Respectful Abortion Care initiative: How a large-scale virtual training for providers in India increased knowledge of the new 2021 Medical Termination of Pregnancy Act.

BACKGROUND: In a historic move to ensure comprehensive abortion care, India amended the 1971 Medical Termination of Pregnancy (MTP) Act in 2021, creating an unprecedented opportunity for accelerating safe, respectful, and rights-based abortion services. The Federation of Obstetric and Gynecological Societies of India (FOGSI), together with World Health Organization (WHO) India and the Ministry of Health and Family Welfare, set up a flagship initiative "Respectful Abortion Care" (RAC) to provide training to obstetricians and gynecologists on the new Act, and also address their values and biases. METHODS: Virtual training sessions were organized during the COVID-19 pandemic to disseminate the amendments made under the MTP Act and address provider values and biases. The primary focus was on private providers as they account for more than half of all abortion services in India (52.9%). The RAC modules were systematically designed and delivered by 690 Master Trainers, trained by FOGSI and WHO. RESULTS: A total of 9051 FOGSI members (22%, with 50% from private clinics) completed the RAC trainings. Pretests and post-tests were conducted for impact assessment. Significant improvement was seen on knowledge of criteria for termination of pregnancy for significant birth defects (52%-83%). The post-training survey showed a high level of commitment to promote RAC: >95% were strongly motivated to perform or assist in abortion; 89% reported that the WHO value clarification exercises were helpful in facilitating open discussions on sensitive topics in a comfortable manner; 96% expressed a strong commitment to addressing the issue of respect and confidentiality in abortion care. CONCLUSION: RAC was a unique initiative around the MTP Act amendment 2021 in India, which demonstrated that collaboration and leadership by professional associations can help motivate providers and lead to improved knowledge and commitment from public and private sector providers.

DHEERA reaching the young, a novel approach addressing gender-based violence in India.

OBJECTIVE: To understand, build capacities, give guidance, and support school-going adolescent boys and girls on gender stereotypes and violence against women (VAW) and to assess the role of educational training in improving knowledge, attitudes, and practice to stop VAW. METHODS: An educational interventional study was conducted for a period of 18 months across schools in India, involving boys and girls studying in grades 9-12. Assessment of the program's effectiveness on influencing young minds in breaking the taboos surrounding gender stereotypes and stopping VAW was completed through a pre-test and post-test, consisting of 12 scenario-based questions. RESULTS: In all, 8931 participants (64% girls and 36% boys) from 26 states in India submitted their pre-test, post-test, and feedback forms. Participants showed improved clarity and comprehension on issues surrounding VAW/gender-based violence. There was a significant improvement in the knowledge on what actions can be taken and whom to approach for cases related to VAW/gender-based violence. The post-test survey showed a high level of commitment to overcoming gender stereotyping and stopping VAW. CONCLUSION: This unique nationwide study demonstrated the effectiveness of an educational intervention that led to improved knowledge, attitude, and commitment towards stopping VAW. A large-scale program can be self-sustaining when it is embedded in the schools responsible for shaping young minds.

Critical Factors Influencing the Acceptability of Post-placental Insertion of Intrauterine Contraceptive Device: A Study in Six Public/Private Institutes in India.

OBJECTIVE: To determine critical factors and barriers to postpartum intrauterine contraceptive device (PPIUCD) use in India in order to guide programs aimed at reducing maternal and child mortality. METHODS: All pregnant women were enrolled for contraception counseling during their visit to the antenatal outpatient clinic. Women who opted for PPIUCDs were enrolled in the study and offered PPIUCD insertion, irrespective of mode of delivery. Those who withdrew consent when in labor or soon after delivery, experienced severe bleeding, or exhibited unstable vital signs were excluded, as were febrile women and those diagnosed with chorioamnionitis. RESULTS: A total of 66,508 women were enrolled in the study. 86.1% indicated they discussed family planning options with their partners/husbands before making a decision. 178 respondents (0.3%) could not mention one advantage of PPIUCDs, while 23.1% could not mention one disadvantage. 13.9% of the women withdrew consent. Family member objections (43.44%), husband/partner objection (27.94%), and deciding on another method (15.59%) were the main reasons for consent withdrawal. CONCLUSIONS: Awareness of PPIUCDs is not a limiting factor in women's consent to PPIUCD insertion. As a woman's decision to use a PPIUCD is significantly influenced by family members and her partner/husband, awareness initiatives that target these populations should be considered.

