Reducing caesarean section rate in an urban hospital serving women attending privately in India - a quality improvement initiative.

BACKGROUND: In line with global trends, India has witnessed a sharp rise in caesarean section (CS) deliveries, especially in the private sector. Despite the urgent need for change, there are few published examples of private hospitals that have successfully lowered their CS rates. Our hospital, serving private patients too, had a CS rate of 79% in 2001. Care was provided by fee-for-service visiting consultant obstetricians without uniform clinical protocols and little clinical governance. Consultants attributed high CS rate to case-mix and maternal demand and showed little inclination for change. We attempted to reduce this rate with the objective of improving the quality of our care and demonstrating that CS could be safely lowered in the private urban Indian healthcare setting. METHODS: We hired full-time salaried consultants and began regular audit of CS cases. When this proved inadequate, we joined an improvement collaborative in 2011 and dedicated resources for quality improvement. We adopted practice guidelines, monitored outcomes by consultant, improved labour ward support, strengthened antenatal preparation, and moved to group practice among consultants. RESULTS: Guidelines ensured admissions in active labour and reduced CS (2011 to 2016) for foetal heart rate abnormalities (23 to 5%; p < 0.001) and delayed progress (19 to 6%; p < 0.001) in low-risk first-birth women. Antenatal preparation increased trial of labour, even among women with prior CS (28 to 79%; p < 0.001). Group practice reduced time pressure and stress, with a decline in CS (52 to 18%; p < 0.001) and low-risk first-birth CS (48 to 12%; p < 0.001). Similar CS rates were maintained in 2017 and 2018. Measures of perinatal harm including post-partum haemorrhage, 3rd-4th degree tears, shoulder dystocia, and Apgar < 7 at 5 min were within acceptable ranges (13, 3, 2% and 3 per thousand respectively in 2016-18,). CONCLUSIONS: It is feasible to substantially reduce CS rate in private healthcare setting of a middle-income country like India. Ideas such as moving to full-time attachment of consultants, joining a collaborative, improving labour ward support, providing resources for data collection, and perseverance could be adopted by other hospitals in their own journey of moving towards a medically justifiable CS rate.

'If I do 10-15 normal deliveries in a month I hardly ever sleep at home.' A qualitative study of health providers' reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India.

BACKGROUND: Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. We present providers' perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend. METHODS: Fourteen in-depth interviews were conducted with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad. RESULTS: Respondents were of the common view that private sector caesarean rates were unreasonably high and perceived time and doctors' convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more support, from either well-trained midwives and junior staff or using a 'shared practice' model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers' caesarean rates. CONCLUSIONS: Commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the 'safe' option have re-defined caesareans as the new 'normal', even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates.

Quality of care, maternal attitude and common physician practices across the socio-economic spectrum: a community survey.

PURPOSE: To evaluate the quality of maternity care, women's perception of the quality of care and factors influencing the same in Delhi. METHOD: Women who delivered a viable live birth in the past 6 months were recruited from South Delhi by a two-stage stratified cluster randomized sampling. In stage 1, two colonies each from three predefined economic strata (high-, middle- or low-income areas) were selected by simple-random sampling. In stage 2, a sequential house-to-house survey was conducted in each selected colony. The information was collected by interview and review of medical records. RESULTS: A total of 5,279 houses were screened to recruit 249 subjects. Several disparities were notable. 25.2 and 14.8% of the women from middle- and lower-income areas delivered by cesarean section, while the rate was 53.6% in the higher-income areas. In women from lower-income areas urine testing was not done in 76.9% and blood sugar was not tested in 18.2%, while in high-income areas 44.6% had > or =10 antenatal visits and 87.8% had > or =3 ultrasounds. Of the women who experienced labor only 11% received support from a friend or family member, 4.4% received any medicine/measures for pain relief, 44.3% were allowed to walk and 14.6% were catheterized. CONCLUSION: Health care providers are unable to meet national minimal care standards in poorer areas, while over investigation and over intervention appear prevalent in higher-income areas. This warrants a more representative evaluation to enable more equitable and evidence-based practice.

The development of 'Quality of Life Instrument for Indian Diabetes patients (QOLID): a validation and reliability study in middle and higher income groups.

