Implementing a quality improvement initiative for private healthcare facilities to achieve accreditation: experience from India.

BACKGROUND: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care. METHODS: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience. RESULTS: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%). CONCLUSION: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification.

A rapid landscape review of postpartum anaemia measurement: challenges and opportunities.

BACKGROUND: Anaemia is a reduction in haemoglobin concentration below a threshold, resulting from various factors including severe blood loss during and after childbirth. Symptoms of anaemia include fatigue and weakness, among others, affecting health and quality of life. Anaemic pregnant women have an increased risk of premature delivery, a low-birthweight infant, and postpartum depression. They are also more likely to have anaemia in the postpartum period which can lead to an ongoing condition and affect subsequent pregnancies. In 2019 nearly 37% of pregnant women globally had anaemia, and estimates suggest that 50-80% of postpartum women in low- and middle-income countries have anaemia, but currently there is no standard measurement or classification for postpartum anaemia. METHODS: A rapid landscape review was conducted to identify and characterize postpartum anaemia measurement searching references within three published systematic reviews of anaemia, including studies published between 2012 and 2021. We then conducted a new search for relevant literature from February 2021 to April 2022 in EMBASE and MEDLINE using a similar search strategy as used in the published reviews. RESULTS: In total, we identified 53 relevant studies. The timing of haemoglobin measurement ranged from within the immediate postpartum period to over 6 weeks. The thresholds used to diagnose anaemia in postpartum women varied considerably, with < 120, < 110, < 100 and < 80 g/L the most frequently reported. Other laboratory results frequently reported included ferritin and transferrin receptor. Clinical outcomes reported in 32 out of 53 studies included postpartum depression, quality of life, and fatigue. Haemoglobin measurements were performed in a laboratory, although it is unclear from the studies if venous samples and automatic analysers were used in all cases. CONCLUSIONS: This review demonstrates the need for improving postpartum anaemia measurement given the variability observed in published measures. With the high prevalence of anaemia, the relatively simple treatment for non-severe cases of iron deficiency anaemia, and its importance to public health with multi-generational effects, it is crucial to develop common measures for women in the postpartum period and promote rapid uptake and reporting.

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

BACKGROUND: In India, more than 60% of hospital beds are in private facilities, yet several studies have observed suboptimal quality of care in private facilities. We aimed to understand the role of Manyata, a quality improvement initiative in private facilities focused on mentorship and clinical standards, to improve the knowledge and skills of health care providers, their adherence to key childbirth-related clinical practices, and health outcomes for women and newborns. METHODS: We conducted a secondary analysis of Manyata program data collected from 466 private facilities across 3 states (Jharkhand, Maharashtra, and Uttar Pradesh) in India from October 2016 to February 2019. We calculated means and 95% confidence intervals for knowledge and skills assessment, adherence to facility standards was analyzed by calculating the proportion of facilities passing a given quality standard at baseline and endline, and changes in pregnancy outcomes were assessed with autoregression modeling. RESULTS: From assessments conducted before and after training among providers in Manyata, we observed a significant increase in average knowledge score (6.3 vs. 13.2 of 20) and skill score (8.0 vs. 34.3 of 40). Overall, a significant increase occurred in adherence to clinical standards between baseline and endline assessments (29% vs. 93%). The standards with the greatest improvements were identification and management of eclampsia/preeclampsia, postpartum hemorrhage, and neonatal resuscitation. There were no significant changes over time in absolute rate of reported complications; however, referral rates from private facilities for preeclampsia and newborn sepsis identification and management declined. CONCLUSION: Our analysis indicates private facilities' adherence to quality standards and nurses' childbirth knowledge and practical skills increased during Manyata. Additional efforts are needed to ensure high-quality care during cesarean deliveries at private facilities. Future studies with rigorous design are required to evaluate the impact of this quality improvement initiative in improving pregnancy outcomes.

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

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.

Implementation of a large-scale breast cancer early detection program in a resource-constrained setting: real-world experiences from 2 large states in India.

