Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India.

BACKGROUND: Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities. METHODS: An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention. RESULTS: In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (ß) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: ß = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: ß = 11.66; 95% CI = 10.06, 13.27. Adjusted: ß = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: ß = 15.74; 95% CI = 14.39, 17.08; Adjusted: ß = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time. CONCLUSIONS: Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care.

Video Monitoring a Simulation-Based Quality Improvement Program in Bihar, India.

BACKGROUND: Simulation-based training has become an accepted clinical training andragogy in high-resource settings with its use increasing in low-resource settings. Video recordings of simulated scenarios are commonly used by facilitators. Beyond using the videos during debrief sessions, researchers can also analyze the simulation videos to quantify technical and nontechnical skills during simulated scenarios over time. Little is known about the feasibility and use of large-scale systems to video record and analyze simulation and debriefing data for monitoring and evaluation in low-resource settings. METHODS: This manuscript describes the process of designing and implementing a large-scale video monitoring system. Mentees and Mentors were consented and all simulations and debriefs conducted at 320 Primary Health Centers (PHCs) were video recorded. The system design, number of video recordings, and inter-rater reliability of the coded videos were assessed. RESULTS: The final dataset included a total of 11,278 videos. Overall, a total of 2,124 simulation videos were coded and 183 (12%) were blindly double-coded. For the double-coded sample, the average inter-rater reliability (IRR) scores were 80% for nontechnical skills, and 94% for clinical technical skills. Among 4,450 long debrief videos received, 216 were selected for coding and all were double-coded. Data quality of simulation videos was found to be very good in terms of recorded instances of "unable to see" and "unable to hear" in Phases 1 and 2. CONCLUSION: This study demonstrates that video monitoring systems can be effectively implemented at scale in resource limited settings. Further, video monitoring systems can play several vital roles within program implementation, including monitoring and evaluation, provision of actionable feedback to program implementers, and assurance of program fidelity.

Tracking and debriefing birth data at scale: A mobile phone application to improve obstetric and neonatal care in Bihar, India.

AIM: This analysis assessed changes over time in skill and knowledge related to the use of evidence-based practices associated with quality of maternal and neonatal care during a nurse midwife mentoring intervention at primary health clinics (PHCs) in Bihar, India. DESIGN: Nurse midwife mentors (NMMs) entered live birth observation data into a mobile App from 320 PHCs. METHODS: The NMMs completed prompted questions in the App after every live birth witnessed. The App consisted of questions around three main themes, "What went well?", "What needed improvement?" and "What can be done differently next time?". RESULTS: Observational data from 5,799 births was recorded by 120 NMMs in 320 PHCs. Knowledge and skill during normal spontaneous vaginal deliveries and complicated deliveries with either a postpartum haemorrhage or non-vigorous infant all showed statistically significant improvement (p < .001) over time using a Chi-squared test for trend with a mean increase of 41% across all indicators.