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Boakye DS, Amoah VMK, Amoah C, Boateng AA, Aduomi-Botchwey CO, Bamfo F, Boampong J. Eclampsia or epilepsy? The intriguing experiences of pregnant women diagnosed with preeclampsia and eclampsia: A descriptive exploratory study. SAGE Open Med 2024; 12:20503121241271768. [PMID: 39139267 PMCID: PMC11320684 DOI: 10.1177/20503121241271768] [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: 03/19/2024] [Accepted: 06/27/2024] [Indexed: 08/15/2024] Open
Abstract
Aim The purpose of this study was to explore the experiences of pregnant women who suffer the stressful effects of preeclampsia and eclampsia through pregnancy, delivery, and postpartum. Methods A descriptive exploratory approach was adopted to gather in-depth data from women diagnosed with preeclampsia and eclampsia during pregnancy from February to March 2022. Purposive sampling was used to enlist 12 participants from a Municipal Hospital in the Ahafo region of Ghana. Data were analyzed thematically following Braun and Clark approach. Results The study found that women had strong negative emotional reactions after being diagnosed with preeclampsia or eclampsia. They frequently felt guilty, angry, scared, in denial, or disbelief about their condition. Many women held mistaken beliefs about the diseases (they misconstrued eclampsia to be epilepsy) and isolated themselves, mainly because of false perceptions and stigma around their illness in the community. Participants expressed unfulfilled needs for informational and emotional support. The information they received about their condition was insufficient, contradictory, and confusing. Some women also felt pressured into having cesarean deliveries without enough discussion or say in the decision-making process. Conclusion These findings reveal important psychosocial impacts of preeclampsia/eclampsia and gaps in condition-specific education and empathetic, patient-centered communication. Improving provider knowledge and counseling skills along with community awareness may help address these unmet needs among Ghanaian women facing this threat to maternal health.
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Affiliation(s)
- Dorothy Serwaa Boakye
- Department of Health Administration and Education, University of Education, Winneba, Winneba, Ghana
| | - Vida Maame Kissiwaa Amoah
- Department of Nursing, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Christian Amoah
- Department of Behavioral Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Agartha Afful Boateng
- Department of Health Administration and Education, University of Education, Winneba, Winneba, Ghana
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Morris G, Maliqi B, Lattof SR, Strong J, Yaqub N. Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review. Front Glob Womens Health 2024; 5:1369792. [PMID: 38707636 PMCID: PMC11066217 DOI: 10.3389/fgwh.2024.1369792] [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: 01/12/2024] [Accepted: 03/21/2024] [Indexed: 05/07/2024] Open
Abstract
The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers. Systematic Review Registration https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].
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Affiliation(s)
- Georgina Morris
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Joe Strong
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Nuhu Yaqub
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
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Dixit P, Sundararaman T, Halli S. Is the quality of public health facilities always worse compared to private health facilities: Association between birthplace on neonatal deaths in the Indian states. PLoS One 2023; 18:e0296057. [PMID: 38150439 PMCID: PMC10752527 DOI: 10.1371/journal.pone.0296057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND The role of place of delivery on the neonatal health outcomes are very crucial. Although the quality of care is being improved, there is no consensus about who is the better healthcare provider in low and middle-income countries (LMICs), public or private facilities. The aim of this study is to assess the differentials in neonatal mortality by the type of healthcare providers in India and its states. METHODS We used the data from the fourth wave of the National Family Health Survey 2015-16 (NFHS-4). Information on 259,627 live births to women within the five years preceding the survey was examined. Neonatal mortality rates for state and national levels were calculated using DHS methodology. Multi-variate logistics regression was performed to find the effect of birthplace on neonatal deaths. Propensity score matching (PSM) was used to evaluate the relationship between place of delivery and neonatal deaths to account for the bias attributable to observable covariates. RESULTS The rise in parity of the women and purchasing power influences the choice of healthcare providers. Increased neonatal mortality was found in private hospital delivery compared to public hospitals in Punjab, Rajasthan, Chhattisgarh, Madhya Pradesh, Bihar, Jharkhand, Odisha, Goa, Maharashtra, Andhra Pradesh and Karnataka states using propensity score matching analysis. However, analysis on the standard of pre-natal and post-natal care indicates that private hospitals generally outperformed public hospitals. CONCLUSIONS The study observed a significant variation in neonatal mortality among public and private health care systems in India. Findings of the study urges that more attention be paid to the improve care at the place of delivery to improve neonatal health. There is a need of strengthened national health policy and public-private partnerships in order to improve maternal and child health care in both private and public health facilities.
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Affiliation(s)
- Priyanka Dixit
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | | | - Shiva Halli
- Department of Community Health Sciences Faculty of Medicine, University of Manitoba, Manitoba, Canada
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Nabulo H, Gottfredsdottir H, Joseph N, Kaye DK. Experiences of referral with an obstetric emergency: voices of women admitted at Mbarara Regional Referral Hospital, South Western Uganda. BMC Pregnancy Childbirth 2023; 23:498. [PMID: 37415127 PMCID: PMC10327367 DOI: 10.1186/s12884-023-05795-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/17/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Life-threatening obstetric complications usually lead to the need for referral and constitute the commonest direct causes of maternal deaths. Urgent management of referrals can potentially lower the maternal mortality rate. We explored the experiences of women referred with obstetric emergencies to Mbarara Regional Referral Hospital (MRRH) in Uganda, in order to identify barriers and facilitating factors. METHODS This was an exploratory qualitative study. In-depth interviews (IDIs) were conducted with 10 postnatal women and 2 attendants as key informants. We explored health system and client related factors to understand how these could have facilitated or hindered the referral process. Data was analyzed deductively employing the constructs of the Andersen Healthcare Utilization model. RESULTS Women experienced transport, care delays and inhumane treatment from health care providers (HCPs). The obstetric indications for referral were severe obstructed labor, ruptured uterus, and transverse lie in advanced labor, eclampsia and retained second twin with intrapartum hemorrhage. The secondary reasons for referral included; non-functional operating theatres due to power outages, unsterilized caesarian section instruments, no blood transfusion services, stock outs of emergency drugs, and absenteeism of HCPs to perform surgery. Four (4) themes emerged; enablers, barriers to referral, poor quality of care and poor health facility organization. Most referring health facilities were within a 30-50 km radius from MRRH. Delays to receive emergency obstetric care (EMOC) led to acquisition of in-hospital complications and eventual prolonged hospitalization. Enablers to referral were social support, financial preparation for birth and birth companion's knowledge of danger signs. CONCLUSION The experience of obstetric referral for women was largely unpleasant due to delays and poor quality of care which contributed to perinatal mortality and maternal morbidities. Training HCPs in respectful maternity care (RMC) may improve quality of care and foster positive postnatal client experiences. Refresher sessions on obstetric referral procedures for HCPs are suggested. Interventions to improve the functionality of the obstetric referral pathway for rural south-western Uganda should be explored.
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Affiliation(s)
- Harriet Nabulo
- Department of Nursing, Mbarara University of Science and Technology, P.O.BOX 4010, Mbarara, Uganda
| | - Helga Gottfredsdottir
- Faculty of Nursing and Midwifery, University of Iceland, Reykjavik, Iceland
- The University Hospital of Iceland, Women’s Clinic, Reykjavik, Iceland
| | - Ngonzi Joseph
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dan K. Kaye
- Obstetrics/Gynaecology Department, College of Health Sciences, Makerere University, Kampala, Uganda
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Seif SA, Rashid SA. Knowledge and skills of pre-eclampsia management among healthcare providers working in antenatal clinics in Zanzibar. BMC Health Serv Res 2022; 22:1512. [PMID: 36510295 PMCID: PMC9746160 DOI: 10.1186/s12913-022-08892-5] [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: 06/10/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pre-eclampsia and eclampsia are the leading causes of perinatal morbidity and mortality worldwide. Early detection and treatment of preeclampsia is lifesaving; however, evidence suggests that the majority of women in low and middle income-countries are not routinely screened for high blood pressure during antenatal care, that those with severe and mild pre-eclampsia are not monitored for blood pressure and proteinuria as needed, and the magnesium sulphate is not administered as needed. The purpose of this study was therefore to assess knowledge and skills in pre-eclampsia and eclampsia management and their associated factors among healthcare providers working in antenatal clinics in Zanzibar. METHODS This was a cross-sectional analytical study conducted in all levels of healthcare facilities in Zanzibar. The study involved 176 healthcare providers (nurses and doctors) who were randomly selected. A self-administered questionnaire was used to collect data and descriptive and inferential statistics were used in the analysis whereby logistic regression models were employed. The Chi-square coefficient, odds ratio, and 95% confidence intervals were reported, and the level of significance was set at p < 0.05. RESULTS The mean age of healthcare providers was 35.94 (SD ± 7.83) years. The proportion of healthcare providers with adequate knowledge was 49.0%, and 47% had adequate skills. Knowledge level was predicted by working in higher healthcare facility levels (AOR: 3.28, 95% CI: 1.29-8.29), and having attended on-the-job training on pre-eclampsia (AOR: 7.8, 95% CI: 2.74 - 22.75). Skills were predicted by having attended on-job training (AOR: 8.6, 95% CI: 2.45 - 30.16), having working experience of five years or above in antenatal care units (AOR: 27.89, 95% CI: 5.28 - 148.89) and being a medical doctor or assistant medical doctor (AOR: 18.9, 95% CI: 2.1-166). CONCLUSION Approximately half of Zanzibar's ANC healthcare workers demonstrated inadequate knowledge and skills in preeclampsia care, indicating a critical need for targeted interventions to reduce maternal morbidity and mortality. Knowledge is predicted by attending on-the-job training and working in higher healthcare facility level, while skills is predicted by attending on job training, more years of working experience in antenatal care units and being a medical doctor or assistant medical doctor The study recommends the healthcare facility institutions to provide on-the-job training to for the healthcare providers working in lower healthcare facility levels.
