Dataset Information

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

ABSTRACT:

Background

Improving 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.

Methods

Nine 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.

Results

Admission 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.

Conclusions

The 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.

SUBMITTER: Saxena M

PROVIDER: S-EPMC6160099 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundPersistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions.ObjectiveThis study aimed to examine pregnant women's expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider's perceptions of the same, as well as the barriers that limit their ability to provide high-quality care.MethodsA qualitative descriptive analysis was conducted on data from two studies - focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women's experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016-17) to understand provision of person-centred care. Provider perspectives were matched with themes of women's perspectives on quality of childbirth care in facilities.ResultsMajor themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries.ConclusionsThis study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers' perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

Project description:IntroductionAbortion is legal in India and medication abortion (MA) using a combined regimen of mifepristone and misoprostol is the preferred method. Users increasingly purchase MA kits directly from pharmacies, in some cases experiencing perceived complications and approaching a facility for care. We present findings of a qualitative research tracing the decision-making pathway(s) of MA users in Uttar Pradesh, India, to help understand knowledge and behaviour gaps, and recommend ways to improve the overall quality of care at these service delivery points.MethodsForty in-depth interviews were conducted with recent MA users (20 each of clinic and pharmacy clients) across three districts. Providers were purposively selected in collaboration with an international organization selling MA kits, using their list of pharmacies and clinics. MA users were identified from the clients of the selected providers, and additionally through the snow ball method. Interviews were conducted in Hindi with verbal informed consent in a private place convenient to the respondent. Transcripts were translated to English and analysed thematically.ResultsUsers first sought MA kits at pharmacies out of convenience, low cost and customer anonymity. Men often purchased kits for their partners and trusted the chemist for guidance on dosage, progression and side effects. For side effects or other concerns after using an MA kit, users first visited their neighbourhood doctor or traditional practitioner. These providers either attempted to treat the issue and failed, or directly advised her to consult a gynaecologist. The final point of care was gynaecologists, preferably female private practitioners with their own clinics. They diagnosed most abortion-related cases as incomplete abortions, emptying the uterus using the dilation and curettage method. Comparatively low cost and convenience made users inclined towards repeat use of MA.ConclusionThere are information gaps at various stages in the MA pathway that need to be addressed. Large scale public information programmes are required on safe abortion care- when is it legal, where to obtain MA, dosage, side effects and signs of possible complications. Pharmacists could be trained or incentivized to improve their quality of care to facilitate adequate exchange of information on MA. Since, for most couples, the male partner purchases MA, information approaches or tools are needed that pharmacists can give men to share directly with the MA user.

Project description:BACKGROUND:Maternal and neonatal outcomes in the immediate post-delivery period are critical indicators of quality of care. Data on childbirth outcomes in low-income settings usually require home visits, which can be constrained by cost and access. We report on the use of a call center to measure post-discharge outcomes within a multi-site improvement study of facility-based childbirth in Uttar Pradesh, India. METHODS:Of women delivering at study sites eligible for inclusion, 97.9% (n = 157,689) consented to follow-up. All consenting women delivering at study facilities were eligible to receive a phone call between days eight and 42 post-partum to obtain outcomes for the seven-day period after birth. Women unable to be contacted via phone were visited at home. Outcomes, including maternal and early neonatal mortality and maternal morbidity, were ascertained using a standardized script developed from validated survey questions. Data Quality Assurance (DQA) included accuracy (double coding of calls) and validity (consistency between two calls to the same household). Regression models were used to identify factors associated with inconsistency. FINDINGS:Over 23 months, outcomes were obtained by the call center for 98.0% (154,494/157,689) consenting women and their neonates. 87.9% of call center-obtained outcomes were captured by phone call alone and 12.1% required the assistance of a field worker. An additional 1.7% were obtained only by a field worker, 0.3% were lost-to-follow-up, and only 0.1% retracted consent. The call center captured outcomes with a median of 1 call (IQR 1-2). DQA found 98.0% accuracy; data validation demonstrated 93.7% consistency between the first and second call. In a regression model, significant predictors of inconsistency included cases with adverse outcomes (p<0.001), and different respondents on the first and validation call (p<0.001). CONCLUSIONS:In areas with widespread mobile cell phone access and coverage, a call center is a viable and efficient approach for measurement of post-discharge childbirth outcomes.

