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Singh S, Hasan Z, Sharma D, Kaur A, Khurana D, Shrivastava JN, Gupta S. Appraising LaQshya's potential in measuring quality of care for mothers and newborns: a comprehensive review of India's Labor Room Quality Improvement Initiative. BMC Pregnancy Childbirth 2024; 24:239. [PMID: 38575944 PMCID: PMC10993574 DOI: 10.1186/s12884-024-06450-x] [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: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Poor intrapartum care in India contributes to high maternal and newborn mortality. India's Labor Room Quality Improvement Initiative (LaQshya) launched in 2017, aims to improve intrapartum care by minimizing complications, enforcing protocols, and promoting respectful maternity care (RMC). However, limited studies pose a challenge to fully examine its potential to assess quality of maternal and newborn care. This study aims to bridge this knowledge gap and reviews LaQshya's ability to assess maternal and newborn care quality. Findings will guide modifications for enhancing LaQshya's effectiveness. METHODS We reviewed LaQshya's ability to assess the quality of care through a two-step approach: a comprehensive descriptive analysis using document reviews to highlight program attributes, enablers, and challenges affecting LaQshya's quality assessment capability, and a comparison of its measurement parameters with the 352 quality measures outlined in the WHO Standards for Maternal and Newborn Care. Comparing LaQshya with WHO standards offers insights into how its measurement criteria align with global standards for assessing maternity and newborn care quality. RESULTS LaQshya utilizes several proven catalysts to enhance and measure quality- institutional structures, empirical measures, external validation, certification, and performance incentives for high-quality care. The program also embodies contemporary methods like quality circles, rapid improvement cycles, ongoing facility training, and plan-do-check, and act (PDCA) strategies for sustained quality enhancement. Key drivers of LaQshya's assessment are- leadership, staff mentoring, digital infrastructure and stakeholder engagement from certified facilities. However, governance issues, understaffing, unclear directives, competency gaps, staff reluctance towards new quality improvement approaches inhibit the program, and its capacity to enhance quality of care. LaQshya addresses 76% of WHO's 352 quality measures for maternal and newborn care but lacks comprehensive assessment of crucial elements: harmful labor practices, mistreatment of mothers or newborns, childbirth support, and effective clinical leadership and supervision. CONCLUSION LaQshya is a powerful model for evaluating quality of care, surpassing other global assessment tools. To achieve its maximum potential, we suggest strengthening district governance structures and offering tailored training programs for RMC and other new quality processes. Furthermore, expanding its quality measurement metrics to effectively assess provider accountability, patient outcomes, rights, staff supervision, and health facility leadership will increase its ability to assess quality improvements.
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Affiliation(s)
- Shalini Singh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Zabir Hasan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- BRAC James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Deepika Sharma
- National Health Systems Resource Center, New Delhi, India
| | - Amarpreet Kaur
- Department of Epidemiology, Biostatistics and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Dadi TL, Abebo TA, Yeshitla A, Abera Y, Tadesse D, Tsegaye S, Gerbaba MJ, Worke MD, Tadesse D, Medhin G. Impact of quality improvement interventions on facility readiness, quality and uptake of maternal and child health services in developing regions of Ethiopia: a secondary analysis of programme data. BMJ Open Qual 2023; 12:e002140. [PMID: 37923343 PMCID: PMC10626795 DOI: 10.1136/bmjoq-2022-002140] [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: 09/30/2022] [Accepted: 10/14/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Quality improvement intervention (QI) was implemented from 2018 to 2021 in health facilities of developing regional states of Ethiopia. The main objective of this study was to examine the impact of QI interventions on facility readiness, service availability, quality and usage of health services in these regions. METHODS We used district health information system data of 56 health facilities (HFs). We also used baseline and endline QI monitoring data from 28 HFs. Data were summarised using descriptive statistics and various tests. Regression analysis was employed to examine the impact of QI interventions on various outcomes. RESULT The QI intervention improved readiness of HFs, service availability and quality of maternal and child health service delivery. The mean availability of basic amenities increased from 1.89 to 2.89; HF cleanliness score increased from 4.43 to 5.96; family planning method availability increased from 4 to 5.75; score for emergency drugs at labour ward increased from 5.32 to 7.00; and the mean score for basic emergency obstetric and newborn care service availability increased from 5.68 to 6.75; intrauterine contraceptive devices removal service increased from 39.3% to 82.1%; and partograph use increased from 53.6% to 92.9%. HFs that use partograph for labour management increased by 39.3%. The QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7% and correct active third-stage labour management, a 19.6% improvement from the baseline. The interventions also increased the service uptake of maternal health services, but not significantly associated with improvement in contraceptive service uptake. CONCLUSION The integrated QI interventions in HFs could have an impact on facility readiness for service delivery, service accessibility and quality of service delivery. The effectiveness of the QI intervention should be evaluated using robust methods, and efforts to enhance contraceptive services through a QI approach requires further study.
