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

Abstract

BackgroundImproving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality.MethodsNine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care.ResultsAdmission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments.ConclusionsThe study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

Successes, Challenges and Opportunities Towards Universal Health Coverage for Maternal and Child Health in South East Asian Countries: A Systematic Review

“…As a positive factor that both government representatives and private practitioners have expressed enthusiasm in collaborating with each other with those programmes 41 . c. Human resources A success / opportunity with availability of adequate human resources for delivery care across most public health facilities has been identi ed only in one study in India 30 . Accredited Social Health Activists (ASHAs) play a key role in facilitating the adoption of safe practices in postnatal care in India 36 .…”

“…In two rural districts of Uttar Pradesh, India, process gaps are observed during delivery and post-delivery stages compromising mothers' safety and quality care 30 . Few other studies pointed out the problems with referral system for the contribution of poor quality 12,36,38,65 .…”

“…Antenatal care is typically delivered at the periphery by nonspecialized providers in rural Karnataka State 39 . Following providers' behaviors were identi ed as challenges for quality maternal and childcare in few institutions; Negligence by health staff 20, rudeness of staff against clients 25 , abuse and demand for informal payments 30 . Cultural norms and practices also play a role in quality care as identi ed by few studies in the region 26,36,73 .…”

Patient and healthcare provider knowledge, attitudes and barriers to handover and healthcare communication during chronic disease inpatient care in India: a qualitative exploratory study

“…A recent (2019) study from South Africa has found inadequate discharge planning to be a significant contributor to avoidable causes of hospital readmission 13. Across India, a handful of predominantly single-site studies have evaluated and described deficiencies in information exchange during referrals, hospital shift change and discharge 14–19. The current study forms part of a series completed for a project investigating handover and continuity of care for patients with chronic NCDs in the states of Kerala and Himachal Pradesh in India.…”

Investigating discharge communication for chronic disease patients in three hospitals in India

“…[31] Across India, a handful of studies have found inconsistencies in the provision of discharge information via HCP and patient reports and discharge ticket evaluations. [32][33][34] In addition, a study in an Indian hospital emergency department reported improvements in recorded discharge information following the implementation of pre-formatted discharge summaries. [35] The importance of investigating factors affecting continuity of care in LMICs and India, in particular, is increasing due to the rising prevalence of chronic NCDs, which require sustained care across settings.…”