Project description:OBJECTIVES:The major objective of this study was to investigate the prevalence of labour room violence (LRV) (one of the forms of obstetric violence) faced by the women during the time of delivery in Uttar Pradesh (UP) (the largest populous state of India which is also considered to be a microcosm of India). Furthermore, this study also analyses the association between prevalence of obstetric violence and socioeconomic characteristics of the respondents. DESIGN:The study was longitudinal in design with the first visit to women made at the time of first trimester. The second visit was made at the time of second trimester and the last visit was made after the delivery. However, we have continuously tracked women over phone to keep record of developments and adverse consequences. SETTINGS:Urban and rural areas of UP, India. PARTICIPANTS:Sample of 504 pregnant women was systematically selected from the Integrated Child Development Scheme Register of pregnant women. OUTCOME:We aimed to assess the levels and determinants of LRV using data collected from 504 pregnant women in a longitudinal survey conducted in UP, India. The dataset comprised three waves of survey from the inception of pregnancy to childbirth and postnatal care. Logistic regression model has been used to assess the association between prevalence of LRV faced by the women at the time of delivery and their background characteristics. RESULT:About 15.12% of women are facing LRV in UP, India. Results from logistic regression model (OR) show that LRV is higher among Muslim women (OR 1.8, 95% CI 0.7 to 4.3) relative to Hindu women (OR 1). The prevalence of LRV is higher among lower castes relative to general category, and is higher among those women who have no mass media exposure (OR 4.7, 95% CI 1.7 to 12.8) compared with those who have (OR 1). CONCLUSION:In comparison with global evidence, the level of LRV in India is high. Women from socially disadvantaged communities are facing higher LRV than their counterparts.

Project description:BACKGROUND:The study aims to assess the discordance between self-reported and observed measures of mistreatment of women during childbirth in public health facilities in Uttar Pradesh, India, as well as correlates of these measures and their discordance. METHODS:Cross sectional data were collected through direct observation of deliveries and follow-up interviews with women (n = 875) delivering in 81 public health facilities in Uttar Pradesh. Participants were surveyed on demographics, mistreatment during childbirth, and maternal and newborn complications. Provider characteristics (training, age) were obtained through interviews with providers, and observation data were obtained from checklists completed by trained nurse investigators to document quality of care at delivery. Mistreatment was assessed via self-report and observed measures which included 17 and 6 items respectively. Cohen's kappas assessed concordance between the 6 items common in the self-report and observed measures. Regression models assessed associations between characteristics of women and providers for each outcome. RESULTS:Most participants (77.3%) self-reported mistreatment in at least 1 of the 17-item measure. For the 6 items included in both self-report and observations, 9.1% of women self-reported mistreatment, whereas observers reported 22.4% of women being mistreated. Cohen's kappas indicated mostly fair to moderate concordance. Regression analyses found that multiparous birth (AOR = 1.50, 95% CI = 1.06-2.13), post-partum maternal complications (AOR = 2.0, 95% CI = 1.34-3.06); new-born complications (AOR = 2.6, 95% CI = 1. 96-4.03) and not having an Skilled Birth Attendant (SBA) trained provider (AOR = 1.47, 95% CI = 1.05-2.04) were associated with increased risk for mistreatment as measured by self-report. In contrast, only provider characteristics like older provider (AOR = 1.03, 95% CI = 1.02-1.05) and provider not trained in SBA (AOR = 1.44, 95% CI = 1.02-2.02) were associated with mistreatment as measured through observations. Younger age at marriage (AOR = 0.86, 95% CI = 0.78-0.95) and provider characteristics (older provider AOR = 1.05, 95% CI = 1.01-1.09; provider not trained in SBA AOR = 0.96, 95% CI = 0.92-0.99) were associated with discordance (based on mistreatment reported by observer but not by women). CONCLUSION:Provider mistreatment during childbirth is prevalent in Uttar Pradesh and may be under-reported by women, particularly when they are younger or when providers are older or less trained. The findings warrant programmatic action as well as more research to better understand the context and drivers of both behavior and reporting. TRIAL REGISTRATION:CTRI/2015/09/006219. Registered 28 September 2015.

