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Ghosh R, Cohen SR, Subramaniam N, Handu S, Vincent D, Lloyd M, Thorn K, Harris HB, Jenny A, Walker D. A comic based interactive digital intervention to enhance facilitation skills of nurse mentors in public facilities - results of a pilot intervention in Bihar, India. Glob Health Action 2023; 16:2185365. [PMID: 36940106 PMCID: PMC10035940 DOI: 10.1080/16549716.2023.2185365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Various trainings are designed to educate nurses to become simulation educators. However, there are no good strategies to sustain their learnings and keep them engaged. We developed a series of 10 interactive digital storytelling comic episodes 'The Adventures of Super Divya (SD)' to strengthen simulation educator's facilitation knowledge, skills, confidence, and engagement. This endline evaluation presents results on the change in knowledge after watching the episodes and retention of that knowledge over 10 months. OBJECTIVES The objectives of this pilot study are to: 1) assess the change in knowledge between the baseline and post-episode surveys; and 2) understand the retention of knowledge between the post-episode and the endline survey. METHODS A human-centred design was used to create the episodes grounded in the lived experience of nurse simulation educators. The heroine of the comic is Divya, a 'Super Facilitator' and her nemesis is Professor Agni who wants to derail simulation as an educational strategy inside obstetric facilities. Professor Agni's schemes represent real-life challenges; and SD uses effective facilitation and communication to overcome them. The episodes were shared with a group of nurse mentors (NM) and nurse mentor supervisors (NMS) who were trained to be champion simulation educators in their own facilities. To assess change in knowledge, we conducted a baseline, nine post-episode surveys and an endline survey between May 2021 and February 2022. RESULTS A total 110 NM and 50 NMS watched all 10 episodes and completed all of the surveys. On average, knowledge scores increased by 7-9 percentage points after watching the episodes. Comparison of survey responses obtained between 1 and 10 months suggest that the gain in knowledge was largely retained over time. CONCLUSIONS Findings suggest that this interactive comic series was successful in a resource limited setting at engaging simulation educators and helped to maintain their facilitation knowledge over time.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Susanna R Cohen
- LIFT Simulation Design Lab, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Nidhi Subramaniam
- Department of Simulation Implementation Research, PRONTO India Foundation, Lucknow, Uttar Pradesh, India
- PRONTO India Foundation, Patna, India
| | | | - Divya Vincent
- Department of Simulation Implementation Research, PRONTO India Foundation, Lucknow, Uttar Pradesh, India
- PRONTO India Foundation, Patna, India
| | - Mikelle Lloyd
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | | | | | - Alisa Jenny
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
- School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
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Kalra A, Subramaniam N, Longkumer O, Siju M, Jose LS, Srivastava R, Lin S, Handu S, Murugesan S, Lloyd M, Madriz S, Jenny A, Thorn K, Calkins K, Breeze-Harris H, Cohen SR, Ghosh R, Walker D. Super Divya, an Interactive Digital Storytelling Instructional Comic Series to Sustain Facilitation Skills of Labor and Delivery Nurse Mentors in Bihar, India-A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052675. [PMID: 35270366 PMCID: PMC8910046 DOI: 10.3390/ijerph19052675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 11/16/2022]
Abstract
To improve the quality of intrapartum care in public health facilities of Bihar, India, a statewide quality improvement program was implemented. Nurses participated in simulation sessions to improve their clinical, teamwork, and communication skills. Nurse mentors, tasked with facilitating these sessions, received training in best practices. To support the mentors in the on-going facilitation of these trainings, we developed a digital, interactive, comic series starring “Super Divya”, a simulation facilitation superhero. The objective of these modules was to reinforce key concepts of simulation facilitation in a less formal and more engaging way than traditional didactic lessons. This virtual platform offers the flexibility to watch modules frequently and at preferred times. This pilot study involved 205 simulation educators who were sent one module at a time. Shortly before sending the first module, nurses completed a baseline knowledge survey, followed by brief surveys after each module to assess change in knowledge. Significant improvements in knowledge were observed across individual scores from baseline to post-survey. A majority found Super Divya modules to be acceptable and feasible to use as a learning tool. However, a few abstract concepts in the modules were not well-understood, suggesting that more needs to be done to communicate their core meaning of these concepts.