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Affiliation(s)
- Tegene Legese Dadi
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Teshome Abuka Abebo
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Aklilu Yeshitla
- USAID Transform Health in Developing Regions, IntraHealth International, Addis Ababa, Ethiopia
| | - Yared Abera
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Derebe Tadesse
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Sentayehu Tsegaye
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Mulusew Jebena Gerbaba
- Department of Epidemiology, Institute of Health Science, Jimma University, Jimma, Ethiopia
| | - Mulugeta Dile Worke
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Girmay Medhin
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
- Aklilu Lema Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
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Singh S, Kannuri NK, Mishra A, Gaikwad L, Shukla R, Tyagi M, Chamarty S. Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys. Arch Public Health 2023; 81:57. [PMID: 37072820 PMCID: PMC10111820 DOI: 10.1186/s13690-023-01028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability. METHODS Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner. RESULTS Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers. CONCLUSION The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.
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Affiliation(s)
- Samiksha Singh
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi, India.
| | - Nanda Kishore Kannuri
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Aparajita Mishra
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi, India
| | - Leena Gaikwad
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Rajan Shukla
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Mukta Tyagi
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
| | - Swecha Chamarty
- Indian Institute of Public Health-Hyderabad, Public Health Foundation of India, Hyderabad, India
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Gaps in the coverage of vitamin K 1 prophylaxis among newborns in India: insights from secondary analysis of data from the Health Management Information System. Public Health Nutr 2021; 24:5589-5597. [PMID: 34431473 DOI: 10.1017/s1368980021003670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Despite operational guidelines, anecdotal evidence suggests that newborn vitamin K1 prophylaxis is not practiced routinely in India. This study determined the coverage of vitamin K1 prophylaxis among newborns in the country. DESIGN Nationwide cross-sectional data on live births and newborns receiving vitamin K1 during the 2019-2020 reporting period were abstracted from the Health Management Information System (HMIS). The coverage estimates of newborn vitamin K1 prophylaxis were derived nationally and also for individual states and union territories (UT). Additionally, coverage heterogeneities were investigated using classifiers, viz. geography, socio-demographic index (SDI), special developmental categories and institutional birth rate (IBR). SETTING India. PARTICIPANTS 20 208 804 newborns documented with HMIS. RESULTS Vitamin K1 was administered to overall 62·36 % newborns (95 % CI: 62·34 to 62·38 %). The Central zone (49·0 %), low SDI states (54·39 %), Empowered Action Group states (53·32 %) and states with low IBR (44·69 %) had the lowest coverage amongst their respective groupings. Across the individual states and UT, the coverage ranged widely from 22·18 % (in Tripura) to 99·38 % (in Puducherry), exhibiting considerable variability (coefficient of variation: 33·74 %) and inequality (Gini coefficient: 0·17). While the coverage in eight states/UT (i.e. Arunachal Pradesh, Manipur, Nagaland, Tripura, Uttar Pradesh, Uttarakhand, Telangana and Andaman & Nicobar Islands) was below 50 %; only five states/UT (i.e. Chandigarh, Gujarat, Goa, Puducherry and Tamil Nadu) achieved above 90 % coverage. CONCLUSION Vitamin K1 prophylaxis was not practiced in more than one-third newborns in India. It calls for identifying the barriers, addressing the gaps and implementing newborn vitamin K1 prophylaxis more effectively throughout the country.