BACKGROUND: The Breast Health Initiative (BHI) was launched to demonstrate a scalable model to improve access to early diagnosis and treatment of breast cancer. METHODS: A package of evidence-based interventions was codesigned and implemented with the stakeholders, as part of the national noncommunicable disease program, through the existing primary health care system. Data from the first 18 months of the BHI are presented. RESULTS: A total of 108,112 women received breast health education; 48% visited the health facilities for clinical breast examination (CBE), 3% had a positive CBE result, and 41% were referred to a diagnostic facility. The concordance of CBE findings between health care providers and adherence to follow-up care improved considerably, with more women visiting the diagnostic facilities and completing diagnostic evaluation within 1 month from initial screening, and with only 9% lost to follow-up. The authors observed a clinically meaningful decrease in time to complete diagnostic evaluation with biopsy, from 37 to 9 days. CONCLUSIONS: The results demonstrate the feasibility and effectiveness of implementing a large-scale, decentralized breast cancer early detection program delivered through the existing primary health care system in India.

Role of financial incentives in family planning services in India: a qualitative study.

BACKGROUND: In an effort to encourage Family Planning (FP) adoption, since 1952, the Government of India has been implementing various centrally sponsored schemes that offer financial incentives (FIs) to acceptors as well as service providers, for services related to certain FP methods. However, understanding of the role of FIs on uptake of FP services, and the quality of FP services provided, is limited and mixed. METHODS: A qualitative descriptive study was conducted in Chatra and Palamu districts of Jharkhand state. A total of 64 interviews involving multiple stakeholders were conducted. The stakeholders included recent FP acceptors or clients, FP service providers of public health facilities including Accredited Social Healthcare Activists (ASHAs), government health officials managing FP programs at the district and state level, and members of development partners supporting FP programs in Jharkhand. Data analysis included both inductive and deductive strategies. It was done using the software Atlas ti version 8. RESULTS: It has emerged that there is a strong felt need for FP among majority of the clients, and FIs may be a motivator for uptake of FP methods only among those belonging to the lower socio economic strata. For ASHAs, FI is the primary motivator for providing FP related services. There may be a tendency among them and the nurses to promote methods which have more financial incentives linked with them. There are mixed opinions on discontinuing FIs for clients or replacing them with non-financial incentives. Delays in payment of FIs to both clients and the ASHAs is a common issue and adversely effects the program. CONCLUSION: FIs for clients have limited influence on their decision to take up a FP method while different amounts of FIs for ASHAs and nurses, linked with different FP methods, may be influencing their service provision. More research is needed to determine the effect of discontinuing FI for FP services.

The role of digital clinical decision support tool in improving quality of intrapartum and postpartum care: experiences from two states of India.

BACKGROUND: Computerized clinical decision support (CDSS) -digital information systems designed to improve clinical decision making by providers - is a promising tool for improving quality of care. This study aims to understand the uptake of ASMAN application (defined as completeness of electronic case sheets), the role of CDSS in improving adherence to key clinical practices and delivery outcomes. METHODS: We have conducted secondary analysis of program data (government data) collected from 81 public facilities across four districts each in two sates of Madhya Pradesh and Rajasthan. The data collected between August -October 2017 (baseline) and the data collected between December 2019 - March 2020 (latest) was analysed. The data sources included: digitized labour room registers, case sheets, referral and discharge summary forms, observation checklist and complication format. Descriptive, univariate and multivariate and interrupted time series regression analyses were conducted. RESULTS: The completeness of electronic case sheets was low at postpartum period (40.5%), and in facilities with more than 300 deliveries a month (20.9%). In multivariate logistic regression analysis, the introduction of technology yielded significant improvement in adherence to key clinical practices. We have observed reduction in fresh still births rates and asphyxia, but these results were not statistically significant in interrupted time series analysis. However, our analysis showed that identification of maternal complications has increased over the period of program implementation and at the same time referral outs decreased. CONCLUSIONS: Our study indicates CDSS has a potential to improve quality of intrapartum care and delivery outcome. Future studies with rigorous study design is required to understand the impact of technology in improving quality of maternity care.

Evaluating the effect of strengthening nurse midwifery pre-service education in two Indian states: A single group pre - and post - intervention study.

