Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India

Abstract

BackgroundWhile increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality.MethodsThe USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time.ResultsCare improved to 90–99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30–70% points was observed during post intervention for all the indicators and 3–17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it.ConclusionThese results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-017-1318-4) contains supplementary material, which is available to authorized users.

Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India

“…All women were allowed to have at least one female companion along with the CHW throughout labour and delivery. Several studies have highlighted women experiencing abandonment and neglect during childbirth [ 29 , 61 , 62 ]. Our study also found that some women were left unattended in the delivery room after childbirth for more than 15 minutes.…”

“…Training and orientation of staff towards aspects of person-centred care including respectful & supportive care; information sharing; effective communication skills and patient privacy can go a long way in sensitizing providers around person-centred care, supported by public display of behavioural norms in the charter of patient rights and entitlements. The findings from a quality improvement (QI) intervention in public health facilities across six states of India, suggest that simple QI methods like redesign of space and task shifting have the potential to improve quality of facility-based routine clinical practices in resource poor settings like India [ 62 ] QI cycles may be followed by performance based grading of facilities on attainment of specific quality benchmarks to encourage adoption of good care practices. A concept of ‘positive deviance approach’ may also be introduced for collating and sharing ‘best practices’ with regards to quality of care in facilities performing better while having access to the same resources and facing similar or worse challenges.…”

“…Clinical supervision of staff; criterion-based audits; near-miss audits; and supportive supervision should be undertaken for ensuring adherence to clinical care protocols and quality norms [ 34 , 67 ]. There is evidence that simple Quality Improvement methods like redesigning of space and task shifting have the potential to improve quality of facility-based routine clinical practices in resource-poor settings like India [ 62 ]. Appreciating positive deviance and recognizing quality of care ‘best practices’ could also encourage facilities to optimize quality within the given resources.…”

The impact of a nurse mentoring program on the quality of labour and delivery care at primary health care facilities in Bihar, India

“…Maternal health providers in Bihar and other states in India have identified the availability of adequate health infrastructure, functioning HMIS and evidence-based training with supportive supervision as enablers of quality in maternal health service provision 30 34. However, intervention studies on improving nurse providers skills and practices have used varied modes of training and duration, with some studies noting significant improvements in adherence to evidence-based practices and reduction in harmful practices like labour augmentation, episiotomy for primigravida and application of fundal pressure 35–38. Studies reported mixed results on other practices, such as position of mother during delivery, the use of partograph and hand-washing 36.…”

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

“…These methods have also been found to be effective in India. 28 , 29 Based on our experience of using the F-BNA tool to identify problems and QI methods to address these problems, we propose that this methodology can help in the identification of health system bottlenecks at the facility level, their prioritisation, and improvement in these key areas. This methodology is of prime importance in low- and middle-income countries (LMICs) where resource constraints are a constant problem.…”