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Affiliation(s)
- Saada Ali Seif
- grid.442459.a0000 0001 1998 2954Department of Nursing Management and Education, The University of Dodoma, P.O.BOX 259, Dodoma, Tanzania
| | - Salma Ali Rashid
- grid.442459.a0000 0001 1998 2954Department of Clinical Nursing, The University of Dodoma, P.O.BOX 259, Dodoma, Tanzania
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Singh L, Dubey R, Singh PK, Nair S, Rao MVV, Singh S. Association between timing and type of postnatal care provided with neonatal mortality: A large scale study from India. PLoS One 2022; 17:e0272734. [PMID: 36112589 PMCID: PMC9480985 DOI: 10.1371/journal.pone.0272734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives
This study examines the association between quality Postnatal Care (PNC) considering timing and providers’ type on neonatal mortality. The aim extends to account for regional disparities in service delivery and mortality including high and non-high focus states.
Methods
Ever-married women aged 15–49 years (1,87,702) who had delivered at least one child in five years preceding the survey date surveyed in National Family Health Survey (2015–16) were included in the study. Neonatal deaths between day two and seven and neonatal deaths between day two and twenty-eight were considered dependent variables. Descriptive statistics and multivariate regression analysis were conducted.
Results
Chances of early neonatal mortality were 29% (OR = 0.71; 95%CI: 0.59–0.84) among newborns receiving PNC within a day compared to ones devoid of it while 40% (OR: 0.60; 95%CI: 0.51–0.71) likelihood for the same was noted if PNC was delivered within a week. Likelihood of neonatal mortality decreased by 24% (OR: 0.76; 95%CI: 0.65–0.88) when skilled PNC was delivered within 24 hours. Receiving quality PNC by skilled providers within a day in a non-high focus state decreased the chances of neonatal mortality by 26% (OR: 0.74; 95%CI: 0.59–0.92) compared to ones who did not receive any PNC.
Conclusions
Neonatal deaths were significantly associated with socioeconomic and contextual characteristics including age, education, household wealth, social group and region. Timing of PNC delivered and by a skilled healthcare provider was found significant in reducing neonatal mortality.
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Affiliation(s)
- Lucky Singh
- ICMR National Institute of Medical Statistics, Ansari Nagar, New Delhi, India
- * E-mail:
| | - Ritam Dubey
- Division of Preventive Oncology and Population Health, ICMR National Institute of Cancer Prevention and Research, Noida, Uttar Pradesh, India
| | - Prashant Kumar Singh
- Division of Preventive Oncology and Population Health, ICMR National Institute of Cancer Prevention and Research, Noida, Uttar Pradesh, India
| | - Saritha Nair
- ICMR National Institute of Medical Statistics, Ansari Nagar, New Delhi, India
| | | | - Shalini Singh
- Division of Preventive Oncology and Population Health, ICMR National Institute of Cancer Prevention and Research, Noida, Uttar Pradesh, India
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Kanyesigye H, Kabakyenga J, Mulogo E, Fajardo Y, Atwine D, MacDonald NE, Bortolussi R, Migisha R, Ngonzi J. Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study. BMC Pregnancy Childbirth 2022; 22:684. [PMID: 36064375 PMCID: PMC9442930 DOI: 10.1186/s12884-022-05007-0] [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: 11/03/2021] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency obstetric referrals develop adverse maternal-fetal outcomes partly due to delays in offering appropriate care at referral hospitals especially in resource limited settings. Referral hospitals do not get prior communication of incoming referrals leading to inadequate preparedness and delays of care. Phone based innovations may bridge such communication challenges. We investigated effect of a phone call communication prior to referral of mothers in labour as intervention to reduce preparation delays and improve maternal-fetal outcome at a referral hospital in a resource limited setting. METHODS This was a quasi-experimental study with non-equivalent control group conducted at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda from September 2020 to March 2021. Adverse maternal-fetal outcomes included: early neonatal death, fresh still birth, obstructed labour, ruptured uterus, maternal sepsis, low Apgar score, admission to neonatal ICU and hysterectomy. Exposure variable for intervention group was a phone call prior maternal referral from a lower health facility. We compared distribution of clinical characteristics and adverse maternal-fetal outcomes between intervention and control groups using Chi square or Fisher's exact test. We performed logistic regression to assess association between independent variables and adverse maternal-fetal outcomes. RESULTS We enrolled 177 participants: 75 in intervention group and 102 in control group. Participants had similar demographic characteristics. Three quarters (75.0%) of participants in control group delayed on admission waiting bench of MRRH compared to (40.0%) in intervention group [p = < 0.001]. There were significantly more adverse maternal-fetal outcomes in control group than intervention group (obstructed labour [p = 0.026], low Apgar score [p = 0.013] and admission to neonatal high dependency unit [p = < 0.001]). The phone call intervention was protective against adverse maternal-fetal outcome [aOR = 0.22; 95%CI: 0.09-0.44, p = 0.001]. CONCLUSION The phone call intervention resulted in reduced delay to patient admission at a tertiary referral hospital in a resource limited setting, and is protective against adverse maternal-fetal outcomes. Incorporating the phone call communication intervention in the routine practice of emergency obstetric referrals from lower health facilities to regional referral hospitals may reduce both maternal and fetal morbidities. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR20200686885039.
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Affiliation(s)
- Hamson Kanyesigye
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Atwine
- Department of Clinical Research, SOAR Research Foundation, Mbarara, Uganda
| | - Noni E MacDonald
- Faculty of Medicine & MicroResearch International, Dalhouise University, Halifax, Canada
| | - Robert Bortolussi
- Faculty of Medicine & MicroResearch International, Dalhouise University, Halifax, Canada
| | - Richard Migisha
- Department of Physiology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Jayanna K, Rao S, Kar A, Gowda PD, Thomas T, Swaroop N, Washington M, Shashidhar AR, Rai P, Chitrapu S, Mohan HL, Martines J, Mony P. Accelerated scale-up of Kangaroo Mother Care: Evidence and experience from an implementation-research initiative in south India. Acta Paediatr 2022. [PMID: 35146803 DOI: 10.1111/apa.16236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Abstract
AIM Though Kangaroo Mother Care (KMC) has demonstrated benefits for low birth weight newborns, coverage continues to be low in India. As part of a World Health Organization (WHO) multi-country study, we explored intervention models to accelerate KMC coverage in a high priority district of Karnataka, India. METHODS We used implementation-research methods, formative assessments and quality improvement approaches to design and scale-up interventions. Evaluation was done using prospective cohort study design; data were collected from facility records, and client interviews during KMC initiation, at discharge and at home after discharge. RESULTS KMC was initiated at health facilities for 87.6% of LBW babies under 2000 g. At discharge, 85.0% received KMC; 67.9% continued to receive KMC at home on the 7th day post-discharge. The interventions included training, mentoring and constant advocacy at many levels: public health facilities, private sector and the community. Innovations like a KMC case sheet, counselling, peer support group triggered KMC in the facilities; a KMC-link card, a microplanning and communication tool for CHWs helped to sustain practice at homes. CONCLUSION The study provides a novel approach to designing and scaling up interventions and suggests lessons that are applicable to KMC as well as to broader reproductive, maternal, neonatal and child health programmes.
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Affiliation(s)
- Krishnamurthy Jayanna
- Karnataka Health Promotion Trust Bangalore India
- M S Ramaiah University of Applied Sciences Bangalore India
| | - Suman Rao
- Department of Neonatology St John’s Medical College and Hospital St John’s National Academy of Health Sciences Bangalore India
- Division of Epidemiology, Biostatistics & Population Health St John’s Research Institute St John’s National Academy of Health Sciences Bangalore India
| | - Arin Kar
- Karnataka Health Promotion Trust Bangalore India
| | | | - Tinku Thomas
- Division of Epidemiology, Biostatistics & Population Health St John’s Research Institute St John’s National Academy of Health Sciences Bangalore India
| | | | - Maryann Washington
- Division of Epidemiology, Biostatistics & Population Health St John’s Research Institute St John’s National Academy of Health Sciences Bangalore India
| | - A Rao Shashidhar
- Department of Neonatology St John’s Medical College and Hospital St John’s National Academy of Health Sciences Bangalore India
| | | | | | | | | | - Prem Mony
- Division of Epidemiology, Biostatistics & Population Health St John’s Research Institute St John’s National Academy of Health Sciences Bangalore India
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Lahariya C, Sharma S, Agnani M, de Graeve H, Srivastava JN, Bekedam H. Attributes of Standard Treatment Guidelines in Clinical Settings and Public Health Facilities in India. Indian J Community Med 2022; 47:336-342. [PMID: 36438529 PMCID: PMC9693950 DOI: 10.4103/ijcm.ijcm_665_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 03/09/2022] [Indexed: 12/26/2022] Open
Abstract
Background Standard Treatment Guidelines (STGs) are time-tested tool to improve healthcare quality and patient safety. This study was done to review the available guidelines and assess their essential attributes using AGREE reporting checklist 2016. Methods Publications from PubMed, World Health Organization, Global Health Regional Libraries, Index Medicus, Google, Google Scholar, and insurers, state/central government portals were searched. Results In total, 241 STGs met the inclusion criteria. A range of developers with a varying focus and priorities developed these guidelines (government mostly under national programs 134 (56%); professional associations 67 (28%), academic/research institutions 36 (15%); international agencies 4 [2%]). The government-led guidelines focused on program operations (mainly infections, maternal, and childcare), whereas insurers focused on surgical procedures for protection against fraudulent intentions for claims. The available STGs varied largely in terms of development process rigor, end-user involvement, updation, applicability, etc.; 12% guidelines developed documented GRADE criteria for evidence. Most guidelines focused on the primary care, and only 27 and 7% included treatment at tertiary and secondary levels, respectively, focused on general practitioners. Conclusion There is a need for coordinated, and collaborative efforts to generate evidence-based guidelines, facilitate periodic revisions, standardized development process, and the standards for monitoring embedded in the guidelines. A single designated authority for the standard treatment guidelines development and a central web-based repository with free access for clinicians/users will ensure wide access to quality guidelines enhancing acceptance and stewardship.
