Facility survey
During first assessment, only half the eligible staff from the labour room was trained under Dakshata program. There were also several staff rotations/ transfers but continuous in-facility mentoring ensured training of all the untrained/ newly posted obstetric staff. The delivery load in the study facilities marginally increased. At both times, essential trays and equipment were available in almost all labour rooms; newborn thermometer was available only in two-thirds. Availability of essentials for hygiene and clinical management protocols improved except for PPH. (Annex Table 1)
Adherence to practices
At the time of admission (pause point 1), the adherences to examination practices were already above 90% pre-mentoring, and they stayed high after one year. But the hand hygiene practice prior to vaginal examination halved from 33–16% (p=0.060). The average of all five practices of pause point 1 was the same at 81% both times, and excluding hand hygiene, it was 93% and 97%, p=0.071. During childbirth (pause point 2), the use of clean cord cut was almost universal. Adherence to pre-filled oxytocin, ready bag and mask, and oxytocin administration within 5 minutes of birth improved significantly. However, the use of clean, dry and warm towels reduced from 72–59%. The average adherence for pause point 2 significantly improved from 78–86% in one year, p=0.016. Within one hour of birth (pause point 3), drying the baby immediately after birth improved (91–99%) while measuring the baby’s weight reduced (96–86%). Early initiation of breastfeeding and mothers’ assessments stayed low. The average adherence in pause point 3 remained similar at 72% and 71%, p=0.723. The immunisation of newborns before discharge significantly improved from 23–45% but was still low. The counselling of the mother for any danger signs and family planning reduced over time (concerns with this evaluation are discussed later). The average adherence for pause point 4 was the lowest and stayed so at 46% and 43%, p=0.724 in the two assessments. Overall average for all 20 selected practices was same at 69% (95% CI, 64-74) and 70% (95% CI, 65-75), p=0.710. (Table 2)
Table 2
Cluster level average adherence for each practice, pause points and overall, over time
|
Bulk trainings completed
|
MSVs completed
|
p value
|
Clinical practices observed
|
Time-1
|
Time-2
|
Longitudinal- Linear mixed regression for cluster level
|
|
N=462
|
N=471
|
|
Blood pressure measured (obs)
|
90 (84-96)
|
93 (88-99)
|
0.310
|
Foetal heart sounds assessed (obs)
|
92 (86-97)
|
97 (95-100)
|
*0.062
|
PA examination (obs)
|
96 (92-99)
|
98 (96-99)
|
0.293
|
PV examination (obs)
|
95 (91-100)
|
98 (96-100)
|
0.238
|
Hand Hygiene in PV examination (obs)
|
33 (24-43)
|
16 (4-28)
|
0.060
|
Pause 1: Average of adherence (per facility) to practices
|
81 (77-85)
|
81 (77-84)
|
0.864
|
Average of adherence excluding hygiene
|
93 (89-97)
|
97 (85-99)
|
0.071
|
|
N=420
|
N=415
|
|
Pre-filled oxytocin (obs)
|
74 (65-83)
|
91 (85-97)
|
0.005
|
Ready bag and mask (obs)
|
77 (66-88)
|
94 (89-99)
|
0.004
|
Clean, dry and warm towels (obs)
|
72 (56-87)
|
59 (45-73)
|
0.120
|
Used clean cord cut (obs)
|
97 (92-100)
|
99 (98-100)
|
0.447
|
Oxytocin within 5 minutes (obs)
|
71 (63-79)
|
88 (84-93)
|
<0.001
|
Pause 2: Average of adherence (per facility) to practices
|
78 (72-85)
|
86 (82-90)
|
0.016
|
Baby dried immediately (obs)
|
91 (84-98)
|
99 (97-100)
|
0.029
|
Baby weight observed (obs)
|
96 (93-99)
|
86 (76-95)
|
0.037
|
Breast feeding initiated within one hour (obs)
|
56 (44-67)
|
54 (42-66)
|
0.702
|
Assessed uterine tone (obs)
|
67 (55-79)
|
66 (54-79)
|
0.959
|
Mothers vitals checked (obs)
|
49 (33-64)
