranjan V, Christmas A, Cohen SR, Sterling M, Shah MB, Das A, Mahapatra T, Walker D. Tracking and debriefing birth data at scale: A mobile phone application to improve obstetric and neonatal care in Bihar, India. Nurs Open 2018; 5:267-274. [PMID: 30062019 PMCID: PMC6056450 DOI: 10.1002/nop2.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 12/22/2017] [Indexed: 11/08/2022] Open
Abstract
AIM This analysis assessed changes over time in skill and knowledge related to the use of evidence-based practices associated with quality of maternal and neonatal care during a nurse midwife mentoring intervention at primary health clinics (PHCs) in Bihar, India. DESIGN Nurse midwife mentors (NMMs) entered live birth observation data into a mobile App from 320 PHCs. METHODS The NMMs completed prompted questions in the App after every live birth witnessed. The App consisted of questions around three main themes, "What went well?", "What needed improvement?" and "What can be done differently next time?". RESULTS Observational data from 5,799 births was recorded by 120 NMMs in 320 PHCs. Knowledge and skill during normal spontaneous vaginal deliveries and complicated deliveries with either a postpartum haemorrhage or non-vigorous infant all showed statistically significant improvement (p < .001) over time using a Chi-squared test for trend with a mean increase of 41% across all indicators.
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Affiliation(s)
- Hilary Spindler
- Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Kingshuk Bagchi
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Vikash Ranjan
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | | | | | - Mona Sterling
- Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Malay Bharat Shah
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Aritra Das
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Dilys Walker
- Department of Obstetrics and Gynecology and Reproductive ServicesUniversity of California San FranciscoSan FranciscoCAUSA
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Neogi SB, Sharma J, Negandhi P, Chauhan M, Reddy S, Sethy G. Risk factors for stillbirths: how much can a responsive health system prevent? BMC Pregnancy Childbirth 2018; 18:33. [PMID: 29347930 PMCID: PMC5774063 DOI: 10.1186/s12884-018-1660-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/07/2018] [Indexed: 03/07/2023] Open
Abstract
Background The stillbirth rate is an indicator of quality of care during pregnancy and delivery. Good quality care is supported by a functional heath system. The objective of this study was to explore the risk factors for stillbirths, particularly those related to a health system. Methods This case-control study was conducted in two districts of Bihar, India. Information on cases (stillbirths) were obtained from facilities as reported by Health Management Information System; controls were consecutive live births from the same population as cases. Data were collected from 400 cases and 800 controls. The risk factors were compared using a hierarchical approach and expressed as odds ratio, attributable fractions and population attributable fractions. Results Of all the factors studied, 22 risk factors were independently associated with stillbirths. Health system-related factors were: administration of two or more doses of oxytocics to augment labour before reaching the facilities (OR 1.6; 95% CI 1.2–2.1), any complications during labour (OR 2.3;1.7–3.1), >30 min to reach a facility from home (OR 1.4;1.05–1.8), >10 min to attend to the pregnant woman after reaching the facility (OR 2.8;1.7–4.5). In the final regression model, modifiable health system-related risk factors included: >10 min taken to attend to women after they reach the facilities (AOR 3.6; 95% CI 2.5–5.1), untreated hypertension during pregnancy (AOR 2.9; 95% CI 1.5–5.6) and presence of any complication during labour, warranting treatment (AOR 1.7; 95% CI 1.2–2.4). Among mothers who reported complications during labour, time taken to reach the facility was significantly different between stillbirths and live births (2nd delay; 33.5 min v/s 25 min; p < 0.001). Attributable fraction for any complication during labour was 0.56 (95% CI 0.42–0.67), >30 min to reach the facility 0.48 (95% CI 0.31–0.60) and institution of management 10 min after reaching the facility 0.68 (95% CI 0.58–0.75). Reaching a facility within 30 min, initiation of management within 10 min of reaching the facility and timely management of complications during labour could have prevented 17%, 37% and 20% of stillbirths respectively. Conclusion A pro-active health system with accessible, timely and quality obstetric services can prevent a considerable proportion of stillbirths in low and middle income countries. Electronic supplementary material The online version of this article (10.1186/s12884-018-1660-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Jyoti Sharma
- Indian Institute of Public Health- Delhi, Public Health Foundation of India, Gurugram, India
| | - Preeti Negandhi
- Indian Institute of Public Health- Delhi, Public Health Foundation of India, Gurugram, India
| | - Monika Chauhan
- Indian Institute of Public Health- Delhi, Public Health Foundation of India, Gurugram, India
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Das A, Nawal D, Singh MK, Karthick M, Pahwa P, Shah MB, Mahapatra T, Ranjan K, Chaudhuri I. Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India. BMC Pregnancy Childbirth 2017; 17:266. [PMID: 28835213 PMCID: PMC5569501 DOI: 10.1186/s12884-017-1452-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/15/2017] [Indexed: 12/19/2022] Open
Abstract
Background Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities. Methods An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention. Results In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (β) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: β = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: β = 11.66; 95% CI = 10.06, 13.27. Adjusted: β = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: β = 15.74; 95% CI = 14.39, 17.08; Adjusted: β = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time. Conclusions Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1452-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aritra Das
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Dipty Nawal
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Manoj Kumar Singh
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Morchan Karthick
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Parika Pahwa
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Malay Bharat Shah
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India. .,Department of Epidemiology, Fielding School of Public Health, University of California - Los Angeles, 650 Charles Young Drive, South. Box 951772, Los Angeles, CA, 90095, USA.
