Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

Abstract

BackgroundLow/middle-income countries need a large-scale improvement in the quality of care (QoC) around the time of childbirth in order to reduce high maternal, fetal and neonatal mortality. However, there is a paucity of scalable models.MethodsWe conducted a stepped-wedge cluster-randomised trial in 15 primary health centres (PHC) of the state of Haryana in India to test the effectiveness of a multipronged quality management strategy comprising capacity building of providers, periodic assessments of the PHCs to identify quality gaps and undertaking improvement activities for closure of the gaps. The 21-month duration of the study was divided into seven periods (steps) of 3 months each. Starting from the second period, a set of randomly selected three PHCs (cluster) crossed over to the intervention arm for rest of the period of the study. The primary outcomes included the number of women approaching the PHCs for childbirth and 12 directly observed essential practices related to the childbirth. Outcomes were adjusted with random effect for cluster (PHC) and fixed effect for ‘months of intervention’.ResultsThe intervention strategy led to increase in the number of women approaching PHCs for childbirth (26 vs 21 women per PHC-month, adjusted incidence rate ratio: 1.22; 95% CI 1.17 to 1.28). Of the 12 practices, 6 improved modestly, 2 remained near universal during both intervention and control periods, 3 did not change and 1 worsened. There was no evidence of change in mortality with a majority of deaths occurring either during referral transport or at the referral facilities.ConclusionA multipronged quality management strategy enhanced utilisation of services and modestly improved key practices around the time of childbirth in PHCs in India.Trial registration numberCTRI/2016/05/006963.

Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study

“…The pooled CS rates were 15.5% (11%-17.8%), which were comparable to the reports from India [54,55]. About 30% of the women in labour from lower-level facilities were referred to these facilities [19,56]. Thus higher CS rates were expected at these facilities.…”

Quality of and barriers to routine childbirth care signal functions in primary level facilities of Tigray, Northern Ethiopia: Mixed method study

“…It has been argued that these processes provide a measurable and meaningful indication of QoC since they describe the potential for health-gain in given clinical scenario. In the context of maternal and newborn health care it is possible to define content of care by drawing on the global recommendations for minimum packages of routine care that should be made available to all women and newborns during intra-partum and immediate postpartum care [13,14].…”

Who are dying and why? A case series study of maternal deaths in Nepal

“…Designated CEmOC sites in health centres or hospitals should have sufficient beds, essential drugs, medical equipment, robust infrastructure, skilled care and consistent operating hours as has been demonstrated in a cluster randomised trial in India. 35 …”

“…Designated CEmOC sites in health centres or hospitals should have sufficient beds, essential drugs, medical equipment, robust infrastructure, skilled care and consistent operating hours as has been demonstrated in a cluster randomised trial in India. 35 Since the majority of cases had complications which started while at home or in lower level facilities and faced difficulty in transportation, the fact that many cases arrived very late at the final hospital is an important risk factor. The very late arrival with severe problems poses risks and challenges for the referral hospitals with limited human and logistic resources.…”