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Affiliation(s)
- Anika Kalra
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
| | | | - Ojungsangla Longkumer
- PRONTO India Foundation, Patna 800025, Bihar, India; (O.L.); (M.S.); (L.S.J.); (R.S.); (S.H.)
| | - Manju Siju
- PRONTO India Foundation, Patna 800025, Bihar, India; (O.L.); (M.S.); (L.S.J.); (R.S.); (S.H.)
| | - Liya Susan Jose
- PRONTO India Foundation, Patna 800025, Bihar, India; (O.L.); (M.S.); (L.S.J.); (R.S.); (S.H.)
| | - Rohit Srivastava
- PRONTO India Foundation, Patna 800025, Bihar, India; (O.L.); (M.S.); (L.S.J.); (R.S.); (S.H.)
| | - Sunny Lin
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
| | - Seema Handu
- PRONTO India Foundation, Patna 800025, Bihar, India; (O.L.); (M.S.); (L.S.J.); (R.S.); (S.H.)
| | | | - Mikelle Lloyd
- Department of OB/GYN, The University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA; (M.L.); (S.R.C.)
| | - Solange Madriz
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
| | - Alisa Jenny
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
| | - Kevin Thorn
- NuggetHead Studioz, LLC, 1862 Gracie Road, Hernando, MS 38632, USA;
| | - Kimberly Calkins
- PRONTO International, 5419 Greenwood Ave N, Seattle, WA 98103, USA; (K.C.); (H.B.-H.)
| | - Heidi Breeze-Harris
- PRONTO International, 5419 Greenwood Ave N, Seattle, WA 98103, USA; (K.C.); (H.B.-H.)
| | - Susanna R. Cohen
- Department of OB/GYN, The University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA; (M.L.); (S.R.C.)
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
- Correspondence:
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA; (A.K.); (S.L.); (S.M.); (A.J.); (D.W.)
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Wilhelm J, Mahapatra T, Das A, Sonthalia S, Srikantiah S, Galavotti C, Shah H, Creanga AA. From direct engagement to technical support: a programmatic evolution to improve large community health worker programs in Bihar, India. BMJ Glob Health 2021; 6:bmjgh-2020-004389. [PMID: 33853844 PMCID: PMC8054080 DOI: 10.1136/bmjgh-2020-004389] [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: 11/05/2020] [Revised: 03/02/2021] [Accepted: 03/20/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In 2011, through a multipartner Integrated Family Health Initiative (IFHI), CARE started supporting maternal and neonatal health (MNH) improvement goals in 8 of 38 districts in Bihar, India. The programme included a frontline health worker (FHW) component offering health advice through household visits and benefited from CARE's direct engagement during IFHI, which then evolved into statewide Technical Support Unit (TSU) to the Government of Bihar in 2014. METHODS Using eight rounds of state-representative household surveys with mothers of infants aged 0-2 months (N=73 093) linked with two facility assessments conducted during 2012-2017, we assessed changes in FHW visit coverage, intensity and quality between IFHI and TSU phases. Using logistic regression models, we ascertained associations between FHW outputs and three MNH core practices: ≥3 antenatal care check-ups (ANC3+), institutional delivery and early breastfeeding initiation. RESULTS Women's receipt of 1+ FHW visits declined from 60.2% (IFHI phase) to 46.3% (TSU phase) in the eight IFHI districts, being below 40% statewide during the TSU phase. Despite a parallel decline in FHW visit quality measured as the number of health advice received, all three outcomes improved during the TSU versus IFHI phase in IFHI districts. We found significant positive associations between all three outcomes and receipt of 1+ FHW visits and programme phase (TSU vs IFHI) in the eight IFHI districts. During the TSU phase, receipt of 2+ FHW visits in the third trimester increased the odds of women receiving ANC3+ (adjusted OR (aOR)=1.21; 95% CI: 1.13 to 1.31), delivering in a facility (aOR=1.64; 95% CI: 1.51 to 1.77) and initiating breast feeding early (aOR=1.18; 95% CI: 1.05 to 1.18). Independent of the number and timing of FHW visits, we also found positive associations between women reporting higher than lower quality of FHW interactions and receiving outcome-specific advice and all three MNH outcomes. CONCLUSION Implementation of large community-based interventions under the technical support model should be continuously and strategically evaluated and adapted.
