Can home visits for early child development be implemented with sufficient coverage and quality at scale? Evidence from the SPRING program in India and Pakistan.

Introduction: There is limited evidence from low and middle-income settings on the effectiveness of early child development interventions at scale. To bridge this knowledge-gap we implemented the SPRING home visiting program where we tested integrating home visits into an existing government program (Pakistan) and employing a new cadre of intervention workers (India). We report the findings of the process evaluation which aimed to understand implementation. Methods and materials: We collected qualitative data on acceptability and barriers and facilitators for change through 24 in-depth interviews with mothers; eight focus group discussions with mothers, 12 with grandmothers, and 12 with fathers; and 12 focus group discussions and five in-depth interviews with the community-based agents and their supervisors. Results: Implementation was sub-optimal in both settings. In Pakistan issues were low field-supervision coverage and poor visit quality related to issues scheduling supervision, a lack of skill development, high workloads and competing priorities. In India, issues were low visit coverage - in part due to employing new workers and an empowerment approach to visit scheduling. Coaching caregivers to improve their skills was sub-optimal in both sites, and is likely to have contributed to caregiver perceptions that the intervention content was not new and was focused on play activities rather than interaction and responsivity - which was a focus of the coaching. In both sites caregiver time pressures was a key reason for low uptake among families who received visits. Discussion: Programs need feasible strategies to maximize quality, coverage and supervision including identifying and managing problems through monitoring and feedback loops. Where existing community-based agents are overstretched and system strengthening is unlikely, alternative implementation strategies should be considered such as group delivery. Core intervention ingredients such as coaching should be prioritized and supported during training and implementation. Given that time and resource constraints were a key barrier for families a greater focus on communication, responsivity and interaction during daily activities could have improved feasibility.

'Good health means being mentally, socially, emotionally and physically fit': women's understanding of health and ill health during and after pregnancy in India and Pakistan: a qualitative study.

OBJECTIVE: To explore what women consider health and ill health to be, in general, and during and after pregnancy. Women's views on how to approach screening for mental ill health and social morbidities were also explored. SETTINGS: Public hospitals in New Delhi, India and Islamabad, Pakistan. PARTICIPANTS: 130 women attending for routine antenatal or postnatal care at the study healthcare facilities. INTERVENTIONS: Data collection was conducted using focus group discussions and key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis identified emerging themes. RESULTS: Women are aware that maternal health is multidimensional and linked to the health of the baby. Concepts of good health included: nutritious diet, ideal weight, absence of disease and a supportive family environment. Ill health consisted of physical symptoms and medical disease, stress/tension, domestic violence and alcohol abuse in the family. Reported barriers to routine enquiry regarding mental and social ill health included a small number of women's perceptions that these issues are 'personal', that healthcare providers do not have the time and/or cannot provide further care, even if mental or social ill health is disclosed. CONCLUSIONS: Women have a good understanding of the comprehensive nature of health and ill health during and after pregnancy. Women report that enquiry regarding mental and social ill health is not part of routine maternity care, but most welcome such an assessment. Healthcare providers have a duty of care to deliver respectful care that meets the health needs of women in a comprehensive, integrated, holistic manner, including mental and social care. There is a need for further research to understand how to support healthcare providers to screen for all aspects of maternal morbidity (physical, mental and social); and for healthcare providers to be enabled to provide support and evidence-based care and/or referral for women if any ill health is disclosed.

Is home delivery really preferred? a mixed-methods national study in Pakistan.

BACKGROUND: Pakistan has a high maternal mortality ratio and a low rate of skilled birth attendants (SBAs). To address these two important issues, the Pakistan Maternal Newborn and Child Health (MNCH) programme launched the community midwives (CMW) initiative in 2007. CMWs are supposed to conduct deliveries at community level outside health facilities. The purpose of the current study is to document perceptions about CMWs and preferences for birthing place. METHODS: A mixed-methods study was conducted covering four provinces. For the quantitative survey, households were selected through a multistage sampling technique from rural districts. In 1,450 rural households, preferences of respondents about CMW-conducted deliveries were recorded. Qualitative data were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs) with women, community elders, CMWs, and MNCH programme personnel in the same areas where the quantitative study was carried out. In both studies, preferences and the reasons behind particular respondent preferences were recorded. Frequencies of responses were analysed for the quantitative study. Narration and quotes from various types of participants were used to present findings from FGDs and IDIs. RESULTS: In the quantitative study, 42% of respondents expressed a preference for birthing stations, i.e. a place where CMWs conduct deliveries; 22% preferred home deliveries. Birthing stations were favoured because of the availability of space and equipment and the proximity to women's homes. These findings were largely supported by the qualitative component, although a range of views about where a CMW should conduct deliveries were expressed. CONCLUSION: Insights into where CMWs might provide delivery services were obtained through this study. Birthing stations may be an option as a preferred location for delivery care and should be considered as part of Pakistan's national CMW programme.