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Affiliation(s)
- Chandrakant Lahariya
- World Health Organization (WHO) Country Office for India, New Delhi, India,Address for correspondence: Dr. Chandrakant Lahariya, National Professional Officer, World Health Organization Country Office for India, Fifth Floor, Nirman Bhawan, New Delhi - 110 011, India. E-mail:
| | - Sangeeta Sharma
- Institute of Human Behaviour and Allied Sciences (IHBAS) and Delhi Society for Promotion of Rational Use of Drugs (DSPRUD), Delhi, India
| | - Manohar Agnani
- National Health Mission, Ministry of Health and Family Welfare, Govt of India, New Delhi, India
| | - Hilde de Graeve
- World Health Organization (WHO) Country Office for India, New Delhi, India
| | | | - Henk Bekedam
- World Health Organization (WHO) Country Office for India, New Delhi, India
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Yeshitila YG, Bante A, Aschalew Z, Afework B, Gebeyehu S. Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020. PLoS One 2021; 16:e0258784. [PMID: 34710153 PMCID: PMC8553034 DOI: 10.1371/journal.pone.0258784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Delays in care have been recognized as a significant contributor to maternal mortality in low-resource settings. The non-pneumatic antishock garment is a low-cost first-aid device that can help women with obstetric haemorrhage survive these delays without long-term adverse effects. Extending professionals skills and the establishment of new technologies in basic healthcare facilities could harvest the enhancements in maternal outcomes necessary to meet the sustainable development goals. Thus, this study aims to assess utilization of non-pneumatic anti-shock garment to control complications of post-partum hemorrhage and associated factors among obstetric care providers in public health institutions of Southern Ethiopia, 2020. METHODS A facility-based cross-sectional study was conducted among 412 obstetric health care providers from March 15 -June 30, 2020. A simple random sampling method was used to select the study participants. The data were collected through a pre-tested interviewer-administered questionnaire. A binary logistic regression model was used to identify determinants for the utilization of non-pneumatic antishock garment. STATA version 16 was used for data analysis. A P-value of < 0.05 was used to declare statistical significance. RESULTS Overall, 48.5% (95%CI: 43.73, 53.48%) of the obstetric care providers had utilized Non pneumatic antishock garment for management of complications from postpartum hemorrhage. Training on Non pneumatic antishock garment (AOR = 2.92; 95% CI: 1.74, 4.92), working at hospital (AOR = 1.81; 95% CI: 1.04, 3.16), good knowledge about NASG (AOR = 1.997; 95%CI: 1.16, 3.42) and disagreed and neutral attitude on Non pneumatic antishock garment (AOR = 0.41; 95%CI: 0.24, 0.68), and (AOR = 0.39; 95% CI: 0.21, 0.73), respectively were significantly associated with obstetric care provider's utilization of Non-pneumatic antishock garment. CONCLUSIONS In the current study, roughly half of the providers are using Non-pneumatic antishock garment for preventing complications from postpartum hemorrhage. Strategies and program initiatives should focus on strengthening in-service and continuous professional development training, thereby filling the knowledge and attitude gap among obstetric care providers. Health centers should be targeted in future programs for accessibility and utilization of non-pneumatic antishock garment.
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Affiliation(s)
- Yordanos Gizachew Yeshitila
- School of Nursing, College of Medicine and Health Science, Arbaminch University, Arba Minch, Ethiopia
- * E-mail:
| | - Agegnehu Bante
- School of Nursing, College of Medicine and Health Science, Arbaminch University, Arba Minch, Ethiopia
| | - Zeleke Aschalew
- School of Nursing, College of Medicine and Health Science, Arbaminch University, Arba Minch, Ethiopia
| | - Bezawit Afework
- Department of Midwifery, College of Medicine and Health Science, Arbaminch University, Arba Minch, Ethiopia
| | - Selamawit Gebeyehu
- School of Public Health, College of Medicine and Health Science, Arbaminch University, Arba Minch, Ethiopia
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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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Creanga AA, Jiwani S, Das A, Mahapatra T, Sonthalia S, Gore A, Kaul S, Srikantiah S, Galavotti C, Shah H. Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices. J Glob Health 2020; 10:021009. [PMID: 33425333 PMCID: PMC7759016 DOI: 10.7189/jogh.10.021009] [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: 11/20/2022] Open
Abstract
BACKGROUND To address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named - Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) - in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees' competency to provide such services in Bihar, India during 2015-2017. METHODS We used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees' practices. We examined changes in nurse-mentees' knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees' knowledge and practices after adjusting for potential confounders. RESULTS On average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees' knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes. CONCLUSION The AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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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
| | - Safia Jiwani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Tanmay Mahapatra
- 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
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Creanga AA, Jiwani S, Das A, Mahapatra T, Sonthalia S, Gore A, Kaul S, Srikantiah S, Galavotti C, Shah H. Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201009] [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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Nkamba DM, Vangu R, Elongi M, Magee LA, Wembodinga G, Bernard P, Ditekemena J, Robert A. Health facility readiness and provider knowledge as correlates of adequate diagnosis and management of pre-eclampsia in Kinshasa, Democratic Republic of Congo. BMC Health Serv Res 2020; 20:926. [PMID: 33028310 PMCID: PMC7542875 DOI: 10.1186/s12913-020-05795-1] [Citation(s) in RCA: 3] [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: 03/23/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy are the second most common cause of maternal mortality in the Democratic Republic of Congo (DRC), accounting for 23% of maternal deaths. This study aimed to assess facility readiness, and providers' knowledge to prevent, diagnose, and treat pre-eclampsia. METHODS A facility-based cross-sectional study was conducted in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, DRC. In each facility, all midwives and physicians involved in maternal care provision (n = 197) were included. Data on facility infrastructure and providers' knowledge about pre-eclampsia were collected using facility checklists and a knowledge questionnaire. Facility readiness score was defined as the sum of 13 health commodities needed to manage pre-eclampsia. A knowledge score was defined as the sum of 24 items about the diagnosis, management, and prevention of pre-eclampsia. The score ranges from 0 to 24, with higher values reflecting a better knowledge. The Mann-Witney U test was used to compare median readiness scores by facility type and ownership; and median knowledge scores between midwives in hospitals and in PHCs, and between physicians in hospitals and in PHCs. RESULTS Overall, health facilities had 7 of the 13 commodities, yielding a median readiness score of 53.8%(IQR: 46.2 to 69.2%). Although all provider groups had significant knowledge gaps about pre-eclampsia, providers in hospitals demonstrated slightly more knowledge than those in PHCs. Midwives in public facilities scored higher than those in private facilities (median(IQR): 8(5 to 12) vs 7(4 to 8), p = 0.03). Of the 197 providers, 91.4% correctly diagnosed severe pre-eclampsia. However, 43.9 and 82.2% would administer magnesium sulfate and anti-hypertensive drugs to manage severe pre-eclampsia, respectively. Merely 14.2 and 7.1% of providers were aware of prophylactic use of aspirin and calcium to prevent pre-eclampsia, respectively. CONCLUSION Our study showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in Kinshasa. While providers demonstrated good knowledge regarding the diagnosis of pre-eclampsia, they have poor knowledge regarding its prevention and management. The study highlights the need for strengthening knowledge of providers toward the prevention and management of pre-eclampsia, and enhancing the availability of supplies needed to address this disease.
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Affiliation(s)
- Dalau Mukadi Nkamba
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
- Pôle d'Épidémiologie et Biostatistique, Université catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Clos Chapelle-aux-champs, 30 bte B1.30.13, 1200, Brussels, Belgium.
| | - Roland Vangu
- Department of Gynecology and Obstetrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Moyene Elongi
- Department of Gynecology and Obstetrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of Congo
- Department of Gynecology and Obstetrics, Provincial General Hospital of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Gilbert Wembodinga
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pierre Bernard
- Pôle de Gynécologie et Obstétrique, Université Catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - John Ditekemena
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Annie Robert
- Pôle d'Épidémiologie et Biostatistique, Université catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Clos Chapelle-aux-champs, 30 bte B1.30.13, 1200, Brussels, Belgium
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Alwy Al-Beity F, Pembe AB, Kwezi HA, Massawe SN, Hanson C, Baker U. "We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage. Glob Health Action 2020; 13:1707403. [PMID: 31928163 PMCID: PMC7006654 DOI: 10.1080/16549716.2019.1707403] [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] [Indexed: 11/22/2022] Open
Abstract
Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH). Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers’ perceptions of their health facilities’ readiness to provide PPH care. Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software. Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care. Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed.