|
48 (34-62)
|
0.953
|
Pause 3: Average of adherence (per facility) to practices
|
72 (63-81)
|
71 (64-77)
|
0.723
|
|
N=1,151
|
N=1,198
|
|
Newborn immunised (cs)
|
23 (8-39)
|
45 (29-61)
|
0.018
|
Mother temperature measured (cs)
|
61 (48-74)
|
58 (46-71)
|
0.880
|
|
N=1,094
|
N=1,020
|
|
Counselled for any danger sign in newborn (int)
|
40 (26-55)
|
26 (9-44)
|
0.304
|
Counselled for any danger sign in mother (int)
|
42 (28-57)
|
32 (16-48)
|
0.395
|
Counselled for family planning (int)
|
62 (52-72)
|
52 (41-62)
|
0.169
|
Pause 4: Average of adherence (per facility) to practices
|
46 (38-54)
|
43 (32-53)
|
0.724
|
Overall average (all 20 practices)
|
69 (64-74)
|
70 (65-75)
|
0.710
|
Overall average excluding pause point 4 (15 practices)
|
77 (72-83)
|
79 (75-83)
|
0.385
|
We calculated average of proportions of adherence in a facility weighted for monthly delivery load per facility. We conducted linear regression for effect of time on the adherence, weighed for monthly delivery load per facility. *After adjusting for type of facility, p<0.05.
Some additional indicators are described in Annex Table 2. Pre-heating the warmer, keeping the suction device ready before birth, and providing uterine massage after childbirth improved. While monitoring mothers’ blood pressure and foetal heart sounds, delayed cord cut, and newborn and mothers’ temperature after birth decreased.
Performance scores of facilities
We observed that a higher number of facilities scored satisfactory in pause point 1 (12 vs 18) and pause point 2 (8 vs 14) attributable to one year of mentoring and support. Overall only 3 facilities served satisfactory at the two assessments over one year (Figure 2).
Outcomes
Stillbirth rate reduced over time from 1.1% (95% CI 0.9-1.4) to 0.4% (95% CI, 0.3-0.6) and newborn referral rate from 0.7% (95% CI 1.1-0.4) to 0.1% (0.0-0.1); p <0.001. There were no changes in mothers’ caesarean or referral rates. (Table 3)
Table 3
Outcomes of obstetric care in the study states, from Labour room registers
|
Bulk trainings completed
|
MSVs completed
|
p value
|
|
Time-1
N=9,381
|
Time-2
N=10,489
|
Poisson regression
|
Caesarean rate, % (95% C.I.)
|
36.6 (35.6-37.6)
|
35.5 (34.6-36.4)
|
0.499
|
Mothers referral rate, % (95% C.I.)
|
0.1 (0.1-0.2)
|
0.1 (0.0-0.1)
|
0.401
|
Stillbirth rate, % (95% C.I.)
|
1.1 (0.9-1.3)
|
0.4 (0.3-0.5)
|
<0.001
|
Newborn referral rate, % (95% C.I.)
|
0.7 (0.6-0.9)
|
0.1 (0.0-0.1)
|
<0.001
|
Qualitative results: We present these in four broad sections: 1) Effectiveness; 2) Program implementation and State’s ownership; 3) Intensity of support by strategic partner; 4) Sustainability and scalability.
Effectiveness
All stakeholders believed that the program was very relevant for upgrading skills and improving the quality of care during childbirth. Since the 3-day training, the nurses noted improvement in their knowledge and skills which, they mentioned, continued to improve through-out the mentoring they received in their workplace. The decision-making capabilities and complication management improved. They believed that improved quality of services resulted in reduction in referrals, stillbirths, maternal and newborn mortality. The district and facility administrators acknowledged that Dakshata program was the game-changer for the improvement in their respective facilities.
Resource availability
Staff noted considerable improvement in infrastructure and availability of resources including clinical protocols that motivated them and facilitated appropriate service delivery. The periodic assessments by the mentors helped them to identify the gaps and rectify the availability as well as the placement of equipment and drugs.