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Affiliation(s)
- Jess Wilhelm
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India.,CARE USA, Atlanta, Georgia, USA
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kane S, Dayal P, Mahapatra T, Kumar S, Bhasin S, Gore A, Das A, Reddy S, Mahal A, Krishnan S, Kermode M. Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states. Gates Open Res 2021; 4:61. [PMID: 34046557 PMCID: PMC8126785 DOI: 10.12688/gatesopenres.13134.3] [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] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by analyzing the implementation of an organizational change intervention in a large, hierarchical and bureaucratic public service in a LMIC health system. Methods: Using qualitative methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.
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Affiliation(s)
- Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | - Prarthna Dayal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Sanjiv Kumar
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, India
| | | | - Aboli Gore
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Aritra Das
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Sandeep Reddy
- School of Medicine, Deakin University, Melbourne, Australia
| | - Ajay Mahal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
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Joudeh A, Ghosh R, Spindler H, Handu S, Sonthalia S, Das A, Gore A, Mahapatra T, Walker D. Increases in diagnosis and management of obstetric and neonatal complications in district hospitals during a high intensity nurse-mentoring program in Bihar, India. PLoS One 2021; 16:e0247260. [PMID: 33735280 PMCID: PMC7971704 DOI: 10.1371/journal.pone.0247260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/04/2021] [Indexed: 11/17/2022] Open
Abstract
Maternal and neonatal mortality in Bihar, India was far higher than the aspirational levels set out by the Sustainable Development Goals. Provider training programs have been implemented in many low-resource settings to improve obstetric and neonatal outcomes. This longitudinal investigation assessed diagnoses and management of postpartum hemorrhage (PPH), hypertensive disorders of pregnancy, birth asphyxia (BA), and low birth weight (LBW), as part of the CARE’s AMANAT program in 22 District Hospitals in Bihar, between 2015 and 2017. Physicians and nurse mentors conducted clinical instruction, simulations and teamwork and communication activities, infrastructure and management support, and data collection for 6 consecutive months. Analysis of diagnosis included 11,259 non-referred and management included 11,800 total (non-referred and referred) admissions that were observed. Data were analyzed using the chi-square test for trend. PPH was diagnosed in 3.7% with no significant trend but diagnosis of hypertensive disorders increased from 1.0% to 1.7%, (ptrend = 0.04), over the 6 months. BA was diagnosed in 5.8% with no significant trend but LBW diagnoses increased from 11% to 16% (ptrend<0.01). Among PPH patients, 96% received fluids, 85% received uterotonics and 11% received Tranexamic Acid (TXA). There was a significant positive trend in the number of patients receiving TXA for PPH (6% to 13.8%, ptrend = 0.03). Of all neonates with BA, there were statistically significant increases in the proportion who were initially warmed, dried, and stimulated (78% to 94%, ptrend = 0.02), received airway suction (80% to 93%, ptrend = 0.03), and supplemental oxygen without positive pressure ventilation (73% to 86%, ptrend = 0.05). Diagnoses of hypertensive disorders and LBW as well as initial management of BA increased during the AMANAT program. However, underdiagnoses of PPH and hypertensive disorders relative to population levels remain critical barriers to improving maternal morbidity and mortality.