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Affiliation(s)
- Fadhlun Alwy Al-Beity
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hilda A Kwezi
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Siriel N Massawe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hanson
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Ulrika Baker
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden.,Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Choudhry V, Weiner B, Karkhanis P, Avinandan V, Shah N, Bahl N, Wadhwa R, Sridhar P, Chandurkar D. Determinants of technology use for a mobile health intervention across public health facilities in rural India: Protocol for implementation research. Gates Open Res 2020. [DOI: 10.12688/gatesopenres.13128.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This paper presents a research protocol for implementation research (IR) to investigate contextual factors influencing the implementation of ASMAN mobile health intervention and their association with maternal, newborn, and child health outcomes. The IR will cover roughly 16-20 public health facilities across the states of Rajasthan and Madhya Pradesh in India. These facilities will be a sub-sample of 49 facilities covered separately under the outcome evaluation. The study employs a longitudinal mixed-methods multiple case study design with sequential data collection using constructs under the Consolidated Framework for Implementation Research (CFIR) across two phases. The first phase will be exploratory and use qualitative inquiry to contextualize the CFIR constructs. The second phase will employ a mixed-methods explanatory design with both validated and contextualized CFIR constructs and standard quantitative measures collected through outcome evaluation. Findings from this study will provide insights into factors that facilitate or impede the implementation of mobile health interventions and their association with MNCH outcomes in public health facilities in India.
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17
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Pati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India. Public Health Rev 2020; 41:8. [PMID: 32435518 PMCID: PMC7222468 DOI: 10.1186/s40985-020-00128-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist. METHOD The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC). RESULT The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level. CONCLUSION This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.
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Affiliation(s)
- Manoj Kumar Pati
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | - N. Swaroop
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | - Arin Kar
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | | | - Krishnamurthy Jayanna
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Wim Van Damme
- Health Policy Department, Institute of Tropical Medicine, Antwerp, Belgium
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Lama TP, Munos MK, Katz J, Khatry SK, LeClerq SC, Mullany LC. Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal. BMC Health Serv Res 2020; 20:16. [PMID: 31906938 PMCID: PMC6945781 DOI: 10.1186/s12913-019-4871-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Increased coverage of antenatal care and facility births might not improve maternal and newborn health outcomes if quality of care is sub-optimal. Our study aimed to assess the facility readiness and health worker knowledge required to provide quality maternal and newborn care. METHODS Using an audit tool and interviews, respectively, facility readiness and health providers' knowledge of maternal and immediate newborn care were assessed at all 23 birthing centers (BCs) and the District hospital in the rural southern Nepal district of Sarlahi. Facility readiness to perform specific functions was assessed through descriptive analysis and comparisons by facility type (health post (HP), primary health care center (PHCC), private and District hospital). Knowledge was compared by facility type and by additional skilled birth attendant (SBA) training. RESULTS Infection prevention items were lacking in more than one quarter of facilities, and widespread shortages of iron/folic acid tablets, injectable ampicillin/gentamicin, and magnesium sulfate were a major barrier to facility readiness. While parenteral oxytocin was commonly provided, only the District hospital was prepared to perform all seven basic emergency obstetric and newborn care signal functions. The required number of medical doctors, nurses and midwives were present in only 1 of 5 PHCCs. Private sector SBAs had significantly lower knowledge of active management of third stage of labor and correct diagnosis of severe pre-eclampsia. While half of the health workers had received the mandated additional two-month SBA training, comparison with the non-trained group showed no significant difference in knowledge indicators. CONCLUSIONS Facility readiness to provide quality maternal and newborn care is low in this rural area of Nepal. Addressing the gaps by facility type through regular monitoring, improving staffing and supply chains, supervision and refresher trainings is important to improve quality.
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Affiliation(s)
- Tsering P. Lama
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD 21205 USA
| | - Melinda K. Munos
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD 21205 USA
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD 21205 USA
| | - Subarna K. Khatry
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS), Kathmandu, Nepal
| | - Steven C. LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD 21205 USA
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS), Kathmandu, Nepal
| | - Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD 21205 USA
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Nsangamay T, Mash R. How to improve the quality of care for women with postpartum haemorrhage at Onandjokwe Hospital, Namibia: quality improvement study. BMC Pregnancy Childbirth 2019; 19:489. [PMID: 31829139 PMCID: PMC6907333 DOI: 10.1186/s12884-019-2635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is the leading direct cause of maternal morbidity and mortality worldwide. The sustainable development goals aim to reduce the maternal mortality ratio to 70 per 100,000 live births. In Namibia, the ratio was reported as 265 per 100,000 live births in 2015 and yet little is published on emergency obstetric care. The majority of deliveries in Namibia are facility-based. The aim of this study was to assess and improve the quality of care for women with PPH at Onandjokwe Hospital, Namibia. Methods A criterion-based audit cycle in all 82 women with PPH from 2015 using target standards for structure, process and outcomes of care. The audit team then planned and implemented interventions to improve the quality of care over a 10-month period. The audit team repeated the audit on all 70 women with PPH from the same 10-month period. The researchers compared audit results in terms of the number of target standards achieved and any significant change in the proportion of patients’ care meeting the predetermined criteria. Results In the baseline audit 12/19 structural, 0/9 process and 0/3 outcome target standards were achieved. On follow up 19/19 structural, 6/9 process and 2/3 outcome target standards were met. There was one maternal death in the baseline group and none in the follow up group. Overall 6/9 process and 2/3 outcome criteria significantly improved (p < 0.05) from baseline to follow up. Key interventions included training of nursing and medical staff in obstetric emergencies, ensuring that guidelines and standard operating protocols were easily available, reorganising care to ensure adequate monitoring of women postpartum and ensuring that essential equipment was available and functioning. Conclusion The study demonstrates that the quality of care for emergency obstetrics can be improved by audit cycles that focus on the structure and process of care. Other hospitals in Namibia and the region could adopt the process of continuous quality improvement and similar strategies.
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Affiliation(s)
- Tshimanga Nsangamay
- Division of Family Medicine and Primary Care, Stellenbosch University, Stellenbosch, South Africa
| | - Robert Mash
- Division of Family Medicine and Primary Care, Stellenbosch University, Stellenbosch, South Africa.
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Khan ANS, Karim F, Chowdhury MAK, Zaka N, Manu A, Arifeen SE, Billah SM. Competence of healthcare professionals in diagnosing and managing obstetric complications and conducting neonatal care: a clinical vignette-based assessment in district and subdistrict hospitals in northern Bangladesh. BMJ Open 2019; 9:e028670. [PMID: 31427325 PMCID: PMC6701613 DOI: 10.1136/bmjopen-2018-028670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 06/24/2019] [Accepted: 07/17/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND This study assesses the competency of maternal and neonatal health (MNH) professionals at district-level and subdistrict-level health facilities in northern Bangladesh in managing maternal and newborn complications using clinical vignettes. The study also examines whether the professional's characteristics and provision of MNH services in health facilities influence their competencies. METHODS 134 MNH professionals in 15 government hospitals were interviewed during August and September 2016 using structured questionnaire with clinical vignettes on obstetric complications (antepartum haemorrhage and pre-eclampsia) and neonatal care (low birthweight and immediate newborn care). Summative scores were calculated for each vignette and median scores were compared across different individual-level and health facility-level attributes to examine their association with competency score. Kruskal-Wallis test was performed to identify the significance of association considering a p value<0.05 as statistically significant. RESULTS The competency of MNH professionals was low. About 10% and 24% of the health professionals received 'high' scores (>75% of total) in maternal and neonatal vignettes, respectively. Medical doctors had higher competency than nurses and midwives (score=11 vs 8 out of 19, respectively; p=0.0002) for maternal vignettes, but similar competency for neonatal vignettes (score=30.3 vs 30.9 out of 50, respectively). Professionals working in health facilities with higher use of normal deliveries had better competency than their counterparts. Professionals had higher competency in newborn vignettes (significant) and maternal vignettes (statistically not significant) if they worked in health facilities that provided more specialised newborn care services and emergency obstetric care, respectively, in the last 6 months. CONCLUSIONS Despite the overall low competency of MNH professionals, exposure to a higher number of obstetric cases at the workplace was associated with their competency. Arrangement of periodic skill-based and drill-based in-service training for MNH professionals in high-use neighbouring health facilities could be a feasible intervention to improve their knowledge and skill in obstetric and neonatal care.
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Affiliation(s)
- Abdullah Nurus Salam Khan
- Health Promotion, Education and Behavior, University of South Carolina, Columbia, South Carolina, USA
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Farhana Karim
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Mohiuddin Ahsanul Kabir Chowdhury
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
- Epidemiology, University of South Carolina, Columbia, South Carolina, USA
| | - Nabila Zaka
- Health Section, Maternal and Newborn Health, UNICEF USA, New York, New York, USA
| | - Alexander Manu
- Department of Population Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
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Kaur J, Franzen SRP, Newton-Lewis T, Murphy G. Readiness of public health facilities to provide quality maternal and newborn care across the state of Bihar, India: a cross-sectional study of district hospitals and primary health centres. BMJ Open 2019; 9:e028370. [PMID: 31362965 PMCID: PMC6678016 DOI: 10.1136/bmjopen-2018-028370] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Poor access to quality healthcare is one of the most important reasons of high maternal and neonatal mortality in India, particularly in poorer states like Bihar. India has implemented initiatives to promote institutional maternal deliveries. It is important to ensure that health facilities are adequately equipped and staffed to provide quality care for mothers and newborns. METHODS We conducted a cross-sectional study of 190 primary health centres (PHCs) and 36 district hospitals (DHs) across all districts in Bihar to assess the readiness of facilities to provide quality maternal and neonatal care. Infrastructure, equipment and supplies and staffing were assessed using the WHO service availability and readiness assessment and Indian public health standard guidelines. Additionally, we used household survey data to assess the quality of care reported by mothers delivering at study facilities. RESULTS PHCs and DHs were found to have 61% and 67% of the mandated structural components to provide maternal and neonatal care, on average, respectively. DHs were, on average, slightly better equipped in terms of infrastructure, equipment and supplies by comparison to PHCs. DHs were found to be inadequately prepared to provide neonatal care. Lack of recommended handwashing stations and bins at both DHs and PHCs suggested low levels of hygiene. Only half of the essential drugs were available in both DHs and PHCs. While no association was revealed between structural capacity and patient-reported quality of care, adequacy of staffing was positively associated with the quality of care in DHs. CONCLUSION Examining all DHs and a representative sample of PHCs in Bihar, this study revealed the gaps in structural components that need to be filled to provide quality care to mothers and newborns. Access to quality care is essential if progress in reducing maternal and neonatal mortality is to be achieved in this high-burden state.
