We present the qualitative results in three broad sections: 1) Effectiveness of intervention; 2) State’s ownership and program implementation and; 3) Sustainability. Lastly, we summarise the facilitators and challenges and suggestions for sustainability and scalability of the program. Table 4 lists stakeholder statements under common themes and sub-themes.
Effectiveness of intervention:
Knowledge and competencies
Staff gained new knowledge about standards and protocols for delivery care and management of complications. The nurses felt more competent and confident in conducting low risk vaginal deliveries by following the checklist and protocols. They were able to manage complications such as PPH and newborn resuscitation, and provide stabilising care for complications with existing resources, prior to referral. They learned how to talk to the client and counsel them. During second assessment, we observed a deeper understanding of the program and clinical management. Nurses were more elaborate about the comprehensive and structured way of providing care to the mother and the newborn, from admission through discharge and the necessity to perform all the steps for prevention of complications to get desired outcomes. They reported that earlier it took them much longer and a lot of effort to practice all the recommended tasks. But with time the tasks seem easier, and the learnt skills were getting embedded in their routine, as per protocols, followed in systematic manner.
Staff noted considerable improvement in infrastructure, and availability of resources including protocols which motivated them and facilitated appropriate service delivery. The periodic assessments by the mentors helped them to identify the gaps and rectify those. Mentors helped in overcoming administrative procedures to avail the resources. They also helped in identifying and instituting local solutions for operational problems.
Perception of quality and service delivery
Earlier the staff perceived quality in terms of improvement in infrastructure, availability of relevant trays, sterilisation of instruments, use of gloves and hygiene practices. But after the program they noted quality as improvement in actual provision of appropriate clinical care and management of complications rather than infrastructure and supplies alone. As told by staff, the emphasis increased on measuring vitals of women, high-risk screening, measuring foetal heart sounds, effectively performing steps in childbirth, administering injection Oxytocin after childbirth, management of post-partum haemorrhage, and use of MgSO4 for prevention and management of eclampsia. By the second program assessment the staff also emphasised on infection control. The nurses mentioned that sterilisation of equipment and use of hypochlorite solution was not done prior to Dakshata program. Hand hygiene was mentioned as one of the practices difficult to follow, especially when the load was high. With introduction of hand rubs there was some improvement in hand hygiene. The participants accepted that they had stopped unnecessary induction of labour, multiple PV examinations and inappropriate management such as fundal pressure. They also added counselling to the mothers and attendants before discharge as components of quality service delivery.
Effectiveness of the program was told to be in being able to provide care as per the need of the pregnant women and reducing adverse outcomes. Over time, the staff emphasised more on physical assessment at the time of admission, filling of partograph, counseling the mother and birth attendant for early identification and tracking of the high-risk cases. The staff mentioned the concept of golden minute, newborn care and resuscitation. A nurse mentioned using balloon tamponade before referring a PPH case which she never did in the past. They also learned and practiced good behaviour with the client.
Outcome of Dakshata program
The stakeholders believed that improved care as per Dakshata program protocols had led to improvement in quality of care and service, reformation in infrastructure and supply, efficient management of complications, reduced referrals and, reduced stillbirth, maternal and neonatal deaths. There was improvement in nurses’ role in decision making for client care and labour room maintenance.
We noted positive change in service providers’ attitude towards providing quality of services with clearer understanding about the benefits associated. The staff believed that the mentoring and periodic assessments contributed to service providers being aware and proactive towards their duties, with increased sense of responsibility.
State’s ownership and program implementation: We reviewed the facilitators, challenges; sustainability and scalability of program components.
Ownership and engagement by state health department
The state health department completely owned the implementation of the program and led it with support from the external agency. The national level stature of the program drove motivated implementation. Rajasthan was among the first few states to successfully implement the program and much appreciated too. State regularly monitored the program activities and performance, and undertook timely decisions to fill in the gaps, provided administrative support and resources, and conducted repeated sensitisation and trainings for lagging practices. We also noted that after our periodic feedbacks from assessments, the state took appropriate measures to improve services. The state realized that the success of the program needed to be sustained and improvement should continue. Thus the state recruited 17 district mentors, and deputed in-service block mentors (nurses/doctors), to continue the program after external support phased out.
The district mentors appreciated the state leadership and attributed the success of the program implementation to the state government health officers. The commitment and accountability at the state trickled to the lower level administrators, hospitals, and service providers too. Some hospital administrators were very proactively involved in bringing changes through Dakshata program. Some other fulfilled the essential resource requirements through public-private partnerships or donations. On the other hand a few interviewees mentioned poor leadership at the district and hospital, and the staff struggled to perform well due to inadequate support.
The state implemented a structured monitoring mechanism, later also strengthened by a newly designed android based software application. The application helped mentors in conducting on spot periodic assessments, scoring the performance and giving feedback to the staff or in-charges. It also helped the district and state administrators to real time track the hospitals’ performance and mentors’ visits. The district administration in Barmer also periodically reviewed the program in district maternal and child health review meetings.