PURPOSE: To develop a reliable and valid quality of life questionnaire for Indian patients with diabetes. METHODS: A draft of 75 questions was prepared on the basis of expert opinion, focus group discussions, review of existing literature and detailed semi-structured interviews of patients with diabetes with the intention of including all aspects of diabetes-specific and quality of life considered relevant by patients and care providers to enable constrict validity. A Stage 2 questionnaire was then prepared with 13 domains and 54 items (questions) after expert panel review for obvious irrelevance and duplication of issues. It was administered to 150 participants visiting a diabetes center at New Delhi. Factor analysis was done using principal component method with varimax rotation. Reliability analysis was done by calculating Cronbach's Alpha. For evaluating concordant validity the questionnaire was co-administered with DQL-CTQ to 30 participants. The discriminant validity of the questionnaire was tested using 't' test for metabolic control, co-morbidities, insulin use and gender. RESULTS: Using principal component method 8 domains were identified on the basis of an apriori hypothesis and the scree plot. These 8 domains explained 49.9% of the total variation. 34 items (questions) were selected to represent these domains on the basis of extraction communality, factor loading, inter-item and item-total correlations. The final questionnaire has an Overall Cronbach's Alpha value of 0.894 (subscale- 0.55 to 0.85) showing high internal consistency. The questionnaire showed good concordance (product moment correlation 0.724; p = 0.001; subscale correlation - 0.457 to 0.779) with the DQL-CTQ. The overall standardized questionnaire score showed good responsiveness to metabolic control and co-morbidities establishing discriminant validity. CONCLUSION: The final version of questionnaire with 8 domains and 34 items is a reliable and valid tool for assessment of quality of life of Indian patients with diabetes.

Direct cost of maternity-care services in South Delhi: a community survey.

The study was conducted to estimate the direct maternity-care expense for women who recently delivered in South Delhi and to explore its sociodemographic associations. A survey was conducted using the two-stage cluster-randomized sampling technique. Two colonies each from high-, middle- and low-income areas were selected by simple random sampling, followed by a house-to-house survey in each selected colony. Information was collected by recall of healthcare expenses for mother and child. In total, 249 subjects (of 282 eligible) were recruited. The mean expense for a normal vaginal delivery (n=182) was US$ 370.7, being much higher in a private hospital (US$ 1,035) compared to a government hospital (US$ 61.1) or a delivery in the home (US$ 55.3). Expenses for a caesarean delivery (n=67) were higher (US$ 1,331.1). Expenses for the lowest-income groups were approximately 10% of their annual family income at government facilities and approximately 26% at private hospitals. The direct maternity expense is high for large subsections of the population.

An exploratory study to evaluate the utility of an adapted Mother Generated Index (MGI) in assessment of postpartum quality of life in India.

BACKGROUND: Given the postulated advantages of mother generated index (MGI) in incorporating the patients' viewpoint and in the absence of a validated India specific postpartum quality of life assessment tool we proposed to evaluate the utility of an adapted Mother-Generated-Index in assessing postpartum quality of life (PQOL) in India. METHODS: The study was integrated into a community survey conducted in one district of Delhi by two-stage cluster randomized sampling to recruit women who delivered in the last 6 months. PQOL was assessed using MGI. Physical morbidity and Edinburgh- postnatal-depression-scale (EPDS) were also recorded for validation purposes. RESULTS: All subjects (249 of 282 eligible) participating in the survey were approached for the MGI evaluation which could be administered to 195 subjects due to inadequate comprehension or refusal of consent. A trend towards lower scores in lower socioeconomic stratum was observed (Primary index score-2.9, 3.7 and 4.0 in lower, middle and higher strata; Secondary Index Score-2.6, 3.2 and 3.0 in lower, middle and higher strata). 59.4% mothers had scores suggestive of possible depression (EPDS; n = 172). Primary index score had a good correlation with validator scores like EPDS (p = 0.024) and number of physical problems (p = 0.022) while the secondary index score was only associated with EPDS score (p = 0.020). CONCLUSION: The study documents that the MGI, with its inherent advantages, is a potentially useful tool for postpartum quality of life evaluation in India especially in the absence of an alternative pre-validated tool.

Quality of diabetes care in the middle- and high-income group populace: the Delhi Diabetes Community (DEDICOM) survey.