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Affiliation(s)
| | - Samuel Richard Piers Franzen
- Oxford Policy Management, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Georgina Murphy
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
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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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Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C. Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India. Health Policy Plan 2019; 34:450-460. [PMID: 31302699 PMCID: PMC6735944 DOI: 10.1093/heapol/czz056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
| | - Katia Bruxvoort
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, USA
| | - Richard Iles
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Manish Subharwal
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Sanjay Gupta
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Manish Jain
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
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Misoprostol, Magnesium Sulphate and Anti-shock garment: A knowledge, availability and utilization study at the Primary Health Care Level in Western Nigeria. PLoS One 2019; 14:e0213491. [PMID: 30897096 PMCID: PMC6460555 DOI: 10.1371/journal.pone.0213491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 02/22/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Nigeria has one of the highest maternal mortality ratios in the world. The
nurses and midwives being the first point of contact play a central role in
addressing these problems. This study was conducted to assess the knowledge
and utilization of the technologies (misoprostol, anti-shock garment and
magnesium sulphate) in the reduction of maternal mortality amongst the
Primary Health Care (PHC) nurses and midwives in Lagos State, Nigeria. In
addition, the availability of the technologies in the flagship Primary
Health Centres (PHCs) was assessed. Methods This was a cross-sectional study among all the nurses and midwives at the
flagship PHCs in Lagos state and a total of 230 were eventually studied.
Data was collected using a self-administered, structured questionnaire and a
checklist. Descriptive and inferential statistics were applied. Level of
significance was set at 5% (p<0.05). Results All the respondents were aware of the technologies but most (73.9%) had poor
knowledge of them. Majority (74.8%) of the respondents had good knowledge of
maternal mortality and its major causes. Most, 81.3% of the respondents have
administered misoprostol, 37.0% magnesium sulphate while 52.2% have
administered anti shock garment. Out of the 57 flagship PHCs, 27 (47.4%) had
magnesium sulphate, 42 (73.7%) had misoprostol and 52 (91.2%) had anti-shock
garments in their facilities. Respondents who were double qualified
(nurse/midwife) had significantly better knowledge of maternal mortality and
its major causes (p = 0.009) than the other cadres. Longer years of
experience (p = 0.019), training in the use of misoprostol (p = 0.020) and
training in the use of magnesium sulphate (p = 0.001) significantly improved
knowledge of the technologies. Conclusion Respondents had good knowledge of maternal mortality and its major causes and
poor knowledge of the technologies for maternal mortality reduction, despite
the trainings attended. Of the three technologies considered, misoprostol
was the most commonly used. Periodic refresher courses for the training and
retraining of PHC nurses and midwives on the technologies for maternal
mortality reduction is recommended.
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Sethi R, Tholandi M, Amelia D, Pedrana A, Ahmed S. Assessment of knowledge of evidence‐based maternal and newborn care practices among midwives and nurses in six provinces in Indonesia. Int J Gynaecol Obstet 2019; 144 Suppl 1:51-58. [DOI: 10.1002/ijgo.12735] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | - Alisa Pedrana
- Disease Elimination Program Burnet Institute Melbourne Australia
| | - Saifuddin Ahmed
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD USA
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26
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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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Raney JH, Morgan MC, Christmas A, Sterling M, Spindler H, Ghosh R, Gore A, Mahapatra T, Walker DM. Simulation-enhanced nurse mentoring to improve preeclampsia and eclampsia care: an education intervention study in Bihar, India. BMC Pregnancy Childbirth 2019; 19:41. [PMID: 30674286 PMCID: PMC6344989 DOI: 10.1186/s12884-019-2186-x] [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] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 01/09/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inadequately treated, preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates, and are estimated to cause 60,000 global maternal deaths annually. Simulation-based training on obstetric and neonatal emergency management has demonstrated promising results in low- and middle-income countries. However, the impact of simulation training on use of evidence-based practices for PE/E diagnosis and management in low-resource settings remains unknown. METHODS This study was based on a statewide, high fidelity in-situ simulation training program developed by PRONTO International and implemented in collaboration with CARE India on PE/E management in Bihar, India. Using a mixed methods approach, we evaluated changes over time in nurse mentees' use of evidence-based practices during simulated births at primary health clinics. We compared the proportion and efficiency of evidence-based practices completed during nurse mentees' first and last participation in simulated PE/E cases. Twelve semi-structured interviews with nurse mentors explored barriers and enablers to high quality PE/E care in Bihar. RESULTS A total of 39 matched first and last simulation videos, paired by facility, were analyzed. Videos occurred a median of 62 days apart and included 94 nurses from 33 primary health centers. Results showed significant increases in the median number of 'key history questions asked,' (1.0 to 2.0, p = 0.03) and 'key management steps completed,' (2.0 to 3.0, p = 0.03). The time from BP measured to magnesium sulfate given trended downwards by 3.2 min, though not significantly (p = 0.06). Key barriers to high quality PE/E care included knowledge gaps, resource shortages, staff hierarchy between physicians and nurses, and poor relationships with patients. Enablers included case-based and simulation learning, promotion of teamwork and communication, and effective leadership. CONCLUSION Simulation training improved the use of evidence-based practices in PE/E simulated cases and has the potential to increase nurse competency in diagnosing and managing complex maternal complications such as PE/E. However, knowledge gaps, resource limitations, and interpersonal barriers must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality PE/E care in Bihar.
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Affiliation(s)
- Julia H. Raney
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, CT 06510 USA
| | - Melissa C. Morgan
- Department of Pediatrics, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158 USA
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Amelia Christmas
- PRONTO International, State RMNCH+A Unit, C-16 Krishi Nagar, A.G. Colony, Patna, Bihar 80002 India
| | - Mona Sterling
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158 USA
| | - Hilary Spindler
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158 USA
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158 USA
| | - Aboli Gore
- CARE India, Bihar technical Support Program, 14, Patliputra Colony, Patna, Bihar 800013 India
| | - Tanmay Mahapatra
- CARE India, Bihar technical Support Program, 14, Patliputra Colony, Patna, Bihar 800013 India
| | - Dilys M. Walker
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA 94158 USA
- Department of Obstetrics and Gynecology and Reproductive Services, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA 94110 USA
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Olaoye T, Oyerinde OO, Elebuji OJ, Ologun O. Knowledge, Perception and Management of Pre-eclampsia among Health Care Providers in a Maternity Hospital. Int J MCH AIDS 2019; 8:80-88. [PMID: 31723478 PMCID: PMC6804318 DOI: 10.21106/ijma.275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Morbidity and mortality of women and children associated with pre-eclampsia present major global health problems in low and middle income countries. The prevalence of pre-eclampsia in Nigeria ranges from 2% to 16.7%, with approximately 37,000 women dying from preeclampsia annually. This study examines knowledge, perception and management of preeclampsia among healthcare providers in a major maternity hospital in Lagos, southwest Nigeria. METHODS In this descriptive cross-sectional study, 110 health care providers comprising of 75 Nurses, 9 Consultant Physicians, and 26 General Medical Practitioners with varying years of service were selected using purposive sampling technique. Data were collected using a self-administered 36-item semi-structured questionnaire. Data were analysed using the Statistical Package for Social Sciences to generate descriptive and inferential statistics with level of significance set at 0.05. RESULTS Health care providers in the study had an average knowledge of pre-eclampsia with a mean score of 16.69±3.53. There was generally a good perception of pre-eclampsia with a mean sore of 28.31±3.71. The most-prevalent clinical management practices were emergency cesarean section (16%), magnesium sulphate infusion (29%), and fluid/electrolyte management (9%). Knowledge of pre-eclampsia and years of practice were significantly associated (F=3.31; p= 0.023). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Gaps in the knowledge of causes, diagnoses, and treatment of pre-eclampsia may be attributable to lack of refresher trainings and absence of written practice guidelines on pre-eclampsia management. Health care providers at this hospital may benefit from training courses that include current nationally and internationally-approved management of pre-eclampsia.