| | - Kunal Ranjan
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Indrajit Chaudhuri
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
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30
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Sharma G, Powell-Jackson T, Haldar K, Bradley J, Filippi V. Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India. Bull World Health Organ 2017; 95:419-429. [PMID: 28603308 PMCID: PMC5463813 DOI: 10.2471/blt.16.179291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. METHODS Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother-neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. FINDINGS The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother-neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. CONCLUSION In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh.
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Affiliation(s)
- Gaurav Sharma
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | | | - Kaveri Haldar
- Sambodhi Research and Communications, New Delhi, India
| | - John Bradley
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Véronique Filippi
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
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Sarin E, Kole SK, Patel R, Sooden A, Kharwal S, Singh R, Rahimzai M, Livesley N. Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India. BMC Pregnancy Childbirth 2017; 17:134. [PMID: 28464842 PMCID: PMC5414154 DOI: 10.1186/s12884-017-1318-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/25/2017] [Indexed: 11/29/2022] Open
Abstract
Background While increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality. Methods The USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time. Results Care improved to 90–99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30–70% points was observed during post intervention for all the indicators and 3–17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it. Conclusion These results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1318-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Enisha Sarin
- Consultant, University Research Company, India Pvt. Ltd B7, 1st floor, Suncity, Gurgaon, 122002, Haryana, India.
| | - Subir K Kole
- Data Manager, University Research Company, India Pvt. Ltd, T8-502 Amrapali Grand Sector Zeta 1, Greater Noida, 201306, UP, India
| | - Rachana Patel
- Consultant, University Research Company, India Pvt. Ltd. E 5, NTRO scientist Hostel, Behind Sahastra Seema Bal, Aya Nagar, Delhi, 110047, India
| | - Ankur Sooden
- Senior Advisor, University Research Company, 1st floor, LMR House, S-16, Uphaar Commercial Complex, Green Park Extension, New Delhi, 110016, India
| | - Sanchit Kharwal
- Doctoral Fellow (Social Epidemiology), Humanities and Social Sciences Discipline, Indian Institute of Technology, Gandhinagar, India
| | - Rashmi Singh
- Lead- Quality and Process Improvement, ACCESS Health International, Nilgiri building, IIIT, Gachibowli, Hyderabad, India
| | - Mirwais Rahimzai
- Project Director, University Research Company, Plot 40, Ntinda II Road, Kampala, Uganda
| | - Nigel Livesley
- Project Director, University Research Company, 1st floor, LMR House, S-16, Uphaar Commercial Complex, Green Park Extension, New Delhi, 110016, India
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32
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Das A, Nawal D, Singh MK, Karthick M, Pahwa P, Shah MB, Mahapatra T, Chaudhuri I. Impact of a Nursing Skill-Improvement Intervention on Newborn-Specific Delivery Practices: An Experience from Bihar, India. Birth 2016; 43:328-335. [PMID: 27321470 DOI: 10.1111/birt.12239] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND High neonatal mortality in India had previously been attributed to the low proportion of institutional deliveries. However, a significant rise in the proportion of facility-based births over the last decade has not achieved the desired reduction in neonatal mortality possibly as a result of low-skilled care at facilities. This study evaluated the effectiveness of "Mobile Nurse Training," a knowledge-based intervention for nurses to improve essential newborn-specific delivery practices. METHODS Eighty health centers with obstetric care facilities were selected from eight districts of Bihar. The intervention teams were composed of two trained nurses who conducted a week-long workshop per month at every health facility for 6 months. An independent evaluation team conducted baseline and postintervention assessments at every facility. The assessments included passive observation of newborn-specific delivery practices and recording of results on a preformatted checklist-based tool. RESULTS The intervention was associated with significant increases in the odds of four recommended practices: placing the newborn on mother's abdomen (adjusted odds ratio (AOR) 4.2 [95% CI 3.0-5.9]), wiping the eyes with sterile gauze (AOR 2.2 [95% CI 1.4-3.4]), skin-to-skin care (AOR 2.7 [95% CI 2.0-3.5]), and guidance for initiation of breastfeeding (AOR 1.6 [95% CI 1.2-2.1]). The intervention was also found to be positively associated with the summary score for improvements in all newborn-specific delivery practices. One year after the intervention, the summary practice score remained higher than at baseline, but with some decline over time. CONCLUSIONS The "Mobile Nurse Training" intervention provides a pathway for improving adherence to recommended newborn-specific delivery practices among institutional birth attendants in rural Bihar.