BACKGROUND: The high focus states of India have higher maternal and neonatal mortality rates as compared to the national average. The quality of pre-service education (PSE) in nursing midwifery institutions in these states was found to be suboptimal. In 2013, Government of India implemented the PSE strengthening program across all public sector nursing midwifery institutions. The program focused on strengthening educational processes, training infrastructure, institutional management and clinical site practices by implementing a set of performance standards. OBJECTIVE: To evaluate the effect of PSE strengthening program on institutional performance and maternal neonatal health (MNH) related competences of nursing midwifery students and faculty. DESIGN: Single group pre-post intervention study. SETTINGS: 15 sampled public sector nursing midwifery institutions in the states of Madhya Pradesh and Odisha, India. PARTICIPANTS: Final-year students and faculty involved in teaching MNH subjects. METHODS: Performance of 15 sampled institutions was assessed at baseline, midline and endline using the performance standards. Additionally, competences of 232, 295 and 298 students and 64, 62 and 63 faculty members at baseline, midline and endline respectively were assessed on six MNH related practices using objective structured clinical examination (OSCE). RESULTS: None of the institutions met 70% standards during baseline. At endline, 13 of the 15 institutions met these standards. The mean OSCE scores of students and faculty at baseline was 17.1 (SD: 8.0) and 23.5 (SD: 14.3) out of 76 respectively. It significantly increased to 66.4 (SD: 8.0) and 71.1 (SD: 5.2) during the endline. The proportion of students and faculty found competent (achieved 75% in OSCE) also significantly increased from none at baseline to 91% and 98% respectively, at endline. CONCLUSION: The combination of attributes included in the PSE strengthening program may have contributed to improvements in institutional performance as well as MNH related competences of nursing midwifery students and faculty.

Acceptability and Barriers to Use of the ASMAN Provider-Facing Electronic Platform for Peripartum Care in Public Facilities in Madhya Pradesh and Rajasthan, India: A Qualitative Study Using the Technology Acceptance Model-3.

The evolving field of mobile health (mHealth) is revolutionizing collection, management, and quality of clinical data in health systems. Particularly in low- and middle-income countries (LMICs), mHealth approaches for clinical decision support and record-keeping offer numerous potential advantages over paper records and in-person training and supervision. We conducted a content analysis of qualitative in-depth interviews using the Technology Acceptance Model 3 (TAM-3) to explore perspectives of providers and health managers in Madhya Pradesh and Rajasthan, India who were using the ASMAN (Alliance for Saving Mothers and Newborns) platform, a package of mHealth technologies to support management during the peripartum period. Respondents uniformly found ASMAN easy to use and felt it improved quality of care, reduced referral rates, ensured timely referral when needed, and aided reporting requirements. The TAM-3 model captured many determinants of reported respondent use behavior, including shifting workflow and job performance. However, some barriers to ASMAN digital platform use were structural and reported more often in facilities where ASMAN use was less consistent; these affect long-term impact, sustainability, and scalability of ASMAN and similar mHealth interventions. The transitioning of the program to the government, ensuring availability of dedicated funds, human resource support, and training and integration with government health information systems will ensure the sustainability of ASMAN.

Designing a resource-stratified, phased implementation strategy for breast health care services in India.

BACKGROUND: Breast cancer is the most common cancer among women in India. Jhpiego, a not-for-profit health organization, is providing technical assistance for developing an evidence-based model of breast health care in the states of Uttar Pradesh and Jharkhand in India. METHODS: A situational assessment of breast health care services using validated tools was conducted in the 2 states. RESULTS: Findings of the assessment were presented to the Breast Health Technical Advisory Committee comprised of subject experts and government functionaries. The committee, guided by Breast Health Global Initiative resource-stratified guidelines, developed a conceptual framework for integration of breast health services into the existing health system. This conceptual framework was presented to the Technical Advisory Groups (TAGs) of the respective state governments. Each TAG then developed an operationally feasible, contextually appropriate implementation plan in alignment with the national guidelines for noncommunicable diseases. This implementation plan guided the rollout of the breast health care program in the Lucknow (Uttar Pradesh) and Ranchi (Jharkhand) districts. CONCLUSIONS: Early results from the implementation suggest that it is feasible to integrate the breast health care pathway with the ongoing National Cancer Control Program of India.

Family-centric safe motherhood approach for marginalized young married couples in rural India.