Project description:ObjectiveEvaluate the impact of a World Health Organization Safe Childbirth Checklist coaching-based intervention (BetterBirth Program) on availability and procurement of essential childbirth-related supplies.DesignMatched pair, cluster-randomized controlled trial.SettingUttar Pradesh, India.Participants120 government-sector health facilities (60 interventions, 60 controls). Supply-availability surveys were conducted quarterly in all sites. Coaches collected supply procurement sources from intervention sites.InterventionsCoaching targeting implementation of Checklist with data feedback and action planning.Main outcome measuresMean supply availability by study arm; change in procurement sources for intervention sites.ResultsAt baseline, 6 and 12 months, the intervention sites had a mean of 20.9 (95% confidence interval (CI): 20.2-21.5); 22.4 (95% CI: 21.8-22.9) and 22.1 (95% CI:21.4-22.8) items, respectively. Control sites had 20.8 (95% CI: 20.3-21.3); 20.9 (95% CI: 20.3-21.5) and 21.7 (95% CI: 20.8-22.6) items at the same time-points. There was a small but statistically significant higher availability in intervention sites at 6 months (difference-in-difference (DID) = 1.43, P < 0.001), which was not seen by 12 months (DID = 0.37, P = 0.53). Greater difference between intervention and control sites starting in the bottom quartile of supply availability was seen at 6 months (DID = 4.0, P = 0.0002), with no significant difference by 12 months (DID = 1.5, P = 0.154). No change was seen in procurement sources with ~5% procured by patients with some rates as high as 29% (oxytocin).ConclusionsImplementation of the BetterBirth Program, incorporating supply availability, resulted in modest improvements with catch-up by control facilities by 12 months. Supply-chain coaching may be most beneficial in sites starting with lower supply availability. Efforts are needed to reduce reliance on patient-funding for some critical medications.Trial registrationClinicalTrials.gov #NCT02148952; Universal Trial Number: U1111-1131-5647.

Project description:Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality. Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality. Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality. Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex. Bill & Melinda Gates Foundation. ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Project description:Shifting childbirth into facilities has not improved health outcomes for mothers and newborns as significantly as hoped. Improving the quality and safety of care provided during facility-based childbirth requires helping providers to adhere to essential birth practices-evidence-based behaviors that reduce harm to and save lives of mothers and newborns. To achieve this goal, we developed the BetterBirth Program, which we tested in a matched-pair, cluster-randomized controlled trial in Uttar Pradesh, India. The goal of this intervention was to improve adoption and sustained use of the World Health Organization Safe Childbirth Checklist (SCC), an organized collection of 28 essential birth practices that are known to improve the quality of facility-based childbirth care. Here, we describe the BetterBirth Program in detail, including its 4 main features: implementation tools, an implementation strategy of coaching, an implementation pathway (Engage-Launch-Support), and a sustainability plan. This coaching-based implementation of the SCC motivates and empowers care providers to identify, understand, and resolve the barriers they face in using the SCC with the resources already available. We describe important lessons learned from our experience with the BetterBirth Program as it was tested in the BetterBirth Trial. For example, the emphasis on relationship building and respect led to trust between coaches and birth attendants and helped influence change. In addition, the cloud-based data collection and feedback system proved a valuable asset in the coaching process. More research on coaching-based interventions is required to refine our understanding of what works best to improve quality and safety of care in various settings.Note: At the time of publication of this article, the results of evaluation of the impact of the BetterBirth Program were pending publication in another journal. After the impact findings have been published, we will update this article with a reference to the impact findings.