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Affiliation(s)
- Ammar Joudeh
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California, United States of America
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Hilary Spindler
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Seema Handu
- PRONTO International, State RMNCH+A, Patna, India
| | | | | | | | | | - Dilys Walker
- School of Medicine and Department of Obstetrics-Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020; 10:021008. [PMID: 33425332 PMCID: PMC7759019 DOI: 10.7189/jogh.10.021008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017. METHODS We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using χ2 tests. RESULTS Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P < 0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P < 0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P < 0.05). CONCLUSION Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sanjiv Daulatrao
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Rohini Durbha
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Creanga AA, 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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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kane S, Dayal P, Mahapatra T, Kumar S, Bhasin S, Gore A, Das A, Reddy S, Mahal A, Krishnan S, Kermode M. Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states. Gates Open Res 2020; 4:61. [PMID: 34046557 PMCID: PMC8126785 DOI: 10.12688/gatesopenres.13134.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 04/03/2024] Open
Abstract
Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by analyzing the implementation of an organizational change intervention in a large, hierarchical and bureaucratic public service in a LMIC health system. Methods: Using qualitative methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.
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Affiliation(s)
- Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | - Prarthna Dayal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Sanjiv Kumar
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, India
| | | | - Aboli Gore
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Aritra Das
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Sandeep Reddy
- School of Medicine, Deakin University, Melbourne, Australia
| | - Ajay Mahal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
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Hoover J, Koon AD, Rosser EN, Rao KD. Mentoring the working nurse: a scoping review. HUMAN RESOURCES FOR HEALTH 2020; 18:52. [PMID: 32727573 PMCID: PMC7388510 DOI: 10.1186/s12960-020-00491-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Mentoring programs for nurses already in the health workforce are growing in importance. Yet, the settings, goals, scale, and key features of these programs are not widely known. OBJECTIVE To identify and synthesize research on in-service nurse mentoring programs. METHODS We reviewed nurse mentoring research from six databases. Studies either referred explicitly to in-service nurse mentoring programs, were reviews of such programs, or concerned nurse training/education in which mentoring was an essential component. RESULTS We included 69 articles from 11 countries, published from 1995 to 2019. Most articles were from high-income countries (n = 46) and in rural areas (n = 22). Programs were developed to strengthen clinical care (particularly maternal and neonatal care), promote evidence-based practice, promote retention, support new graduate nurses, and develop nurse leaders. Of the articles with sufficient data, they typically described small programs implemented in one facility (n = 23), with up to ten mentors (n = 13), with less than 50 mentees (n = 25), meeting at least once a month (n = 27), and lasting at least a year (n = 24). While over half of the studies (n = 36) described programs focused almost exclusively on clinical skills acquisition, many (n = 33) specified non-clinical professional development activities. Reflective practice featured to a varying extent in many articles (n = 29). Very few (n = 6) explicitly identified the theoretical basis of their programs. CONCLUSIONS Although the literature about in-service nurse mentoring comes mostly from small programs in high-income countries, the largest nurse mentoring programs in the world are in low- and middle-income countries. Much can be learned from studying these programs in greater detail. Future research should analyze key features of programs to make models of mentoring more transparent and translatable. If carefully designed and flexibly implemented, in-service nurse mentoring represents an exciting avenue for enhancing the role of nurses and midwives in people-centered health system strengthening. The contents in this article are those of the authors and do not necessarily reflect the view of the U.S. President's Emergency Plan for AIDS Relief, the U.S. Agency for International Development or the U.S. Government.