BACKGROUND: India contributes high broaden of maternal and child death globally. Over the past decade, there has been considerably improvement in maternal and child health indicator in India with intervention of national health mission. However, inequalities in basic health outcomes, lack of access and poor quality of medical care still exists. Marginalized, poor, and rural populations have noticeable low health indicators. AIM: The aim of this study isto describe the design, implementation, and baseline findings of "family centric safe motherhood approach among marginalized young married couples in rural India. SETTINGS AND DESIGN: To establish a baseline, we completed 1347 interviews in 100 villages from two rural blocks (Balotra and Siwana) of Rajasthan, India. METHODS: The progress of health outcomes is to be measured by set of indicators. Based on results, intervention package was developed. STATISTICAL ANALYSIS USED: The data were entered in SPSS 22 version. Bivariate analysis was performed. RESULTS: Around two-fifth of couples (42.9%) used any temporary contraceptive method. Although the percentage of antenatal care (ANC) in the first trimester (77%) was high, but only 10% of them received three or more ANC check-up. Institutional delivery was reported to be 64.5%. Less than 10% of the women reported that they received quality of ANC (7.1%) and 32.7% was tetanus vaccination coverage in the study area. Aware of any contraceptive method was above 92.7% and 64.3% of respondents have an intention to use any family planning method in the next 12 months. CONCLUSIONS: These data provide a baseline of crucial information for evidence-based action on maternal and child health at rural inaccessible villages. Our baseline estimates will facilitate the evaluation of interventions and feasibility of scaling up of intervention.

Comparative Estimates of Crude and Effective Coverage of Measles Immunization in Low-Resource Settings: Findings from Salud Mesoamérica 2015.

Timely and accurate measurement of population protection against measles is critical for decision-making and prevention of outbreaks. However, little is known about how survey-based estimates of immunization (crude coverage) compare to the seroprevalence of antibodies (effective coverage), particularly in low-resource settings. In poor areas of Mexico and Nicaragua, we used household surveys to gather information on measles immunization from child health cards and caregiver recall. We also collected dried blood spots (DBS) from children aged 12 to 23 months to compare crude and effective coverage of measles immunization. We used survey-weighted logistic regression to identify individual, maternal, household, community, and health facility characteristics that predict gaps between crude coverage and effective coverage. We found that crude coverage was significantly higher than effective coverage (83% versus 68% in Mexico; 85% versus 50% in Nicaragua). A large proportion of children (19% in Mexico; 43% in Nicaragua) had health card documentation of measles immunization but lacked antibodies. These discrepancies varied from 0% to 100% across municipalities in each country. In multivariate analyses, card-positive children in Mexico were more likely to lack antibodies if they resided in urban areas or the jurisdiction of De Los Llanos. In contrast, card-positive children in Nicaragua were more likely to lack antibodies if they resided in rural areas or the North Atlantic region, had low weight-for-age, or attended health facilities with a greater number of refrigerators. Findings highlight that reliance on child health cards to measure population protection against measles is unwise. We call for the evaluation of immunization programs using serological methods, especially in poor areas where the cold chain is likely to be compromised. Identification of within-country variation in effective coverage of measles immunization will allow researchers and public health professionals to address challenges in current immunization programs.

Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015.

BACKGROUND: Individual income and poverty are associated with poor health outcomes. The poor face unique challenges related to access, education, financial capacity, environmental effects, and other factors that threaten their health outcomes. METHODS: We examined the variation in the health outcomes and health behaviors among the poorest quintile in eight countries of Mesoamerica using data from the Salud Mesomérica 2015 baseline household surveys. We used multivariable logistic regression to measure the association between delivering a child in a health facility and select household and maternal characteristics, including education and measures of wealth. RESULTS: Health indicators varied greatly between geographic segments. Controlling for other demographic characteristics, women with at least secondary education were more likely to have an in-facility delivery compared to women who had not attended school (OR: 3.20, 95 % confidence interval [CI]: 2.56-3.99, respectively). Similarly, women from households with the highest expenditure were more likely to deliver in a health facility compared to those from the lowest expenditure households (OR 3.06, 95 % CI: 2.43-3.85). Household assets did not impact these associations. Moreover, we found that commonly-used definitions of poverty do not align with the disparities in health outcomes observed in these communities. CONCLUSIONS: Although poverty measured by expenditure or wealth is associated with health disparities or health outcomes, a composite indicator of health poverty based on coverage is more likely to focus attention on health problems and solutions. Our findings call for the public health community to define poverty by health coverage measures rather than income or wealth. Such a health-poverty metric is more likely to generate attention and mobilize targeted action by the health communities than our current definition of poverty.

Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings.