OBJECTIVE: We sought to evaluate the quality of care in known diabetic patients from the middle- and high-income group populace of Delhi. RESEARCH DESIGN AND METHODS: A cross-sectional survey was conducted using a probability proportionate to size (systematic), two-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit a minimum of 25 subjects (known diabetes >/= 1 year; aged 35-65 years) per area. Data were collected by interview, by blood sampling, and from medical records. RESULTS: A total of 819 subjects (of 1,153 eligible) were enrolled from 20,666 houses. In total, 13.0% (95% CI 9.6-17.3) of the patients had an HbA(1c) (A1C) estimation and 16.2% (13.5-19.4) had a dilated eye examination in the last year, 32.1% (27.5-36.6) had serum cholesterol estimation in the last year, and 17.5% (14.2-21.5) were taking aspirin. An estimated 42.0% (37.7-46.2) had an A1C value >8%, 40.6% (36.5-44.7) had an LDL cholesterol level >130 mg/dl, and 63.2% (59.6-66.6) had blood pressure levels >140/90 mmHg. CONCLUSIONS: A wide gap exists between practice recommendations and delivery of diabetes care in Delhi.

The Laparoscopic Re-Exploration in the Management of the Gallbladder Remnant and the Cystic Duct Stump Calculi.

INTRODUCTION: The gallbladder remnant and the cystic duct stump calculi are uncommon causes of post-cholecystectomy syndrome. Re-exploration is usually needed in the cases where symptom persists. Very few case series and reports are available regarding laparoscopic re-exploration. AIM: To assess the safety and feasibility of Laparoscopic re-exploration in the cases of gallbladder remnant and cystic duct stump calculi leading to post cholecystectomy syndromes. MATERIALS AND METHODS: In this study, laparoscopic re-explorations was done in 22 patients in which 17 patients had gallbladder remnant calculi and 5 had cystic duct stump calculi. The study considered parameters like the operative time, conversion rate, post-operative complications, post-operative hospital stay and mortality in these patients. The duration of study was 15 years and the data was retrospectively reviewed. RESULTS: The median operating time was 83 minutes (range 51 to 134 minutes). Only one patient had conversion to open surgery. In postoperative period two patients had bile leak. They were managed conservatively and leak subsided in 8 and 11 days respectively. One patient had postoperative bleeding not requiring blood transfusion. There was no major complication requiring further intervention and no mortality. Patients were discharged on median day 4 (range 2-11) after the surgery. Patients were followed up every 3 months for one year. However, out of these three patients did not turn up for follow-up. CONCLUSION: In expert hands laparoscopic re-exploration of the gallbladder remnant/cystic duct stump calculi can be performed within a reasonable operating time. The conversion to conventional re-exploration rate was very low with minimal post-operative complications and shorter hospital stay.

Laparoscopic Repair of Congenital Diaphragmatic Hernia in Adults.

Background, Aims, and Objectives. Congenital diaphragmatic hernia typically presents in childhood but in adults is extremely rare entity. Surgery is indicated for symptomatic and asymptomatic patients who are fit for surgery. It can be done by laparotomy, thoracotomy, thoracoscopy, or laparoscopy. With the advent of minimal access techniques, the open surgical repair for this hernia has decreased and results are comparable with early recovery and less hospital stay. The aim of this study is to establish that laparoscopic repair of congenital diaphragmatic hernia is a safe and effective modality of surgical treatment. Materials and Methods. A retrospective study of laparoscopic diaphragmatic hernia repair done during May 2011 to Oct 2014. Total n = 13 (M/F: 11/2) cases of confirmed diaphragmatic hernia on CT scan, 4 cases Bochdalek hernia (BH), 8 cases of left eventration of the diaphragm (ED), and one case of right-sided eventration of the diaphragm (ED) were included in the study. Largest defect found on the left side was 15 × 6 cm and on the right side it was 15 × 8 cm. Stomach, small intestine, transverse colon, and omentum were contents in the hernial sac. The contents were reduced with harmonic scalpel and thin sacs were usually excised. The eventration was plicated and hernial orifices were repaired with interrupted horizontal mattress sutures buttressed by Teflon pieces. A composite mesh was fixed with nonabsorbable tackers. All patients had good postoperative recovery and went home early with normal follow-up and were followed up for 2 years. Conclusion. The laparoscopic repair is a safe and effective modality of surgical treatment for congenital diaphragmatic hernia in experienced hands.