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Affiliation(s)
- Titilayo Olaoye
- Department of Public Health, Babcock University, Ilishan Remo, Ogun State, Nigeria
| | - Oyewole O Oyerinde
- Department of Public Health, Babcock University, Ilishan Remo, Ogun State, Nigeria
| | - Oluwatoyin J Elebuji
- Department of Public Health, Babcock University, Ilishan Remo, Ogun State, Nigeria
| | - Oluwapelumi Ologun
- Department of Public Health, Babcock University, Ilishan Remo, Ogun State, Nigeria
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Katageri G, Charantimath U, Joshi A, Vidler M, Ramadurg U, Sharma S, Bannale S, Payne BA, Rakaraddi S, Karadiguddi C, Mungarwadi G, Kavi A, Sawchuck D, Derman R, Goudar S, Mallapur A, Bellad M, Magee LA, Qureshi R, von Dadelszen P. Availability and use of magnesium sulphate at health care facilities in two selected districts of North Karnataka, India. Reprod Health 2018; 15:91. [PMID: 29945665 PMCID: PMC6020005 DOI: 10.1186/s12978-018-0531-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-eclampsia and eclampsia are major causes of maternal morbidity and mortality. Magnesium sulphate is accepted as the anticonvulsant of choice in these conditions and is present on the WHO essential medicines list and the Indian National List of Essential Medicines, 2015. Despite this, magnesium sulphate is not widely used in India for pre-eclampsia and eclampsia. In addition to other factors, lack of availability may be a reason for sub-optimal usage. This study was undertaken to assess the availability and use of magnesium sulphate at public and private health care facilities in two districts of North Karnataka, India. METHODS A facility assessment survey was undertaken as part of the Community Level Interventions for Pre-eclampsia (CLIP) Feasibility Study which was undertaken prior to the CLIP Trials (NCT01911494). This study was undertaken in 12 areas of Belagavi and Bagalkote districts of North Karnataka, India and included a survey of 88 facilities. Data were collected in all facilities by interviewing the health care providers and analysed using Excel. RESULTS Of the 88 facilities, 28 were public, and 60 were private. In the public facilities, magnesium sulphate was available in six out of 10 Primary Health Centres (60%), in all eight taluka (sub-district) hospitals (100%), five of eight community health centres (63%) and both district hospitals (100%). Fifty-five of 60 private facilities (92%) reported availability of magnesium sulphate. Stock outs were reported in six facilities in the preceding six months - five public and one private. Twenty-five percent weight/volume and 50% weight/volume concentration formulations were available variably across the public and private facilities. Sixty-eight facilities (77%) used the drug for severe pre-eclampsia and 12 facilities (13.6%) did not use the drug even for eclampsia. Varied dosing schedules were reported from facility to facility. CONCLUSIONS Poor availability of magnesium sulphate was identified in many facilities, and stock outs in some. Individual differences in usage were identified. Ensuring a reliable supply of magnesium sulphate, standard formulations and recommendations of dosage schedules and training may help improve use; and decrease morbidity and mortality due to pre-eclampsia/ eclampsia. TRIAL REGISTRATION The CLIP trial was registered with ClinicalTrials.gov ( NCT01911494 ).
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Affiliation(s)
- Geetanjali Katageri
- Department of Obstetrics and Gynaecology, S Nijalingappa Medical College, Bagalkot, Karnataka, India
| | - Umesh Charantimath
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India.
| | - Anjali Joshi
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Umesh Ramadurg
- Department of Community Medicine, S Nijalingappa Medical College, Bagalkot, Karnataka, India
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sheshidhar Bannale
- Department of Pharmacology, S Nijalingappa Medical College, Bagalkot, Karnataka, India
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sangamesh Rakaraddi
- Department of Anatomy, S Nijalingappa Medical College, Bagalkot, Karnataka, India
| | | | - Geetanjali Mungarwadi
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, British Columbia, Canada
| | - Richard Derman
- Global Affairs, Thomas Jefferson University, Philadelphia, USA
| | - Shivaprasad Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Ashalata Mallapur
- Department of Obstetrics and Gynaecology, S Nijalingappa Medical College, Bagalkot, Karnataka, India
| | - Mrutyunjaya Bellad
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Laura A Magee
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rahat Qureshi
- Division of Women and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Peter von Dadelszen
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Millard C, Kadam AB, Mahajan R, Pollock AM, Brhlikova P. Availability of brands of six essential medicines in 124 pharmacies in Maharashtra. J Glob Health 2018; 8:010402. [PMID: 29423188 PMCID: PMC5782832 DOI: 10.7189/jogh.08.010402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study is to assess the availability and rational use of six essential medicines in private retail outlets in Maharashtra state. The study focuses on the range of brands for each medicine, and the availability of these brands in the pharmacies. The medicines were chosen because they are included in the World Health Organization's (WHO) essential medicines list (EML), the Indian national and Maharashtra state medicines list, and are all included in existing Indian public health initiatives and national disease control programmes. Methods Data was gathered on the availability of the medicines and the range and frequency of brands in 124 private retail pharmacies between January and May 2012. As there is currently no centralised database in India of available pharmaceutical brands, we collected data on the range of products of the 6 essential medicines available in the Indian market by consulting three open access Indian pharmaceutical databases, CIMS India, Medindia, and Medguide, and the commercial database, Pharmatrac; we compared this data with the results of the survey. The six essential medicines used in this study are: artemisinin (malaria), lamivudine (HIV/AIDS), rifampicin (tuberculosis control), oxytocin (reproductive health), fluoxetine (mental health) and metformin (diabetes). Results The study found that for each of the selected medicines there were multiple approved products listed in Indian databases, 2186 in total. The Pharmatrac database lists only 1359 brands of the selected medicines; 978 (72%) of these had zero sales in 2011-2012. Our survey found very low availability of the brands: 17% Pharmatrac marketed brands (163/978) and 12% of all Pharmatrac brands (163/1359) were available. Metformin was the only medicine with high availability in the study pharmacies at 91%, Rifampacin was the second highest at 64.5%; the other four medicines were available in less than half the pharmacies. A small number of brands were dominating the market. Conclusion the survey shows that market competition has generated a large number of brands of the six study medicines but this has not translated into sufficient availability of these medicines in the study pharmacies. The data calls for a review of available brands, taking into consideration levels of sale and grounds for approval, and the setting up of a centralised database of registered pharmaceutical products.
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Affiliation(s)
- Colin Millard
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
| | - Abhay B Kadam
- Lakshya, Society for Public Health Education and Research, and Foundation for Research in Community Health, Mumbai, India
| | | | - Allyson M Pollock
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
| | - Petra Brhlikova
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
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Abazinab S, Woldie M, Alaro T. Readiness of Health Centers and Primary Hospitals for the Implementation of Proposed Health Insurance Schemes in Southwest Ethiopia. Ethiop J Health Sci 2018; 26:449-456. [PMID: 28446850 PMCID: PMC5389059 DOI: 10.4314/ejhs.v26i5.6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background In response to the 2005 World Health Assembly, many low income countries developed different healthcare financing mechanisms with risk pooling stategy to ensure universal coverage of health services. Accordingly, service availability and readiness of the health system to bear the responsibility of providing service have critical importance. The objective of this study was to assess service availability and readiness of health centers and primary hospitals to bear the responsibility of providing service for the members of health insurance schemes. Methods and Materials A facility based cross sectional study design with quantitative data collection methods was employed. Of the total 18 districts in Jimma Zone, 6(33.3%) districts were selected randomly. In the selected districts, there were 21 functional public health facilities (health centers and primary hospitals) which were included in the study. Data were collected by interviewer administered questionnaire. Descriptive statistics were calculated by using SPSS version 20.0. Prior to data collection, ethical clearance was obtained. Results Among the total 21 public health facilities surveyed, only 38.1% had all the categories of health professionals as compared to the national standards. The majority, 85.2%, of the facilities fulfilled the criteria for basic equipment, but 47.7% of the facilities did not fulfill the criteria for infection prevention supplies. Moreover, only two facilities fulfilled the criteria for laboratory services, and 95.2% of the facilities had no units/departmenst to coordinate the health insurance schemes. Conclusions More than nine out of ten facilities did not fulfill the criteria for providing healthcare services for insurance beneficiaries and are not ready to provide general services according to the standard. Hence, policy makers and implementers should devise strategies to fill the identified gaps for successful and sustainable implementation of the proposed insurance scheme.
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Affiliation(s)
| | - Mirkuzie Woldie
- Department of Health Economics, Management and Policy, College of Health Sciences, Jimma University
| | - Tesfamichael Alaro
- Department of Health Economics, Management and Policy, College of Health Sciences, Jimma University
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Kibira D, Kitutu FE, Merrett GB, Mantel-Teeuwisse AK. Availability, prices and affordability of UN Commission's lifesaving medicines for reproductive and maternal health in Uganda. J Pharm Policy Pract 2017; 10:35. [PMID: 29163976 PMCID: PMC5686951 DOI: 10.1186/s40545-017-0123-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/12/2017] [Indexed: 11/10/2022] Open
Abstract
Background Uganda was one of seven countries in which the United Nations Commission on Life Saving Commodities (UNCoLSC) initiative was implemented starting from 2013. A nationwide survey was conducted in 2015 to determine availability, prices and affordability of essential UNCoLSC maternal and reproductive health (MRH) commodities. Methods The survey at health facilities in Uganda was conducted using an adapted version of the standardized methodology co-developed by World Health Organisation (WHO) and Health Action International (HAI). In this study, six maternal and reproductive health commodities, that were part of the UNCoLSC initiative, were studied in the public, private and mission health sectors. Median price ratios were calculated with Management Sciences for Health International Drug Price Indicator prices as reference. Maternal and reproductive health commodity stocks were reviewed from stock cards for their availability for a period of 6 months preceding the survey. Affordability was measured using wages of the lowest paid government worker. Results Overall none of the six maternal and reproductive commodities was found in the surveyed health facilities. Public sector had the highest availability (52%), followed by mission sector (36%) and then private sector had the least (30%). Stock outs ranged from 7 to 21 days in public sector; 2 to 23 days in private sector and 3 to 27 days in mission sector. During the survey, maternal health commodities were more available and had less number of stock out days than reproductive health commodities. Median price ratios (MPR) indicated that medicines and commodities were more expensive in Uganda compared to international reference prices. Furthermore, MRH medicines and commodities were more expensive and less affordable in private sector compared to mission sector. Conclusion Access to MRH commodities is inadequate in Uganda. Maternal health commodities were more available, cheaper and thus more affordable than reproductive health commodities in the current study. Efforts should be undertaken by the Ministry of Health and stakeholders to improve availability, prices and affordability of MRH commodities in Uganda to ensure that sustainable Development Goals are met.