Quality of care
Stakeholders stated that quality of services improved, where the quality was expressed in terms of infection prevention (personal hygiene and sanitation, sterilization, biomedical waste management, use of protective gear) and following protocols while assisting vaginal delivery. The service providers stated that the most significant knowledge gained from the program was the complication management (such as postpartum haemorrhage and newborn resuscitation) and early referrals with appropriate pre-referral treatments. The staff also reduced harmful practices such as unnecessary augmentation of labour, fundus pressure, and repeated vaginal examinations, which we also observed. On the other hand, certain practices that staff mentioned had improved were observed to not improve or reduce on direct observation, such as hand hygiene, postnatal check-ups, early initiation of breastfeeding, counselling for exclusive breast-feeding and postpartum care.
The facility and district administrators also noted tremendous improvement in knowledge, practices, and confidence of the staff particularly in the delivery of services during and immediately after childbirth. They also mentioned that the unavailability of staff for post-natal wards was one of the limitations in providing appropriate post-natal care.
Recording information
Service providers admitted that prior to Dakshata, they did not place much emphasis on recording clinical history, or information from client reports; even diagnosis of complications was recorded for very few. They mentioned that the ongoing mentoring and periodic checks on missing information made them document better; as they also realized it helped in risk identification, early diagnosis, and ease in sharing information between shifts. They, however, were unable to follow complete documentation due to inadequate staff and high workload. The checklist was often entered after admission and after childbirth instead of simultaneously doing so.
Accountability of service providers
Stakeholders’ perceived accountability in terms of involvement in, and ownership of, the program components. All stakeholders believed that mentoring and periodic assessments were the main reasons behind service providers being aware and proactive towards their duties, with an increased sense of responsibility. But none of the service providers mentioned using their data efficiently to monitor performance to set accountability.
We noted a positive change in service providers’ attitudes towards providing quality services with a clearer understanding of the benefits. They also mentioned the importance of leadership, external motivation, and encouragement, as well as self-motivation as enablers.
Work satisfaction
Nurses were empowered and mentioned an increase in their work satisfaction due to improved competencies. District-level administrators identified concerns with the work satisfaction of the obstetricians and doctors within the existing intricate health system. This did affect the overall team performance.
Others
Staff mentioned that there was an inappropriate risk management during the antenatal period in peripheral facilities, thus several patients landed with untreated long-standing complications of pregnancy such as eclampsia, pre-eclampsia, diabetes. Such complications were often not managed at the secondary level and thus led to referral or poor outcomes.
Ownership by state health system and program implementation
As this was the program primarily run by the state with support from the external agency, the state’s ownership and engagement was a key factor for implementation and sustainability and scalability.
Ownership and engagement by state administration
State health administration sanctioned resources for 3-day training readily but delayed the in-facility mentorship. Monitoring was mainly done by the strategic partner. We observed no active monitoring by the state for the Dakshata quality improvement program. On the other hand, state led and directly monitored implementation of Laqshya certification (accreditation) and encouraged the quality of infrastructure and services in labour rooms. Other component of Laqshya, quality improvement cycles, was not yet implemented. District administrators were not satisfied with infrastructure alone and complained about improper allotments of specialists, inadequate technical support, no monitoring and review, and no encouragement and moral support.
Leadership
Service providers stated that the significant changes in resources and services were possible due to the active involvement of the district and facility leadership. The leadership, however, stated that this program alone couldn’t bring huge improvements thus they need to also focus on nutrition and adequate antenatal care.
Efficiency of mentoring and periodic assessments
The mentors and the program managers stated that the success of the mentoring lay in the standard training of mentors on content and pedagogy, mentoring package, periodic assessment application, and feasibility of frequent follow-ups (mentor being from within the facility). As per the district administrators and strategic partner, the identified mentors were clinically capable, had a good rapport and they effectively engaged with the facility leadership and motivated obstetric teams. The program managers mentioned that in-facility mentoring strengthened in-service training as well as reduced the delays in capacity building for new recruits/transfers. The quarterly periodic assessments were considered an essential pillar and integral to mentoring. Although there were some challenges with the resistant and reluctant staff (mainly doctors), and obstetric teams were not yet functional as a quality team.
