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.

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.

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.

Women's experience with postpartum intrauterine contraceptive device use in India.

BACKGROUND: Postpartum intrauterine contraceptive devices (PPIUCD) are increasingly included in many national postpartum family planning (PPFP) programs, but satisfaction of women who have adopted PPIUCD and complication rates need further characterization. Our specific aims were to describe women who accepted PPIUCD, their experience and satisfaction with their choice, and complication of expulsion or infection. METHODS: We studied 2,733 married women, aged 15-49 years, who received PPIUCD in sixteen health facilities, located in eight states and the national capital territory of India, at the time of IUCD insertion and six weeks later. The satisfaction of women who received IUCD during the postpartum period and problems and complications following insertion were assessed using standardized questionnaires. RESULTS: Mean (SD) age of women accepting PPIUCD was 24 (4) years. Over half of women had parity of one, and nearly one-quarter had no formal schooling. Nearly all women (99.6%) reported that they were satisfied with IUCD at the time of insertion and 92% reported satisfaction at the six-week follow-up visit. The rate of expulsion of IUCD was 3.6% by six weeks of follow-up. There were large variations in rates of problems and complications that were largely attributable to the individual hospitals implementing the study. CONCLUSIONS: Women who receive PPIUCD show a high level of satisfaction with this choice of contraception, and the rates of expulsion were low enough such that the benefits of contraceptive protection outweigh the potential inconvenience of needing to return for care for that subset of women.

One-year continuation of postpartum intrauterine contraceptive device: Findings from a prospective cohort study in India.

OBJECTIVE(S): To estimate continuation rates for postpartum intrauterine contraceptive device (PPIUD) at 6 weeks, 6 months and 1-year within existing programs in an under-resourced setting, and to identify determinants of discontinuation, removal and expulsion. STUDY DESIGN: We used a prospective cohort design and enrolled recent PPIUD adopter women across 100 public healthcare facilities in Odisha and Chhattisgarh, India. We collected their socio-demographic information and followed them up telephonically at 6 weeks, 6 months and 1 year for complications and continuation status. We assessed PPIUD continuation rates and factors associated with PPIUD discontinuation, removal, and expulsion using Cox proportional hazards modelling. RESULTS: We enrolled 916 participants (579 (63.2%) from Odisha and 337 (36.8%) from Chhattisgarh). The continuation rate of PPIUD was 88.7% at 6 weeks, 74.8% at 6 months 60.1% at one year. Once discontinued, chances of not opting for any family planning method was high (up to 81.2%). Participants with education of 6th to 12th class and those experiencing complications (pain abdomen, bleeding and discharge per vaginum) were more likely to remove the IUD with adjusted hazard ratio of 1.82 (95% CI: 1.18-2.79) and 4.39 (95% CI: 3.25-5.93) respectively. For expulsion, we did not find any factor that was statistically significant. CONCLUSION(S): PPIUD continuation rates declined considerably after the initial 6 weeks. Counselling and follow-up services for managing complications must be strengthened, especially in the first 6 weeks of PPIUD insertion, to enhance and sustain programmatic impact. IMPLICATIONS: Our findings emphasize on the need to strengthen client counseling and follow-up for management of complications, especially in the first 6 weeks of insertion of PPIUDs. Ongoing programs need to address comprehensive capacity building efforts in this regard.

Quasi-experimental Study of Systematic Screening for Family Planning Services among Postpartum Women Attending Village Health and Nutrition Days in Jharkhand, India.

BACKGROUND: Systematic screening helps increase family planning uptake through integration with other services, including immunization. Though successfully demonstrated at health facilities, this strategy has not been demonstrated in communities. This study assessed the effectiveness of systematic screening to increase postpartum family planning use during community health days in India without adversely affecting immunization services. METHODS: The study was conducted during 180 individual Village Health and Nutrition Days in Jharkhand, India. All health workers were trained in postpartum family planning counseling. Intervention providers were also trained in systematic screening. 217 postpartum women aged 15-49 years participated in baseline and endline exit interviews and routine service statistics were analyzed from 2,485 facility visits at affiliated health centers. RESULTS: No difference in family planning service use was found in the intervention group, but significantly fewer interviewed women reported receiving family planning services at endline in the comparison group (p = 0.014). Family planning acceptance at affiliated health centers increased significantly in intervention areas (p < 0.001) but not in comparison areas, while immunization service use increased in both groups (p = 0.002 intervention, p < 0.001 comparison). CONCLUSIONS: The use of the postpartum systematic screening tool appears to increase acceptance of family planning services when integrated with community-based services in Jharkhand.