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Affiliation(s)
- Denis Kibira
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands.,Coalition for Health Promotion and Social Development (HEPS-Uganda), Plot 351A, Balintuma Road, Namirembe Hill, Kampala, Uganda
| | - Freddy Eric Kitutu
- Makerere University, School of Public Health and Pharmacy Department, College of Health Sciences, PO Box 7072, Kampala, Uganda.,Uppsala University, Department of Women's and Children's Health, International Maternal and Child Health, SE-751 85 Uppsala, Sweden
| | | | - Aukje K Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
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Examining the Use of Magnesium Sulfate to Treat Pregnant Women with Preeclampsia and Eclampsia: Results of a Program Assessment of Emergency Obstetric Care (EmOC) Training in India. J Obstet Gynaecol India 2017; 67:330-336. [PMID: 28867883 DOI: 10.1007/s13224-017-0964-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia-eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings. METHODS Trainees' curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia-eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states. RESULTS Of 1320 cases of preeclampsia-eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia-eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia-eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity. CONCLUSION To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia-eclampsia could lead to notable improvements in maternal and infant mortality.
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Bradley J, Jayanna K, Shaw S, Cunningham T, Fischer E, Mony P, Ramesh BM, Moses S, Avery L, Crockett M, Blanchard JF. Improving the knowledge of labour and delivery nurses in India: a randomized controlled trial of mentoring and case sheets in primary care centres. BMC Health Serv Res 2017; 17:14. [PMID: 28061783 PMCID: PMC5219705 DOI: 10.1186/s12913-016-1933-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India. METHODS Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses' knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets. RESULTS Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience. CONCLUSIONS This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India. TRIAL REGISTRATION This study is registered at clinicaltrials.gov, Identifier No. NCT02004912 , November 27, 2013.
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Affiliation(s)
- Janet Bradley
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - Krishnamurthy Jayanna
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
- Karnataka Health Promotion Trust, IT Park 5th floor, #1-4 Rajajinagar Industrial Area, Behind KSSIDC Admin Office, Rajajinagar, Bangalore, 560 044 India
| | - Souradet Shaw
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - Troy Cunningham
- Karnataka Health Promotion Trust, IT Park 5th floor, #1-4 Rajajinagar Industrial Area, Behind KSSIDC Admin Office, Rajajinagar, Bangalore, 560 044 India
| | - Elizabeth Fischer
- IntraHealth, 6340 Quadrangle Drive, Suite 200, Chapel Hill, NC 27517 USA
| | - Prem Mony
- St. John’s National Academy of Health Sciences, Sarjapur Road, Bangalore, Karnataka State 560 034 India
| | - B. M. Ramesh
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - Stephen Moses
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - Lisa Avery
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - Maryanne Crockett
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
| | - James F. Blanchard
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 Mc Dermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB R3E 0T6 Canada
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Macaden L, Washington M, Smith A, Thooya V, P. Selvam S, George N, K. Mony P. Continuing Professional Development: Needs, Facilitators and Barriers of Registered Nurses in India in Rural and Remote Settings: Findings from a Cross Sectional Survey. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojn.2017.78069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Varghese B, Krishnamurthy J, Correia B, Panigrahi R, Washington M, Ponnuswamy V, Mony P. Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study. GLOBAL HEALTH, SCIENCE AND PRACTICE 2016; 4:582-593. [PMID: 27993924 PMCID: PMC5199176 DOI: 10.9745/ghsp-d-16-00143] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 09/20/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The majority of the maternal and perinatal deaths are preventable through improved emergency obstetric and newborn care at facilities. However, the quality of such care in India has significant gaps in terms of provider skills and in their preparedness to handle emergencies. We tested the feasibility, acceptability, and effectiveness of a "skills and drills" intervention, implemented between July 2013 and September 2014, to improve emergency obstetric and newborn care in the state of Karnataka, India. METHODS Emergency drills through role play, conducted every 2 months, combined with supportive supervision and a 2-day skills refresher session were delivered across 4 sub-district, secondary-level government facilities by an external team of obstetric and pediatric specialists and nurses. We evaluated the intervention through a quasi-experimental design with 4 intervention and 4 comparison facilities, using delivery case sheet reviews, pre- and post-knowledge tests among providers, objective structured clinical examinations (OSCEs), and qualitative in-depth interviews. Primary outcomes consisted of improved diagnosis and management of selected maternal and newborn complications (postpartum hemorrhage, pregnancy-induced hypertension, and birth asphyxia). Secondary outcomes included knowledge and skill levels of providers and acceptability and feasibility of the intervention. RESULTS Knowledge scores among providers improved significantly in the intervention facilities; in obstetrics, average scores between the pre- and post-test increased from 49% to 57% (P=.006) and in newborn care, scores increased from 48% to 56% (P=.03). Knowledge scores in the comparison facilities were similar but did not improve significantly over time. Skill levels were significantly higher among providers in intervention facilities than comparison facilities (mean objective structured clinical examination scores for obstetric skills: 55% vs. 46%, respectively; for newborn skills: 58% vs. 48%, respectively; P<.001 for both obstetric and newborn), along with their confidence in managing complications. However, this did not result in significant differences in correct diagnosis and management of complications between intervention and comparison facilities. Shortage of trained nurses and doctors along with unavailability of a consistent supply chain was cited by most providers as major health systems barriers affecting provision of care. CONCLUSIONS Improvements in knowledge, skills, and confidence levels of providers as a result of the skills and drills intervention was not sufficient to translate into improved diagnosis and management of maternal and newborn complications. System-level changes including adequate in-service training may also be necessary to improve maternal and newborn outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Prem Mony
- St. Johns Research Institute, Bangalore, India
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Sheikh S, Qureshi RN, Khowaja AR, Salam R, Vidler M, Sawchuck D, von Dadelszen P, Zaidi S, Bhutta Z. Health care provider knowledge and routine management of pre-eclampsia in Pakistan. Reprod Health 2016; 13:104. [PMID: 27719673 PMCID: PMC5056497 DOI: 10.1186/s12978-016-0215-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Maternal mortality ratio is 276 per 100,000 live births in Pakistan. Eclampsia is responsible for one in every ten maternal deaths despite the fact that management of this disease is inexpensive and has been available for decades. Many studies have shown that health care providers in low and middle-income countries have limited training to manage patients with eclampsia. Hence, we aimed to explore the knowledge of different cadres of health care providers regarding aetiology, diagnosis and treatment of pre-eclampsia and eclampsia and current management practices. METHODS We conducted a mixed method study in the districts of Hyderabad and Matiari in Sindh province, Pakistan. Focus group discussions and interviews were conducted with community health care providers, which included Lady Health Workers and their supervisors; traditional birth attendants and facility care providers. In total seven focus groups and 26 interviews were conducted. NVivo 10 was used for analysis and emerging themes and sub-themes were drawn. RESULTS All participants were providing care for pregnant women for more than a decade except one traditional birth attendant and two doctors. The most common cause of pre-eclampsia mentioned by community health care providers was stress of daily life: the burden of care giving, physical workload, short birth spacing and financial constraints. All health care provider groups except traditional birth attendants correctly identified the signs, symptoms, and complications of pre-eclampsia and eclampsia and were referring such women to tertiary health facilities. Only doctors were aware that magnesium sulphate is recommended for eclampsia management and prevention; however, they expressed fears regarding its use at first and secondary level health facilities. CONCLUSION This study found several gaps in knowledge regarding aetiology, diagnosis and treatment of pre-eclampsia among health care providers in Sindh. Findings suggest that lesser knowledge regarding management of pre-eclampsia is due to lack of refresher trainings and written guidelines for management of pre-eclampsia and presentation of fewer pre-eclamptic patients at first and secondary level health care facilities. We suggest to include management of pre-eclampsia in regular trainings of health care providers and to provide management protocols at all health facilities. TRIAL REGISTRATION NCT01911494.
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Affiliation(s)
- Sana Sheikh
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Asif Raza Khowaja
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, V5Z 4H4 Canada
| | - Rehana Salam
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, V5Z 4H4 Canada
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, Victoria, V8R 1J8 Canada
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St George’s, University of London, London, SW17 0RE UK
| | - Shujat Zaidi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Program for Global Pediatric Research, Hospital for Sick Children, Toronto, M5G 2L3 Canada
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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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Pino A, Albán M, Rivas A, Rodríguez E. Maternal Deaths Databases Analysis: Ecuador 2003-2013. J Public Health Res 2016; 5:692. [PMID: 27747203 PMCID: PMC5062756 DOI: 10.4081/jphr.2016.692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/13/2016] [Indexed: 11/23/2022] Open
Abstract
Background: Maternal mortality ratio in Ecuador is the only millennium goal on which national agencies are still making strong efforts to reach 2015 target. The purpose of the study was to process national maternal death databases to identify a specific association pattern of variable included in the death certificate. Design and methods: The study processed mortality databases published yearly by the National Census and Statistics Institute (INEC). Data analysed were exclusively maternal deaths. Data corresponds to the 2003-2013 period, accessible through INEC's website. Comparisons are based on number of deaths and use an ecological approach for geographical coincidences. Results: The study identified variable association into the maternal mortality national databases showing that to die at home or in a different place than a hospital is closely related to women's socioeconomic characteristics; there was an association with the absence of a public health facility. Also, to die in a different place than the usual residence could mean that women and families are searching for or were referred to a higher level of attention when they face complications. Conclusions: Ecuadorian maternal deaths showed Patterns of inequity in health status, health care provision and health risks. A predominant factor seems unclear to explain the variable association found processing national databases; perhaps every pattern of health systems development played a role in maternal mortality or factors different from those registered by the statistics system may remain hidden. Some random influences might not be even considered in an explanatory model yet.