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Affiliation(s)
- Jerilyn Hoover
- Credence Management Solutions, LLC, the Global Health Technical Professionals, USAID, 8609 Westwood Center Drive, Suite 300, Vienna, VA 22192 USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Erica N. Rosser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
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Kane S, Dayal P, Mahapatra T, Kumar S, Bhasin S, Gore A, Das A, Reddy S, Mahal A, Krishnan S, Kermode M. Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states. Gates Open Res 2020; 4:61. [PMID: 34046557 PMCID: PMC8126785 DOI: 10.12688/gatesopenres.13134.1] [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] [Accepted: 05/19/2020] [Indexed: 04/03/2024] Open
Abstract
Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by adding to the knowledge base on strategies for implementing change interventions in large, hierarchical and bureaucratic public services in LMIC health systems. Methods: Using a mix of methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.
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Affiliation(s)
- Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | - Prarthna Dayal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Sanjiv Kumar
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, India
| | | | - Aboli Gore
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Aritra Das
- Bihar Technical Support Unit, CARE India, Patna, Bihar, India
| | - Sandeep Reddy
- School of Medicine, Deakin University, Melbourne, Australia
| | - Ajay Mahal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
| | | | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melblourne, Victoria, Australia
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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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Serra G, Miceli V, Albano S, Corsello G. Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy). Ital J Pediatr 2019; 45:152. [PMID: 31783883 PMCID: PMC6884854 DOI: 10.1186/s13052-019-0751-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer. METHODS We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present. RESULTS Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%). CONCLUSIONS Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.
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Affiliation(s)
- Gregorio Serra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy. .,"G. Giglio" Hospital Institute Foundation, Cefalù, Italy.
| | | | | | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy
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Dandona R, Kumar GA, Bhattacharya D, Akbar M, Atmavilas Y, Nanda P, Dandona L. Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar. BMC Med 2019; 17:140. [PMID: 31319860 PMCID: PMC6639919 DOI: 10.1186/s12916-019-1372-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/18/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. METHODS Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. RESULTS The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days. CONCLUSIONS To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.
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Affiliation(s)
- Rakhi Dandona
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India. .,Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA.
| | - G Anil Kumar
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India
| | | | - Md Akbar
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Priya Nanda
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Lalit Dandona
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, 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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Ghosh R, Spindler H, Morgan MC, Cohen SR, Begum N, Gore A, Mahapatra T, Walker DM. Diagnosis and management of postpartum hemorrhage and intrapartum asphyxia in a quality improvement initiative using nurse-mentoring and simulation in Bihar, India. PLoS One 2019; 14:e0216654. [PMID: 31276503 PMCID: PMC6611567 DOI: 10.1371/journal.pone.0216654] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/25/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program. METHODS During the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding. RESULTS This analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention (PPH: 2.5-5.4%, intrapartum asphyxia: 4.2-5.6%) relative to the first week (PPH: 1.2-2.1%, intrapartum asphyxia: 0.7-3.3%). Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time. CONCLUSIONS The nurse-mentoring program appears to have built providers' capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Hilary Spindler
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Melissa C. Morgan
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States of America
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Susanna R. Cohen
- College of Nursing, University of Utah, Salt Lake City, UT, United States of America
| | | | | | | | - Dilys M. Walker
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
- Department of Obstetrics and Gynecology and Reproductive Services, University of California, San Francisco, San Francisco, CA, United States of America
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Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births. BMC Med 2019; 17:28. [PMID: 30728016 PMCID: PMC6366028 DOI: 10.1186/s12916-019-1265-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/21/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population. METHODS Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach. RESULTS A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43). CONCLUSIONS We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.
