Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Post-tonsillectomy pain: Different modes of pain relief.

Sixty patients aged 15 to 40 years of either sex, American Society of Anaesthesiologists (ASA) grade I and II, undergoing tonsillectomy, were randomly allocated to receive either preroperative intramuscular diclofenac sodium(group A) or pre- incisional bilateral infiltration of bupivacaine in the peritonsillar fossa (group B) or post operative Trunscutaneous Electric Nerve Stimulation - TENS (group C) at fixed time intervals. Pain scores (Visual analogue scale VAS, 0- 100 mm) were assessed at rest and on deglutition at 1,3,6,9,12 and 24 hours after surgery. Pentazocine 1actale 15 mg IV was given as rescue analgesic whenever VAS estimation was more than 30 mm at rest (not deglutition). Constant incisional pain was significantly less ( p < 0.01 ANOVA) in group C after 3 hours of surgery as compared to group A and B. Similarly pain on deglutition was significantly less (p <0.01, ANOVA) in group C during the entire study period as compared to Group A and B. There was significant reduction of VAS (p< 0.01) immediately after TENS therapy at 0, 4 and 8 hours. Rescue analgesic consumption was significantly lower in TENS group. Thus, TENS seems to be an effective therapeutic modality for post tonsillectomy pain relief as compared to the other two methods.