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Affiliation(s)
- Antonio Pino
- Pontifical Catholic University of Ecuador , Quito, Ecuador
| | - María Albán
- Pontifical Catholic University of Ecuador , Quito, Ecuador
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Mony PK, Jayanna K, Varghese B, Washington M, Vinotha P, Thomas T. Adoption and Completeness of Documentation Using a Structured Delivery Record in Secondary Care, Subdistrict Government Hospitals of Karnataka State, India. Health Serv Res Manag Epidemiol 2016; 3:2333392816647605. [PMID: 28462277 PMCID: PMC5266437 DOI: 10.1177/2333392816647605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/05/2016] [Indexed: 12/01/2022] Open
Abstract
Objective: Poor medical record documentation remains a pervasive problem in hospital delivery rooms, hampering efforts aimed at improving the quality of maternal and neonatal care in resource-limited settings. We evaluated the feasibility and completeness of labor room documentation within a quasi-experimental study aimed at improving emergency preparedness for obstetric and neonatal emergencies in 8 nonteaching, subdistrict, secondary care hospitals of Karnataka state, India. Methods: We redesigned the existing open-ended case sheet into a structured, delivery record cum job aide adhering to principles of local clinical relevance, parsimony, and computerizability. Skills and emergency drills training along with supportive supervision were introduced in 4 “intervention arm” hospitals while the new delivery records were used in eight intervention and control hospitals. Results: Introduction of the new delivery record was feasible over a “run-in” period of 4 months. About 92% (6103 of 6634) of women in intervention facilities and 80% (6205 of 7756) in control facilities had their delivery records filled in during the 1-year study period. Completeness of delivery record documentation fell into one of two subsets with one set of parameters being documented with minimal inputs (in both intervention and control sites) and another set of parameters requiring more intensive training efforts (and seen more in intervention than in control sites; P < .05). Conclusion: Under the stewardship of the local government, it was possible to institute a robust, reliable, and valid medical record documentation system as part of efforts to improve intrapartum and postpartum maternal and newborn care in hospitals.
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Affiliation(s)
- Prem K Mony
- Division of Epidemiology, Biostatistics & Population Health, St John's Medical College & Research Institute, Koramangala, Bangalore, India
| | | | - Beena Varghese
- Division of Epidemiology, Biostatistics & Population Health, St John's Medical College & Research Institute, Koramangala, Bangalore, India
| | - Maryann Washington
- Division of Epidemiology, Biostatistics & Population Health, St John's Medical College & Research Institute, Koramangala, Bangalore, India
| | - P Vinotha
- Division of Epidemiology, Biostatistics & Population Health, St John's Medical College & Research Institute, Koramangala, Bangalore, India
| | - Tinku Thomas
- Division of Epidemiology, Biostatistics & Population Health, St John's Medical College & Research Institute, Koramangala, Bangalore, India
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Fischer EA, Jayana K, Cunningham T, Washington M, Mony P, Bradley J, Moses S. Nurse Mentors to Advance Quality Improvement in Primary Health Centers: Lessons From a Pilot Program in Northern Karnataka, India. GLOBAL HEALTH: SCIENCE AND PRACTICE 2015; 3:660-75. [PMID: 26681711 PMCID: PMC4682589 DOI: 10.9745/ghsp-d-15-00142] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/27/2015] [Indexed: 11/15/2022]
Abstract
Trained nurse mentors catalyzed quality improvements in facility-based maternal and newborn care by: (1) encouraging use of self-assessment checklists and team-based problem solving, (2) introducing case sheets to ensure adherence to clinical guidelines, and (3) strengthening clinical skills through on-site demonstrations and bedside teaching. Inadequate leadership and staffing were challenges in some facilities. Some social norms, such as client resistance to referral and to staying 48 hours after delivery, also impact quality and mandate community mobilization efforts. High-quality care during labor, delivery, and the postpartum period is critically important since maternal and child morbidity and mortality are linked to complications that arise during these stages. A nurse mentoring program was implemented in northern Karnataka, India, to improve quality of services at primary health centers (PHCs), the lowest level in the public health system that offers basic obstetric care. The intervention, conducted between August 2012 and July 2014, employed 53 full-time nurse mentors and was scaled-up in 385 PHCs in 8 poor rural districts. Each mentor was responsible for 6 to 8 PHCs and conducted roughly 6 mentoring visits per PHC in the first year. This paper reports the results of a qualitative inquiry, conducted between September 2012 and April 2014, assessing the program's successes and challenges from the perspective of mentors and PHC teams. Data were gathered through 13 observations, 9 focus group discussions with mentors, and 25 individual and group interviews with PHC nurses, medical officers, and district health officers. Mentors and PHC staff and leaders reported a number of successes, including development of rapport and trust between mentors and PHC staff, introduction of team-based quality improvement processes, correct and consistent use of a new case sheet to ensure adherence to clinical guidelines, and increases in staff nurses’ knowledge and skills. Overall, nurses in many PHCs reported an increased ability to provide care according to guidelines and to handle maternal and newborn complications, along with improvements in equipment and supplies and referral management. Challenges included high service delivery volumes and/or understaffing at some PHCs, unsupportive or absent PHC leadership, and cultural practices that impacted quality. Comprehensive mentoring can build competence and improve performance by combining on-the-job clinical and technical support, applying quality improvement principles, and promoting team-based problem solving.
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Affiliation(s)
| | - Krishnamurthy Jayana
- Karnataka Health Promotion Trust, Bangalore, India University of Manitoba, Department of Community Health Services, Winnipeg, Canada
| | | | - Maryann Washington
- St. John's National Academy of Health Sciences, St. John's Research Institute, Bangalore, India
| | - Prem Mony
- St. John's National Academy of Health Sciences, St. John's Research Institute, Bangalore, India
| | - Janet Bradley
- University of Manitoba, Department of Community Health Services, Winnipeg, Canada
| | - Stephen Moses
- University of Manitoba, Department of Community Health Services, Winnipeg, Canada
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Hirschhorn LR, Semrau K, Kodkany B, Churchill R, Kapoor A, Spector J, Ringer S, Firestone R, Kumar V, Gawande A. Learning before leaping: integration of an adaptive study design process prior to initiation of BetterBirth, a large-scale randomized controlled trial in Uttar Pradesh, India. Implement Sci 2015; 10:117. [PMID: 26271331 PMCID: PMC4536663 DOI: 10.1186/s13012-015-0309-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/06/2015] [Indexed: 11/30/2022] Open
Abstract
Background Pragmatic and adaptive trial designs are increasingly used in quality improvement (QI) interventions to provide the strongest evidence for effective implementation and impact prior to broader scale-up. We previously showed that an on-site coaching intervention focused on the World Health Organization Safe Childbirth Checklist (SCC) improved performance of essential birth practices (EBPs) in one facility in Karnataka, India. We report on the process and outcomes of adapting the intervention prior to larger-scale implementation in a randomized controlled trial in Uttar Pradesh (UP), India. Methods Initially, we trained a local team of physicians and nurses to coach birth attendants in SCC use at two public facilities for 4–6 weeks. Trained observers evaluated adherence to EBPs before and after coaching. Using mixed methods and a systematic adaptation process, we modified and strengthened the intervention. The modified intervention was implemented in three additional facilities. Pre/post-change in EBP prevalence aggregated across facilities was analyzed. Results In the first two facilities, limited improvement was seen in EBPs with the exception of post-partum oxytocin. Checklists were used <25 % of observations. We identified challenges in physicians coaching nurses, need to engage district and facility leadership to address system gaps, and inadequate strategy for motivating SCC uptake. Revisions included change to peer-to-peer coaching (nurse to nurse, physician to physician); strengthened coach training on behavior and system change; adapted strategy for effective leadership engagement; and an explicit motivation strategy to enhance professional pride and effectiveness. These modifications resulted in improvement in multiple EBPs from baseline including taking maternal blood pressure (0 to 16 %), post-partum oxytocin (36 to 97 %), early breastfeeding initiation (3 to 64 %), as well as checklist use (range 32 to 88 %), all p < 0.01. Further adaptations were implemented to increase the effectiveness prior to full trial launch. Conclusions The adaptive study design of implementation, evaluation, and feedback drove iterative redesign and successfully developed a SCC-focused coaching intervention that improved EBPs in UP facilities. This work was critical to develop a replicable BetterBirth package tailored to the local context. The multi-center pragmatic trial is underway measuring impact of the BetterBirth program on EBP and maternal-neonatal morbidity and mortality. Trial registration Clinical trials identifier: NCT02148952.
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Affiliation(s)
- Lisa Ruth Hirschhorn
- Ariadne Labs, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
| | - Katherine Semrau
- Ariadne Labs, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
| | - Bhala Kodkany
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India.
| | | | - Atul Kapoor
- Population Services International, Delhi, India.
| | - Jonathan Spector
- Lao Friends Hospital for Children, Luang Prabang, Lao People's Democratic Republic.
| | - Steve Ringer
- Department of Neonatology, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | - Atul Gawande
- Ariadne Labs, Boston, MA, USA. .,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Health Policy Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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