Factors influencing the likelihood of acceptance of postpartum intrauterine devices across four countries: India, Nepal, Sri Lanka, and Tanzania.

OBJECTIVE: To examine the factors that positively influenced the likelihood of accepting provision of postpartum intrauterine devices (PPIUDs) across four countries: Sri Lanka, Nepal, Tanzania, and India. METHODS: Healthcare providers were trained across 24 facilities in counselling and insertion of PPIUDs as part of a large multicountry study. Women delivered were asked to take part in a 15-minute face-to-face structured interview conducted by in-country data collection officers prior to discharge. Univariate analysis was performed to investigate factors associated with acceptance. RESULTS: From January 2016 to November 2017, 6477 health providers were trained, 239 033 deliveries occurred, and 219 242 interviews were conducted. Of those interviewed, 68% were counselled on family planning and 56% on PPIUD, with 20% consenting to PPIUD. Multiple counselling sessions was the only factor resulting in higher consent rates (OR 1.30-1.39) across all countries. Odds ratios for women's age, parity, and cadre of provider counselling varied between countries. CONCLUSION: Consent for contraception, specifically PPIUD, is such a culturally specific topic and generalization across countries is not possible. When planning contraceptive policy changes, it is important to have an understanding of the sociocultural factors at play.

The impact of using nurses to perform postpartum intrauterine device insertions in Kalyani Hospital, India.

In the postpartum period women are vulnerable to unintended pregnancy, which may lead to legal or illegal abortion and impact on maternal and neonatal morbidity and mortality. Although several postpartum family planning options are available, lack of access to and availability of family planning services and trained staff pose serious challenges. Peripheral centers may not have a doctor; however, they will have nursing staff that can be trained to offer family planning counselling and services. The present study demonstrates how task sharing with nurses to provide postpartum intrauterine device (PPIUD) services worked to give women a convenient and safe contraceptive method. PPIUD insertion provides women the additional advantage of leaving hospital with appropriate long-term contraception after institutional delivery, and also decreases the costs borne by patients and the government. This approach also impacts maternal and newborn health by avoiding unwanted pregnancy.

Examining the Use of Magnesium Sulfate to Treat Pregnant Women with Preeclampsia and Eclampsia: Results of a Program Assessment of Emergency Obstetric Care (EmOC) Training in India.

BACKGROUND: The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia-eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings. METHODS: Trainees' curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia-eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states. RESULTS: Of 1320 cases of preeclampsia-eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia-eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia-eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity. CONCLUSION: To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia-eclampsia could lead to notable improvements in maternal and infant mortality.

Task shifting: A key strategy in the multipronged approach to reduce maternal mortality in India.

Task shifting from specialist to nonspecialist doctors (NSDs) is an important strategy that has been implemented in India to overcome the critical shortage of healthcare workers by using the human resources available to serve the vast population, particularly in rural areas. A competency-based training program in comprehensive emergency obstetric care was implemented to train and certify NSDs. Trained NSDs were able to provide key services in maternal health, which contribute toward reductions in maternal morbidity and mortality. The present article provides an overview of the maternal health challenges, shares important steps in program implementation, and shows how challenges can be overcome. The lessons learned from this experience contribute to understanding how task shifting can be used to address large-scale public health issues in low-resource countries and in particular solutions to address maternal health issues.

Every death counts: electronic tracking systems for maternal death review in India.

Maternal death review (MDR) is an important strategy to improve the quality of obstetric care and reduce maternal morbidity and mortality. MDR provides detailed information on various factors at community, facility, and district levels that influence maternal health outcomes. One of the key challenges is to analyze large volumes of data collected via a paper-based system that uses facility and community level forms. This database continues to expand quantitatively (multiple forms and data elements), which makes analysis of data increasingly difficult for timely management and analysis. The present paper describes the development process involved in linking the paper-based system with an electronic system for MDR in India. The lessons learnt from this experience can contribute to understanding how innovative technologies can be used to address large-scale public health issues in low-resource countries and in particular solutions to address maternal health.