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Morgan MC, Dyer J, Abril A, Christmas A, Mahapatra T, Das A, Walker DM. Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study. BMC Pregnancy Childbirth 2018; 18:420. [PMID: 30359240 PMCID: PMC6202860 DOI: 10.1186/s12884-018-2059-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/15/2018] [Indexed: 01/28/2023] Open
Abstract
Background Globally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs. Methods In partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach. Results Mentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback. Conclusions This study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts. Electronic supplementary material The online version of this article (10.1186/s12884-018-2059-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melissa C Morgan
- Department of Pediatrics, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA, 94158, USA. .,Institute for Global Health Sciences, 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 & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Jessica Dyer
- Pronto International, 5419 Greenwood Avenue North, Seattle, WA, 98103, USA
| | - Aranzazu Abril
- Médecins Sans Frontières, Nou de la Rambla 26, 08001, Barcelona, Spain
| | - Amelia Christmas
- Pronto International; State RMNCH+A Unit, C-16 Krishi Nagar, A.G. Colony, Patna, Bihar, 80002, India
| | | | - Aritra Das
- CARE India, 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.,Pronto International, 5419 Greenwood Avenue North, Seattle, WA, 98103, USA.,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
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Vail B, Morgan MC, Dyer J, Christmas A, Cohen SR, Joshi M, Gore A, Mahapatra T, Walker DM. Logistical, cultural, and structural barriers to immediate neonatal care and neonatal resuscitation in Bihar, India. BMC Pregnancy Childbirth 2018; 18:385. [PMID: 30268110 PMCID: PMC6162900 DOI: 10.1186/s12884-018-2017-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 09/18/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND In India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized. METHODS To better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors' perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar's rural primary health centers. Data was analyzed using the thematic content approach. RESULTS Mentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients' relatives. Poverty was described as an overarching structural barrier. CONCLUSION Interacting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers' clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.
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Affiliation(s)
- Brennan Vail
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94143 USA
| | - Melissa C. Morgan
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94143 USA
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, Box 1224, San Francisco, CA 94158 USA
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Jessica Dyer
- PRONTO International, 1820 E. Thomas Street APT 16, Seattle, WA USA
| | - Amelia Christmas
- PRONTO International, State RMNCH+A Unit, C-16 Krishi Nagar, A.G. Colony, Patna, Bihar 80002 India
| | - Susanna R. Cohen
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84112 USA
| | - Megha Joshi
- CARE India Solutions for Sustainable Development, Bihar Technical Support Unit, House No.14, Patliputra Colony, Patna, Bihar 800013 India
| | - Aboli Gore
- CARE India Solutions for Sustainable Development, Bihar Technical Support Unit, House No.14, Patliputra Colony, Patna, Bihar 800013 India
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Bihar Technical Support Unit, House No.14, Patliputra Colony, Patna, Bihar 800013 India
| | - Dilys M. Walker
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, Box 1224, San Francisco, CA 94158 USA
- PRONTO International, 1820 E. Thomas Street APT 16, Seattle, WA 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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Vail B, Morgan MC, Spindler H, Christmas A, Cohen SR, Walker DM. The power of practice: simulation training improving the quality of neonatal resuscitation skills in Bihar, India. BMC Pediatr 2018; 18:291. [PMID: 30176831 PMCID: PMC6122678 DOI: 10.1186/s12887-018-1254-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood. METHODS This study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India. Further, it explores barriers to performance of key NR skills. PRONTO training was conducted within CARE India's AMANAT intervention, a maternal and child health quality improvement project. Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training. Performance in live deliveries was evaluated in real time using a mobile-phone application. Barriers were explored through semi-structured interviews with simulation facilitators. RESULTS In total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated. From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01). No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps. In 252 live deliveries, identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23% respectively (all p < 0.01) between weeks 1-3 and 4-8. Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills. CONCLUSION PRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar. Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training. In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process.