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Khurshid Z, De Brún A, Martin J, McAuliffe E. A Systematic Review and Narrative Synthesis: Determinants of the Effectiveness and Sustainability of Measurement-Focused Quality Improvement Trainings. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:210-220. [PMID: 33470729 PMCID: PMC8404965 DOI: 10.1097/ceh.0000000000000331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION The ability of health care professionals to measure change is critical for successful quality improvement (QI) efforts. Currently, there are no systematic reviews focusing on continuing education for health care professionals in data skills for QI. The purpose of this systematic review is to define effectiveness and sustainability of QI programs for health care professionals containing a measurement skills component and to identify barriers and facilitators to effectiveness and sustainability. METHODS The systematic review involved study identification, screening, full text review, and data extraction. Four electronics databases and grey literature sources were searched to identify studies published between 2009 and 2019 (11 years). A customized data extraction form was developed. Mixed methods appraisal tool was used for quality assessment and a thematic analysis was conducted for narrative synthesis. RESULTS Fifty-three studies from 11 countries were included. Most study designs were quantitative descriptive (17/53) and used a blended learning approach (25/53) combining face-to face and distance learning modes. The programs included basic, intermediate, and advanced data skills concepts. Overall, studies reported positive outcomes for participant reaction, learning, and behavior, but reported variable success in sustainability and spread of QI. DISCUSSION Studies discussed measurement as a key competency for clinical QI. Effectiveness definitions focused on the short-term impact of the programs, whereas sustainability definitions emphasized maintenance of outcomes and skills in the long-term. Factors that influenced effectiveness and sustainability of the included studies were strategic approach to QI, organizational support, intervention design, communication, accountability, leadership support, and learning networks.
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Catalytic Support for Improving Clinical Care in Special Newborn Care Units (SNCU) Through Composite SNCU Quality of Care Index (SQCI). Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2192-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Singh A, Vellakkal S. Impact of public health programs on maternal and child health services and health outcomes in India: A systematic review. Soc Sci Med 2021; 274:113795. [PMID: 33667744 DOI: 10.1016/j.socscimed.2021.113795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes. OBJECTIVES AND METHODS This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings. FINDINGS AND CONCLUSION We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care.
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Affiliation(s)
- Abinash Singh
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India
| | - Sukumar Vellakkal
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India; Department of Economic Sciences, Indian Institute of Technology Kanpur, Uttar Pradesh, India.
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Hategeka C, Ruton H, Karamouzian M, Lynd LD, Law MR. Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review. BMJ Glob Health 2020; 5:e003567. [PMID: 33055094 PMCID: PMC7559052 DOI: 10.1136/bmjgh-2020-003567] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions. METHODS We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427). RESULTS Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time. CONCLUSIONS The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hinda Ruton
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Mohammad Karamouzian
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- HIV/STI Surveillance Research Centre, and WHO Collaborating Centre for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcome Sciences, Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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Ahmed S, Srivastava S, Warren N, Mayra K, Misra M, Mahapatra T, Rao KD. The impact of a nurse mentoring program on the quality of labour and delivery care at primary health care facilities in Bihar, India. BMJ Glob Health 2020; 4:e001767. [PMID: 31908856 PMCID: PMC6936590 DOI: 10.1136/bmjgh-2019-001767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/04/2019] [Accepted: 11/10/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Although the number of women who deliver with a skilled birth attendant in India has almost doubled between 2006 and 2016, the country still has the second highest number of maternal deaths and the highest number of neonatal deaths globally. This study examines the impact of a nurse mentoring programme intended to improve the quality of intrapartum care at primary healthcare centre (PHC) facilities in Bihar, India. Method We conducted an evaluation study in 319 public PHCs in Bihar, where nurses participated in a mentoring programme. Using a quasi-experimental trial design, we compared the intrapartum quality of care between the mentored (n=179) and non-mentored PHCs (n=80). Based on direct observation of 847 women, we examined percent differences in 39 labour, delivery and postpartum care-related recommended tasks on five domains: vital sign and labour progress monitoring after admission, second and third stages of labour management, postpartum counselling, infection prevention and essential newborn care practices. Results A significantly higher proportion of women at mentored PHCs received the recommended clinical care, compared with women at non-mentored PHCs. The overall total score of quality of care, expressed in percent of tasks performed, was 30.2% (95% CI: 28.3 to 32.2) in the control PHCs, suggesting that less than one-third of the expected tasks during labour and delivery were performed by nurses in these facilities; the score was 44.2% (95% CI: 42.1 to 46.4) among the facilities where the nurses were trained within last 3 months. The task completion score was slightly attenuated when observed 1 year after mentoring (score 39.1% [37.7–40.5]). Conclusion Mentoring improved intrapartum care by nurses at PHCs in Bihar. However, less than half of the recommended normal delivery intrapartum tasks were completed by the nurse providers. This suggests the need for further improvement in the provision of quality of intrapartum care when risks to maternal and perinatal mortality are highest.
