Improving quality of intrapartum and immediate postpartum care in public facilities: experiences and lessons learned from Rajasthan state, India

Abstract

Background In spite of considerable improvement in maternal and neonatal outcomes over the past decade in India, the current maternal mortality ratio and neonatal mortality rate are far from the Sustainable Development Goal targets due to suboptimal quality of maternity care. A package of interventions for improving quality of intrapartum and immediate postpartum care was co-designed with the Ministry of Health as the Dakshata program and implemented in public sector health facilities in selected districts in the state of Rajasthan of India since June 2015. This article describes the key strategies, interventions, results and challenges from four years of Dakshata program implementation. Methods We have conducted secondary analysis of program data (government data) collected from 202 public facilities across 20 districts of Rajasthan state. The data collected between June–August 2015 (baseline) and the data collected between May-August 2019 (latest) were analyzed. The data sources included: facility assessments, service statistics, monthly progress reports. Results During the period of program implementation, there were 17,94,249 deliveries accounting for 70% of institutional deliveries in intervention districts. As a result of the intervention, there was a notable increase in competency of health care providers, availability of essential resources, achievement of labour room standards and adherence to evidence-based clinical standards. We also observed reductions in the proportion of referrals for pre-eclampsia/eclampsia, postpartum hemorrhage and neonatal asphyxia by 11, 8 and 3 percentage points respectively. Similarly, data revealed a reduction in stillbirth rates in Dakshata intervention facilities (19.3 vs 15.3) compared to non-Dakshata facilities (21.8 vs 18). Conclusions Our experience and findings indicate that the quality of intrapartum and immediate postpartum care can be improved in low- and middle-income countries with the approach presented in this paper.

Does Quality Certification Work? An Assessment of Manyata, a Childbirth Quality Program in India’s Private Sector

“…33 , 34 In Manyata, since health outcomes were self-reported by the facilities and collected during the approximately 5-month program implementation (and generally stopped once accreditation was reached), it is possible that change in maternal and neonatal health outcomes requires longer duration of exposure and data collection as was found in other similar programs in India’s public sector. 20 , 21 , 30 …”

“…A recent analysis of the Dakshata program, 21 a similarly structured program for the public sector in India, showed that the program was associated with a decrease in maternal morbidity and stillbirths when evaluated at a large scale (17 million births) over a longer time frame. Moreover, a quasi-experimental observational study of the Safe Childbirth Checklist conducted over a period of 2 years in high delivery load facilities in India revealed the increased adherence to evidence-based practices 20 that resulted in an 11.16% reduction in early neonatal deaths and an 11.3% reduction in stillbirth rates.…”

“…The assessment adapted the methodology and tools approved by the Government of India for quality improvement initiatives in public settings, 29 which have been used in other studies. 21 , 30 The assessment took an estimated 4 hours to complete for each facility and included a combination of direct observation (preferred), medical record review, and interviews with facility leaders, staff, and patients. If a practice was directly observed, then no further verification was needed.…”

“…33,34 In Manyata, since health outcomes were selfreported by the facilities and collected during the approximately 5-month program implementation (and generally stopped once accreditation was reached), it is possible that change in maternal and neonatal health outcomes requires longer duration of exposure and data collection as was found in other similar programs in India's public sector. 20,21,30 A recent analysis of the Dakshata program, 21 a similarly structured program for the public sector in India, showed that the program was associated with a decrease in maternal morbidity and stillbirths when evaluated at a large scale (17 million births) over a longer time frame. Moreover, a quasi-experimental observational study of the Safe Childbirth Checklist conducted over a period of 2 years in high delivery load facilities in India revealed the increased adherence to evidence-based practices 20 that resulted in an 11.16% reduction in early neonatal deaths and an 11.3% reduction in stillbirth rates.…”

“… 9 , 11 , 12 Respectful maternity care practices in the private sector, while frequently reported to be better than in public facilities, have room for improvement. 15 The Government of India launched various initiatives for improving the quality of maternity care in public facilities, 16 – 19 some of which have now shown to have a meaningful impact on reducing neonatal deaths and stillbirths, 20 , 21 yet there are no comparable quality improvement initiatives for private health facilities.…”