Accountability of mentors
The handholding support from the strategic partner was immensely useful and regular follow-up by them improved accountability of the mentors. The JHPIEGO mangers told that the periodic assessment application could be used for monitoring and assigning accountability provided the state and district officers used it too and provided feedback.
Motivation, encouragement, awards
Stakeholders at all levels identified the requirement for establishing mechanisms for motivation and encouragement to service providers to improve services, sustain the achievements, and encourage better performance. They also admitted that motivation need not be in terms of monetary rewards, instead presenting a memento/garland/certificate of appreciation during public meetings could bring marvels in their practices. Self-motivation, on the other hand, differed from person to person and was told to be stimulated with an understanding of the importance of Dakshata programme, perceived need for improvement and acknowledgment by seniors. We noted that self-motivation strongly contributed to better performance and accountability at all levels.
Intensity of support by strategic partner
JHPIEGO state team was the connection between the state, districts and the facilities. The JHPIEGO state team had responsibility for advocacy and persuasion for program strategy, budget and resource allocations by the state.
Administrative planning and support
The mid-level administrative support was crucial. They supported all the administrative and managerial planning, conducted supervision and follow-up of the program activities at the state and district. They closely worked with each facility for better preparedness in the labour room and availability of resources via bridging communication between hierarchies, managing supply chain and following up with administrative processes. By the end of one year, the JHPIEGO team supported district administration to take over majority of their tasks.
Capabilities of JHPIEGO’s team
All team members were doctors with experience in public health program management. The staff and administrators mentioned that the team from JHPIEGO was highly competent, professional, and motivated. They appreciated the JHPIEGO managers for their expertise and effective way of training and supervision, communication skills, rapport building, problem-solving and innovative approaches to improve quality. The team was noted to be perseverant and approachable. The facility and district leaderships also appreciated the JHPIEGO team’s consistency which was the key to drive their attention and contribution to project activities.
Sustainability
We tried to understand the perception of stakeholders regarding the sustainability and scalability of the Dakshata program in terms of practices being part of the routine, and the continuation of program components within similar new programs. Service providers described factors that supported the sustainability of the program and provided suggestions (Table 4). A detailed list of facilitators, enablers, suggestions and recommendations for each of the program component are presented in Annex Table 3.
The stakeholders unanimously felt the program shall be scaled-up to other districts and states.
Table 4
Key enablers and suggestions for sustainability of Dakshata program as per the stakeholders
Enablers for sustainability
|
Suggestions for sustainability
|
Infrastructure and supply-demand chain of essential resources created an enabling environment and motivation to practice the skills learned.
|
Sustain and update supplies and resources. Extend to, and strengthen peripheral care facilities under Dakshata program.
|
New competencies and skills learnt, increased the confidence of the staff. Likely to sustain the practice
|
Timely trainings and skill up-gradation for the new staff; refresher training for existing staff to reinforce protocols and new evidence.
|
Improvement in outcomes inspires to sustain or further improve performance. Feedback useful.
|
Engage and empower the community for better understanding and cooperation to care providers.
|
Mentoring and periodic assessments at the workplace most essential for continuous quality improvement.
|
Build systems for mentoring, periodic assessment. Continue periodic visits by an external expert, this will support and ensure the motivation of mentors. The later will reduce the burden on already overburdened administrators.
|
Supportive leadership and administration, and collective accountability at all the levels of service. Encouragement and motivation.
|
Structure mechanism for feedback, encouragement, and assigning accountability. Promote a culture of quality improvement.
|
Monitoring by higher officials and managers essential for program success. Support in problem-solving and addressing resistant uncooperative staff or incoherent quality teams.
|
At least quarterly monitoring visits and strict follow up. Include Dakshata program review under District and State MCH review meetings, link with outcomes.
|
Concurrent programs and initiatives that promote quality of care of the pregnant women and newborns shifted focus on the quality of services. Laqshya, and other initiatives contributed to the sustenance of the program by provisions of infrastructure, resources, and skills labs.
|
The state should lead the program by itself with some support of quality experts. The state should address the gaps in human resources recruitment and allotment. Devise protocols for rationale client distribution, referral system.
|