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Affiliation(s)
- Saifuddin Ahmed
- Population, Family and Reproductive Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Swati Srivastava
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | | | | | | | - K D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nyakura J, Shewade HD, Ade S, Mushavi A, Mukungunugwa SH, Chimwaza A, Owiti P, Senkoro M, Mugurungi O. Viral load testing among women on 'option B+' in Mazowe, Zimbabwe: How well are we doing? PLoS One 2019; 14:e0225476. [PMID: 31794561 PMCID: PMC6890256 DOI: 10.1371/journal.pone.0225476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Globally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'. OBJECTIVE Among a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing. METHODS This was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing. RESULTS Of 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)]. CONCLUSION Among women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided.
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Affiliation(s)
- Justice Nyakura
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- The Union South-East Asia, New Delhi, India
- Karuna Trust, Bengaluru, Karnataka, India
| | - Serge Ade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- Faculté de Médecine, Université de Parakou, Parakou, Benin
| | - Angela Mushavi
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Anesu Chimwaza
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Philip Owiti
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Mbazi Senkoro
- National Institute for Medical Research- Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Owen Mugurungi
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
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Datta V, Srivastava S, Garde R, Tluangi L, Giri H, Sangma S, Burman H, Pahwa P, Pemde H, Livesley N. Combining bottleneck analysis and quality improvement as a novel methodology to improve the quality of neonatal care in a northeastern state of India: a feasibility study. Int Health 2019; 11:52-63. [PMID: 30247590 PMCID: PMC6314155 DOI: 10.1093/inthealth/ihy062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/23/2018] [Accepted: 08/10/2018] [Indexed: 01/25/2023] Open
Abstract
Background The State of Meghalaya, India, has some of the worst newborn health outcomes in the country. State health authorities commissioned an assessment of newborn service delivery to improve services. This study proposes bottleneck analysis (BNA) and quality improvement (QI) methods as a combined method to improve compliance with evidence-based neonatal interventions in newborn health facilities. Methods An adapted Every Newborn BNA tool was applied to collect data on barriers to providing quality care in five district hospitals. Subsequently, health workers were coached to use QI methodology to overcome identified bottlenecks. Data from QI projects were analysed using run charts. Results BNA revealed that interventions directed toward basic newborn care and special newborn care facilities needed attention. Facilities that undertook QI projects showed an improvement in neonates having early initiation of breastfeeding within the first hour of birth, from 64% to a peak of 94% in one facility and from 75% to 91% in another. Skin-to-skin contact increased from 49% to a peak of 78% and is sustained at 58%. Improved performance has been sustained in some facilities. Conclusions The combination of BNA and QI is a successful method for identifying and overcoming bottlenecks in newborn care in resource-limited settings.