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Affiliation(s)
- Brennan Vail
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94158 USA
| | - Melissa C. Morgan
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94158 USA
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Hilary Spindler
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Amelia Christmas
- PRONTO International, State RMNCH+A Unit, C-16 Krishi Nagar, A.G. Colony, Patna, Bihar 80002 India
| | - Susanna R. Cohen
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84112 USA
| | - Dilys M. Walker
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 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
- PRONTO International, 1820 E. Thomas Street APT 16, Seattle, WA 98112 USA
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Spindler H, Dyer J, Bagchi K, Ranjan V, Christmas A, Cohen SR, Sterling M, Shah MB, Das A, Mahapatra T, Walker D. Tracking and debriefing birth data at scale: A mobile phone application to improve obstetric and neonatal care in Bihar, India. Nurs Open 2018; 5:267-274. [PMID: 30062019 PMCID: PMC6056450 DOI: 10.1002/nop2.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 12/22/2017] [Indexed: 11/08/2022] Open
Abstract
AIM This analysis assessed changes over time in skill and knowledge related to the use of evidence-based practices associated with quality of maternal and neonatal care during a nurse midwife mentoring intervention at primary health clinics (PHCs) in Bihar, India. DESIGN Nurse midwife mentors (NMMs) entered live birth observation data into a mobile App from 320 PHCs. METHODS The NMMs completed prompted questions in the App after every live birth witnessed. The App consisted of questions around three main themes, "What went well?", "What needed improvement?" and "What can be done differently next time?". RESULTS Observational data from 5,799 births was recorded by 120 NMMs in 320 PHCs. Knowledge and skill during normal spontaneous vaginal deliveries and complicated deliveries with either a postpartum haemorrhage or non-vigorous infant all showed statistically significant improvement (p < .001) over time using a Chi-squared test for trend with a mean increase of 41% across all indicators.
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Affiliation(s)
- Hilary Spindler
- Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Kingshuk Bagchi
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Vikash Ranjan
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | | | | | - Mona Sterling
- Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Malay Bharat Shah
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Aritra Das
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable DevelopmentBihar Technical Support UnitPatnaBiharIndia
| | - Dilys Walker
- Department of Obstetrics and Gynecology and Reproductive ServicesUniversity of California San FranciscoSan FranciscoCAUSA
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Das A, Nawal D, Singh MK, Karthick M, Pahwa P, Shah MB, Mahapatra T, Chaudhuri I. Impact of a Nursing Skill-Improvement Intervention on Newborn-Specific Delivery Practices: An Experience from Bihar, India. Birth 2016; 43:328-335. [PMID: 27321470 DOI: 10.1111/birt.12239] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND High neonatal mortality in India had previously been attributed to the low proportion of institutional deliveries. However, a significant rise in the proportion of facility-based births over the last decade has not achieved the desired reduction in neonatal mortality possibly as a result of low-skilled care at facilities. This study evaluated the effectiveness of "Mobile Nurse Training," a knowledge-based intervention for nurses to improve essential newborn-specific delivery practices. METHODS Eighty health centers with obstetric care facilities were selected from eight districts of Bihar. The intervention teams were composed of two trained nurses who conducted a week-long workshop per month at every health facility for 6 months. An independent evaluation team conducted baseline and postintervention assessments at every facility. The assessments included passive observation of newborn-specific delivery practices and recording of results on a preformatted checklist-based tool. RESULTS The intervention was associated with significant increases in the odds of four recommended practices: placing the newborn on mother's abdomen (adjusted odds ratio (AOR) 4.2 [95% CI 3.0-5.9]), wiping the eyes with sterile gauze (AOR 2.2 [95% CI 1.4-3.4]), skin-to-skin care (AOR 2.7 [95% CI 2.0-3.5]), and guidance for initiation of breastfeeding (AOR 1.6 [95% CI 1.2-2.1]). The intervention was also found to be positively associated with the summary score for improvements in all newborn-specific delivery practices. One year after the intervention, the summary practice score remained higher than at baseline, but with some decline over time. CONCLUSIONS The "Mobile Nurse Training" intervention provides a pathway for improving adherence to recommended newborn-specific delivery practices among institutional birth attendants in rural Bihar.
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Affiliation(s)
- Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Dipty Nawal
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Manoj K Singh
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Morchan Karthick
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Parika Pahwa
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Malay B Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Tanmay Mahapatra
- Department of Epidemiology, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA, USA
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