Efficiency of training, mentoring and periodic assessments by partner agency
The hospital administrators and service providers appreciated the short duration and effective mode of training. The Dakshata training was perceived to be different from previous trainings, including that for skilled birth attendance. Mentoring and supervision visits and periodic assessments were perceived to be the most prominent feature and strong pillars of Dakshata program. Staff mentioned that mentoring visits helped them internalize the standard practices without having to put a lot of effort in the learning process. The mock drills and the briefing-debriefing helped in improving clinical skills. All the stakeholders admitted that mentoring in staff’s work place was more conducive and with regular follow up it improved sense of responsibility and accountability at all levels. Mentoring visits were of particular importance in setting all the infrastructure and resources right.
Motivation, encouragement, awards
The state provided recognition and award (mementos, certificates) to best performers. A few providers and administrators felt that these measures encouraged and motivated staff, and improved accountability. The review of program in monthly maternal health meetings at district and state also provided opportunities for cross learning and finding solutions for common challenges.
Sustainability: The stakeholders shared their understanding of factors for successful sustainability of the program, and the threats.
Improved infrastructure and demand supply chain
The labour room infrastructure and demand supply chain significantly improved, and that were among the key factors for improvement in staff motivation and service delivery. The mentors played the central role in facilitating these changes, post phase-out the labour room in-charges would need to pro-actively take over this role to maintain resources.
Improved competence and quality of service delivery
The evidence-based practices improved, and staff noted the difference in their practices pre- and post-Dakshata. The program encouraged and enabled them to improve the quality of services, and these improvements gave them job satisfaction. They aimed to continue the same practices and improve with guidance.
Continuous skill upgradation
The stakeholders mentioned that regular skill upgradation trainings or mentoring were required to sustain quality services, and incorporate newer evidence-based improvements to clinical care.
Quality of mentors
All the stakeholders stated dynamic relationship with JHPIEGO mentors; mentoring and periodic assessments made the program desired. These JHPIEGO mentors were mostly MBBS doctors, while the new government mentors were a mix of trained para-medical staff and nurses, and a very few doctors. Administrators told that post-phase out, the government mentors have to do a lot to fill in the shoes of earlier mentors. The service providers were skeptical about the performance after shifting from JHPIEGO mentors to government mentors.
Motivation and accountability
The recognition and monetary awards were motivation to continue good work.
Linkage and support from other program
The providers told that the incentives provided under Janani Suraksha Yojana ensured that the mother stayed at the hospital for atleast 48 hours post-delivery, which provided an opportunity to deliver post-natal care. Programs such as Kayakalp helped in instituting sanitation and hygiene; Laqshya had standards for resources and services, and provided certification of quality of services in labour rooms and pediatric units.
Challenges and suggestions to effectiveness, accountability and sustainability of Dakshata program:
Community level care and practices
Inadequate antenatal care, high prevalence of severe anaemia, late arrival at the health facility, poor awareness about delivery processes, unhygienic practices, and requests for early intervention or early discharge negatively affected the quality of services. Staff reported referring most of the late arriving complication cases.
Shortage of staff and inadequate resources amidst high patient load worsens the ability to provide quality services and documentation; and postnatal care was negligible. The state recruitment for 800 nurses was on hold since 3 years due to a court case. Despite huge improvements, the gaps in infrastructure and supply chain were still pertinent.
Local political influence and interference
District level officials were displeased with political interference that resulted in irrational positioning of human and other resources. Some service providers used political influence as means to escape from their daily duties and responsibilities; they were difficult to supervise or descipline.
Unmotivated staff and reluctant doctors
Not all staff were similarly motivated. Most obstetricians and few medical doctors did not want to participate in Dakshata program. In their understanding the program was only for nurses and support staff.
There were certain reports of malpractices, such as doctor referring the patient to his/her personal clinic, and staff asking for monetary remuneration for otherwise free services.
Inconsistent support from administration
District and hospital participants reported inconsistent support from government for adequate human resource, reinforcement of trainings and monitoring. Staff perceived that the government had poor understanding of the practical problems at the bottom level. Staff felt that the Government won’t be able to provide proper follow-up mentoring after the phase out of JHPIEGO mentors.
The suggestions are compiled as bellow.
Provide pre-service trainings and regular refresher trainings in a systematic manner close to workplace, and update the latest protocols.
Establish stringent monitoring and feedback system; strengthen periodic assessments through mentors and reviews by administrators in routine MCH meetings.
Empower and support the new government mentors for efficient mentoring and periodic assessments. Monitor mentoring.
Ensure minimum human resource as per the load, particularly nurses. Don’t rotate staff; commit trained obstetric staff to only obstetric wards or labour rooms.
Ensure availability of essential equipment and supplies; maintain consistency.
Adopt quality improvement approach in lines with programs such as Laqshya and Kayakalp; make use of these for identification of local problems and solutions. Formation of quality circles/ teams supported by administration may help.
Establish advisory support and redressal mechanism for technical as well as managerial concerns.
Strengthen and improve antenatal care and empower the community regarding obstetric care. Target specifically poor performing and deprived communities.