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Affiliation(s)
- Vikram Datta
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
| | - Sushil Srivastava
- Department of Pediatrics, University College of Medical Sciences, Delhi, India
| | - Rahul Garde
- Public Health Consultant, R39E Dilshad Garden, Delhi, India
- cNQOCN, India
| | | | - Hunsi Giri
- Department of Pediatrics, Ganesh Das Hospital, Shillong, Meghalaya
| | | | - Himesh Burman
- Department of Pediatrics, North East Indira Gandhi Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Parika Pahwa
- Improvement Advisor, University Research Co., LLC, USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Green Park, New Delhi, India
| | - Harish Pemde
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
| | - Nigel Livesley
- Project Director, University Research Co., LLC, USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, 5404 Wisconsin Avenue, Suite 800, Chevy Chase, MD, USA
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Naimoli JF, Saxena S. Realizing their potential to become learning organizations to foster health system resilience: opportunities and challenges for health ministries in low- and middle-income countries. Health Policy Plan 2018; 33:1083-1095. [DOI: 10.1093/heapol/czy100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Sweta Saxena
- Bureau for Asia/Technical Services, US Agency for International Development, 1300 Pennsylvania Avenue, Washington, DC, USA
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Saxena M, Srivastava A, Dwivedi P, Bhattacharyya S. Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India. PLoS One 2018; 13:e0204607. [PMID: 30261044 PMCID: PMC6160099 DOI: 10.1371/journal.pone.0204607] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022] Open
Abstract
Background Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.
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Affiliation(s)
- Malvika Saxena
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Aradhana Srivastava
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Pravesh Dwivedi
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
| | - Sanghita Bhattacharyya
- Research Department, Public Health Foundation of India, Gurugram, Haryana, India
- * E-mail:
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14
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Quality Improvement Approaches Associated with Quality of Childbirth Care Practices in Six Indian States. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1383-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Semrau KEA, Hirschhorn LR, Marx Delaney M, Singh VP, Saurastri R, Sharma N, Tuller DE, Firestone R, Lipsitz S, Dhingra-Kumar N, Kodkany BS, Kumar V, Gawande AA. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. N Engl J Med 2017; 377:2313-2324. [PMID: 29236628 PMCID: PMC5672590 DOI: 10.1056/nejmoa1701075] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. METHODS We conducted a matched-pair, cluster-randomized, controlled trial in 60 pairs of facilities across 24 districts of Uttar Pradesh, India, testing the effect of the BetterBirth program, an 8-month coaching-based implementation of the Safe Childbirth Checklist, on a composite outcome of perinatal death, maternal death, or maternal severe complications within 7 days after delivery. Outcomes - assessed 8 to 42 days after delivery - were compared between the intervention group and the control group with adjustment for clustering and matching. We also compared birth attendants' adherence to 18 essential birth practices in 15 matched pairs of facilities at 2 and 12 months after the initiation of the intervention. RESULTS Of 161,107 eligible women, we enrolled 157,689 (97.9%) and determined 7-day outcomes for 157,145 (99.7%) mother-newborn dyads. Among 4888 observed births, birth attendants' mean practice adherence was significantly higher in the intervention group than in the control group (72.8% vs. 41.7% at 2 months; 61.7% vs. 43.9% at 12 months; P<0.001 for both comparisons). However, there was no significant difference between the trial groups either in the composite primary outcome (15.1% in the intervention group and 15.3% in the control group; relative risk, 0.99; 95% confidence interval, 0.83 to 1.18; P=0.90) or in secondary maternal or perinatal adverse outcomes. CONCLUSIONS Birth attendants' adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups. (Funded by the Bill and Melinda Gates Foundation; Clinical Trials number, NCT02148952 .).
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Affiliation(s)
- Katherine E A Semrau
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Lisa R Hirschhorn
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Megan Marx Delaney
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Vinay P Singh
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Rajiv Saurastri
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Narender Sharma
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Danielle E Tuller
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Rebecca Firestone
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Stuart Lipsitz
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Neelam Dhingra-Kumar
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Bhalachandra S Kodkany
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Vishwajeet Kumar
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
| | - Atul A Gawande
- From Ariadne Labs-Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health (K.E.A.S., M.M.D., D.E.T., S.L., A.A.G.), the Divisions of Global Health Equity (K.E.A.S.) and General Internal Medicine (S.L.) and the Department of Surgery (A.A.G.), Brigham and Women's Hospital, the Department of Medicine, Harvard Medical School (K.E.A.S.), and the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (A.A.G.) - all in Boston; Feinberg School of Medicine, Northwestern University, Chicago (L.R.H.); Population Services International (V.P.S., R.S., N.S.) and the Community Empowerment Lab (V.K.), Lucknow, and Jawaharlal Nehru Medical College, Belgaum (B.S.K.) - all in India; Population Services International, Washington, DC (R.F.); and the World Health Organization, Geneva (N.D.-K.)
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