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Affiliation(s)
- Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Dipty Nawal
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Manoj K Singh
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Morchan Karthick
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Parika Pahwa
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Malay B Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Tanmay Mahapatra
- Department of Epidemiology, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA, USA
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Jayanna K, Bradley J, Mony P, Cunningham T, Washington M, Bhat S, Rao S, Thomas A, S R, Kar A, N S, B M R, H L M, Fischer E, Crockett M, Blanchard J, Moses S, Avery L. Effectiveness of Onsite Nurse Mentoring in Improving Quality of Institutional Births in the Primary Health Centres of High Priority Districts of Karnataka, South India: A Cluster Randomized Trial. PLoS One 2016; 11:e0161957. [PMID: 27658215 PMCID: PMC5033379 DOI: 10.1371/journal.pone.0161957] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/12/2016] [Indexed: 01/24/2023] Open
Abstract
Background In India, although the proportion of institutional births is increasing, there are concerns regarding quality of care. We assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 hours a day, 7 days a week) of two high priority districts in Karnataka state, South India. Primary outcomes were improved facility readiness and provider preparedness in managing institutional births and associated complications during child birth. Methods All functional 24/7 PHCs in the two districts were included in the study. We used a parallel, cluster randomized trial design in which 54 of 108 facilities received six onsite mentoring visits, along with an initial training update and specially designed case sheets for providers; the control arm received just the initial training update and the case sheets. Pre- and post-intervention surveys were administered in April-2012 and August-2013 using facility audits, provider interviews and case sheet audits. The provider interviews were administered to all staff nurses available at the PHCs and audits were done of all the filled case sheets during the month prior to data collection. In addition, a cost analysis of the intervention was undertaken. Results Between the surveys, we achieved coverage of 100% of facilities and 91.2% of staff nurse interviews. Since the case sheets were newly designed, case-sheet audit data were available only from the end line survey for about 80.2% of all women in the intervention facilities and 57.3% in the control facilities. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with gestational hypertension (19 vs.3, OR (odds ratio) 9.2, 95% C.I 2.5 to33.6), postpartum haemorrhage (29 vs. 12, OR 3.7, 95% C.I 1.6 to8.3); and obstructed labour (25 vs.9, OR 3.4, 95% CI 1.6 to8.3). The providers in the intervention arm had better knowledge of active management of the third stage of labour (82.4% vs.35.8%, AOR (adjusted odds ratio) 10, 95% C.I 5.5 to 18.2); management of maternal sepsis (73.5% vs. 10.9%, AOR 36.1, 95% C.I 13.6 to 95.9); neonatal resuscitation (48.5% vs.11.7%, AOR 10.7, 95% C.I 4.6 to 25.0) and low birth weight newborn care (58.1% vs. 40.9%, AOR 2.4, 95% C.I 1.2 to 4.7). The case sheet audits revealed that providers in the intervention arm showed greater compliance with the protocols during labour monitoring (77.3% vs. 32.1%, AOR 25.8, 95% C.I 9.6 to 69.4); delivery and immediate post-partum care for mothers (78.6% vs. 31.8%, AOR 22.1, 95% C.I 8.0 to 61.4) and for newborns (73.9% vs. 32.8%, AOR 24.1, 95% C.I 8.1 to 72.0). The cost analysis showed that the intervention cost an additional $5.60 overall per delivery. Conclusions The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications. It is feasible to improve the quality of institutional births at a large operational scale, without substantial incremental costs. Trial Registration ClinicalTrials.gov NCT02004912
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Affiliation(s)
- Krishnamurthy Jayanna
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
- * E-mail:
| | - Janet Bradley
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Prem Mony
- St John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Troy Cunningham
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Maryann Washington
- St John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Swarnarekha Bhat
- St John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Suman Rao
- St John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Annamma Thomas
- St John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Rajaram S
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Arin Kar
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Swaroop N
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Ramesh B M
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Mohan H L
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Karnataka Health Promotion Trust, Bangalore, Karnataka, India
| | - Elizabeth Fischer
- IntraHealth International, Chapel Hill, North Carolina, United States of America
| | - Maryanne Crockett
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Blanchard
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen Moses
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Avery
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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