Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India

Abstract

BackgroundAfter the launch of Janani Suraksha Yojana, a conditional cash transfer scheme in India, the proportion of women giving birth in institutions has rapidly increased. However, there are important gaps in quality of childbirth services during institutional deliveries. The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan. This intervention titled “Parijaat” was designed by Action Research & Training for Health, in partnership with the state government and United Nations Population Fund.MethodsThe intervention was carried out in 44 public health facilities in 10 districts of Rajasthan, India. These included district hospitals (9), community health centres (32) and primary health centres (3). The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment, feedback, training and action. The adherence to evidence based practices before, during and after this intervention were measured using structured checklists and scoring sheets. Main outcome measures included changes in practices during labour, delivery or immediate postpartum period.ResultsUse of several unnecessary or harmful practices reduced significantly. Most importantly, proportion of facilities using routine augmentation of labour reduced (p = 0), episiotomy for primigravidas (p = 0.0003), fundal pressure (p = 0.0003), and routine suction of newborns (0 = 0.0005). Among the beneficial practices, use of oxytocin after delivery increased (p = 0.0001) and the practice of listening foetal heart sounds during labour (p = 0.0001). Some practices did not show any improvements, such as dorsal position for delivery, use of partograph, and hand-washing.ConclusionsAn intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practices at health facilities.

Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India

“…Our informal observations during data collection – of labour room environments that often appeared chaotic and of some health workers that could be abusive, dominating and threatening on occasions (available from the corresponding author) – were consistent with those previously found in Madhya Pradhesh 46 and Rajasthan 25 . Inadequate knowledge and skills, lack of enabling environments, limited supportive supervision, staffing shortages and the poor quality of in-service training could all be underlying causes of the generally poor quality of maternity care in India 24 , 46 . The Indian government is currently implementing a range of schemes to improve the quality of intrapartum and immediate postpartum care 47 .…”

“…In a study based in Rajasthan, partograph use was found to be especially weak and monitoring was found often to consist only of repeated unhygienic vaginal examinations 24 . We found active management of the third stage of labour to be more common in the facilities we surveyed than reported in some neighbouring districts of Uttar Pradesh 23 .…”

Evidence Based Intrapartum Care and Factors among Obstetric CareProviders, Northwest Ethiopia: An Institution Based Cross-Sectional Study,2015

“…The current study is lower than study done in California (74.4%), Iran (78%), Brazil (50%) [13,26,27]. This may be possibly due to cross cultural difference, divided loyalty, self-selection, and limited number of staffs serving in the hospital [28].…”

“…An institution based cross-sectional study from Cameroon found out that age; sex, profession, and experience were associated with evidence based intrapartum care [13][14][15][16]. Several studies have shown that age, sex, profession, qualification, experience, access to internet, workshop, conferences, searching for the Cochrane database, were statistical associated with evidence based practice [17][18][19].…”

An Assessment of High Delivery Load Facilities under the Dakshata Program

“…Filler et al [7] also found that critical steps of resuscitation have not being followed and improved education and further training on resuscitation need to be imparted in labor room team [6]. Furthermore, availability of commodities in the newborn care corner for resuscitation is also an important bottleneck found in our surveys such as availability of functional radiant warmer and Ambu bag was approximately 80%; shoulder roll 29%; either availability of mask 0 or 1 was 50%; availability of both masks was 28% [8].…”