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.

A comprehensive mobile application tool for disease surveillance, workforce management and supply chain management for Malaria Elimination Demonstration Project.

BACKGROUND: Health care technologies are now offering accountability, quality, robustness, and accuracy in disease surveillance and health care delivery programmes. With the advent of mobile hand-held devices, these technologies have become more accessible and adaptable for use by field staff working in remote areas. The Malaria Elimination Demonstration Project started collection of data and conduct of routine operations using paper-based reporting systems. Observing the need for a robust and quality digital mobile application, a comprehensive mobile application tool was developed that allowed the project to conduct disease surveillance, workforce management and supply chain management. METHODS: In June 2017, the project conceptualized a comprehensive mobile application tool in the local language (Hindi) for disease surveillance, human resources management, and supply chain management. The tool is also available in English. Solution for Community Health-workers (SOCH) mobile app is an android native application developed using android SDK and web-based tool using MVC.net framework. Construction of the application started in November 2017 and rolled out its pilot in April 2018, followed by pan-district roll out in July 2018. The application uses self-validation tools to ensure high level of data quality and integrity. RESULTS: The software is available in android based hand-held devices and web-screens with built-in data analytical capabilities. Using SOCH, the project has now successfully digitized its routine surveillance, attendance, tour plans, supply chain management components. The project has documented a reduction in 91% indigenous cases in the district, 60% improvement in stock accountability, and 99.6% accuracy in data collected through the mobile application. CONCLUSION: SOCH is an excellent and user-friendly tool, which can be customized for any public health management programme. The system ensures accountability and data robustness, which is needed for malaria elimination efforts throughout the country. The mobile application can be adapted for English or any other Indian or international language for use for malaria or any other disease surveillance and control programme. Another expansion feature of this mobile application is incorporation of indicators for Indoor Residual Spraying (IRS), Long-Lasting Insecticidal Nets (LLINs), and minor engineering by the residents of community under surveillance. The authors believe that it would be highly desirable and appropriate for an international organization, such as the World Health Organization (WHO), to conduct an independent comparison of all available mobile e-surveillance tools, so that a high-performing and globally suitable system can be selected for use in malaria elimination programmes. The Foundation of Disease Elimination and Controlof India has decided to make the SOCH mobile application available to anyone who would like to use it for disease surveillance and health care programmes.

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.

Study design and operational framework for a community-based Malaria Elimination Demonstration Project (MEDP) in 1233 villages of district Mandla, Madhya Pradesh.

BACKGROUND: In the past decade substantial reduction in malaria morbidity and mortality has been observed through well-implemented case management and vector control strategies. India has also achieved a significant reduction in malaria burden in 2018 and has committed to eliminate malaria by 2030. The Mandla Malaria Elimination Demonstration Project (MEDP) was started in 2017 in 1233 villages of District Mandla to demonstrate malaria elimination in a tribal district with hard-to-reach areas was possible using active and passive surveillance, case management, vector control, and targeted information, education and communication campaigns. An operational plan was developed to strengthen the existing surveillance and malaria elimination systems, through fortnightly active case detection to ensure that all cases including those that are introduced into the communities are rapidly identified and treated promptly. The plan also focused on the reduction of human-mosquito contact through the use of Long-Lasting Insecticial Nets (LLINs) and Indoor Residual Spray (IRS). The operational plan was modified in view of the present COVID-19 pandemic by creating systems of assistance for the local administration for COVID-related work while ensuring the operational integrity of malaria elimination efforts. RESULTS: The use of MEDP study design and operational plan, with its built-in management control systems, has yielded significant (91%) reduction of indigenous cases of malaria during the period from June 2017 to May 2020. The malaria positivity rate was 0.33% in 2017-18, 0.13% in 2018-19, and 0.06% in 2019-20. Mass screening revealed 0.18% malaria positivity in September-October 2018, followed by 0.06% in June 2019, and 0.03% in December 2019, and these were mostly asymptomatic cases in the community. The project has been able to sustain the gains of the past three years during the ongoing COVID-19 pandemic. CONCLUSION: This paper provides the study design and the operational plan for malaria elimination in a high-burden district of Central India, which presented difficulties of hard to reach areas, forest malaria, and complex epidemiology of urban and rural malaria. The lessons learned could be used for malaria elimination efforts in rest of the country and other parts of South Asia with comparable demography and epidemiology.

Effectiveness of the WHO SCC on improving adherence to essential practices during childbirth, in resource constrained settings.

BACKGROUND: India accounts for 27 % of world's neonatal deaths. Although more Indian women deliver in facilities currently than a decade ago, early neonatal mortality has not declined, likely because of insufficient quality of care. The WHO Safe Childbirth Checklist (SCC) was developed to support health workers to perform essential practices known to reduce preventable maternal and new-born deaths around the time of childbirth. Despite promising early research many outstanding questions remain about effectiveness of the SCC in low-resource settings. METHODS: In collaboration with the Ministry of Health SCC was modified for Indian context and introduced in 101 intervention facilities in Rajasthan, India and 99 facilities served as comparison to study if it reduces mortality. This Quasi experimental Observational intervention-comparison was embedded in this larger program to test whether a program for introduction of SCC with simple implementation package was associated with increased adherence to 28 evidence-based practices. This study was conducted in 8 intervention and 8 comparison sites. Program interventions to promote appropriate use of the SCC included orienting providers to the checklist, modest modifications of the SCC to promote provider uptake and accountability, ensuring availability of essential supplies, and providing supportive supervision for helping providers in using the SCC. RESULTS: The SCC was used by providers in 86 % of 240 deliveries observed in the eight intervention facilities. Providers in the intervention group significantly adhered to practices included in the SCC than providers in the comparison group controlling for baseline scores and confounders. Women delivering in the intervention facilities received on an average 11.5 more of the 28 practices included compared with women in the comparison facilities. For selected practices provider performance in the intervention group increased as much as 93 % than comparison sites. CONCLUSION: Use of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.