BACKGROUND: Health has improved markedly in Mesoamerica, the region consisting of southern Mexico and Central America, over the past decade. Despite this progress, there remain substantial inequalities in health outcomes, access, and quality of medical care between and within countries. Poor, indigenous, and rural populations have considerably worse health indicators than national or regional averages. In an effort to address these health inequalities, the Salud Mesoamérica 2015 Initiative (SM2015), a results-based financing initiative, was established. METHODS: For each of the eight participating countries, health targets were set to measure the progress of improvements in maternal and child health produced by the Initiative. To establish a baseline, we conducted censuses of 90,000 households, completed 20,225 household interviews, and surveyed 479 health facilities in the poorest areas of Mesoamerica. Pairing health facility and household surveys allows us to link barriers to care and health outcomes with health system infrastructure components and quality of health services. RESULTS: Indicators varied significantly within and between countries. Anemia was most prevalent in Panama and least prevalent in Honduras. Anemia varied by age, with the highest levels observed among children aged 0 to 11 months in all settings. Belize had the highest proportion of institutional deliveries (99%), while Guatemala had the lowest (24%). The proportion of women with four antenatal care visits with a skilled attendant was highest in El Salvador (90%) and the lowest in Guatemala (20%). Availability of contraceptives also varied. The availability of condoms ranged from 83% in Nicaragua to 97% in Honduras. Oral contraceptive pills and injectable contraceptives were available in just 75% of facilities in Panama. IUDs were observed in only 21.5% of facilities surveyed in El Salvador. CONCLUSIONS: These data provide a baseline of much-needed information for evidence-based action on health throughout Mesoamerica. Our baseline estimates reflect large disparities in health indicators within and between countries and will facilitate the evaluation of interventions and investments deployed in the region over the next three to five years. SM2015's innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Results of the Global Youth Tobacco Survey and implementation of the WHO Framework Convention on Tobacco Control in the WHO Eastern Mediterranean Region (EMR) countries.

UNLABELLED: We used Global Youth Tobacco Survey (GYTS) data collected over time to monitor articles of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) in WHO Eastern Mediterranean Region (EMR). METHODS: The GYTS is a school-based survey, conducted in 23 countries in WHO EMR countries from 1999-2008. RESULTS: The prevalence of current smokeless tobacco use was high compared to cigarette use in all countries. In general, the following changes were observed between baseline and repeated surveys: in five countries fewer youth supported a ban on smoking in public places. In four countries more youth saw actors smoking on TV and were exposed to second-hand smoke (SHS) outside of home. Fewer youth were offered free cigarettes in ten countries; in eight countries youth saw less advertisement on TV; in seven countries youth had fewer items with a tobacco logo, discussed more reasons for smoking and dangers of smoking, and were less exposed to SHS at home; in six countries youth saw less advertisement at sports events. CONCLUSION: The GYTS data can be used for monitoring, evaluation of national tobacco control plans and defining future directions for tobacco control.

Results of the Global Youth Tobacco Survey and implementation of WHO Framework Convention on Tobacco Control in former Soviet Union countries.

OBJECTIVES: We used data from the Global Youth Tobacco Survey (GYTS) to monitor articles of the World Health Organization Framework Convention on Tobacco Control in Former Soviet Union (FSU) countries. METHODS: The GYTS is a school-based survey, which uses a two-stage sample design to produce representative, independent, cross-sectional estimates. The GYTS was conducted in 10 out of 12 FSU countries from 1999 to 2008. RESULTS: The prevalence of ever smoking and current smoking, smoking initiation, and exposure to second-hand smoking decreased over time. Overall, willingness to stop smoking, supporting smoking bans, and receiving information about the dangers of smoking increased over time. CONCLUSIONS: Overall, our study shows that FSU countries had positive changes in tobacco-use prevalence and perception among youth over time. Our findings should be used as baseline measures for future tobacco-control interventions aimed at reducing tobacco use among youth. Moreover, our results call for the enforcement of restricting advertising for tobacco products.

Patterns of adult tobacco use in Uzbekistan.

BACKGROUND: Little is known about the prevalence of tobacco use in Uzbekistan, a country targeted intensively by the international tobacco industry. METHODS: A national household survey elicited information about cigarette smoking and nasway use (a form of smokeless tobacco). RESULTS: Prevalence of past-month smoking and nasway use among men (N=1795) was 19.6% and 22.3%, respectively, and 1.6% and 0.5% among women (N=1831). Among men, smoking was independently associated with Uzbek ethnicity, urban residence, age and occupation; nasway use was associated with rural residence, age, being married and occupation. CONCLUSIONS: The smoking rate in Uzbekistan remains low relative to neighbouring countries, perhaps due to widespread use of cheaper nasway. These findings establish a baseline for future surveys and highlight the importance of smokeless tobacco in assessing overall consumption.