Assessing the Effect of Integrated Health Interventions on Maternal and Neonatal Health Outcomes in an aspirational district of Uttar Pradesh: A mixed method study

doi:10.21203/rs.3.rs-3726529/v1

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Assessing the Effect of Integrated Health Interventions on Maternal and Neonatal Health Outcomes in an aspirational district of Uttar Pradesh: A mixed method study

https://doi.org/10.21203/rs.3.rs-3726529/v1

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Introduction: India has made significant progress in maternal and neonatal health, yet challenges persist. This study examines Shrawasti, a Uttar Pradesh district, to understand strategies for enhancing maternal and neonatal health. It particularly focuses on birth asphyxia and postpartum haemorrhage due to oxytocin misuse.

Objective: To compare pre- and post-intervention maternal and newborn complications in Shrawasti and identify factors decreasing postpartum haemorrhage, newborn deaths, stillbirths, and birth asphyxia. The study aims to elucidate effective interventions for improving maternal and neonatal health.

Methodology: A retrospective observational study collected data from labour rooms and the Special Newborn Care Unit in Shrawasti. In-depth interviews with healthcare workers provided qualitative insights. Interventions were implemented based on initial findings and evaluated through systematic data organization and assessment. Results: Post-intervention, there was a significant reduction in stillbirths, asphyxia, and postpartum haemorrhage. Asphyxia decreased from 74.5% to 33.2%, stillbirths from 28.5% to 12.5%, and postpartum haemorrhage from 53.8% to 26%. Qualitative analysis highlighted improved healthcare practices, training effectiveness, staff behaviour shifts, and enhanced patient awareness. Documentation and monitoring practices also improved significantly.

Conclusion: Interventions significantly transformed maternal and neonatal healthcare in Shrawasti. Enhanced awareness, revised practices in oxytocin administration, effective training, and improved documentation were pivotal in reducing adverse outcomes. Addressing challenges through targeted interventions is crucial for better healthcare outcomes.

Maternal Health

Neonatal Health

Birth Asphyxia

Postpartum Hemorrhage

Healthcare Interventions

The progress India has made in improving maternal and neonatal health is remarkable. The maternal mortality ratio (MMR) has been significantly reduced by 77% from 556 per 100,000 live births in 1990 to 130 per 100,000 live births in 2016, and further to 97 per lakh live births in 2020. Similarly, the Infant Mortality Rate (IMR) has seen a decrease from 39 per 1000 live births in 2014 to 30 per 1,000 live births in 2019 at the National Level.^1,2 Despite these advancements, India continues to face persistent challenges in maternal and neonatal health, characterized by limited access to healthcare, inadequate infrastructure, and cultural barriers.³

Globally, neonatal mortality remains a significant concern, particularly in low- and middle-income countries, where approximately 2.5 million newborns die within their first month.^4,5 Birth asphyxia, responsible for about 8.5% of all under-five child mortality, is a substantial issue, particularly in developing countries, where it leads to around 42 million disability-adjusted life years (DALYs).⁶ The economic impact on families is also noteworthy, with acute care for such patients accounting for 9.1% of their annual income.⁷

The gap in addressing specific challenges in maternal and neonatal health is evident in the case of birth asphyxia and its associated factors. The misuse of oxytocin, for example, significantly increases the risks of birth asphyxia, stillbirth, and neonatal encephalopathy.^8–12 This highlights a crucial area where existing interventions might not be fully effective.

Our study focuses on Shrawasti, an aspirational district in northeastern Uttar Pradesh, identified by the Indian government for rapid transformation. Shrawasti has shown remarkable improvement, with a 37.8% enhancement in the Health & Nutrition theme since 2018, climbing from a baseline delta ranking of 97 (28.13%) in 2018 to one of the top ten districts in 2023.^13,14 This makes Shrawasti an ideal case study for understanding the effective strategies that have led to significant improvements in maternal and neonatal health.

Before data collection, a discussion with various health officials of Shrawasti district divulged that postpartum haemorrhage (PPH) and neonatal asphyxia were the prevalent causes of maternal and neonatal mortality. Precisely, improper use of Oxytocin, a surge in deliveries before shift changes, and reluctance among families to transfer newborns suffering from asphyxia to the Special Newborn Care Unit (SNCU), outdated practices, lack of knowledge and awareness and inadequate monitoring were identified as the contributing factors. To tackle these challenges, comprehensive interventions were implemented across both healthcare and administrative domains. The health officials were Community Development Officer (CDO), Chief Medical Officer (CMO), Chief Medical Superintendent (CMS), Additional Chief Medical Officer (ACMO) ,Medical Officer-in-charge (MOIC), Special Newborn Care Unit/ Newborn Care Unit/ Labour Room (SNCU/NBSU/LR) staff of District Hospital (DH) & Community Health Centers (CHCs).

The rationale behind this study is to provide valuable insights into the specific interventions and practices contributing to health improvements. The novel aspect of this study lies in its focus on an aspirational district, where unique challenges and efforts converge to address healthcare disparities.

The expected outcome is to gain a comprehensive understanding of the factors leading to improved maternal and neonatal health outcomes in Shrawasti. Such findings could be instrumental in guiding future healthcare policies and interventions in similar settings.

In this context, our study objectives are as follows: First, to compare the maternal and newborn deaths and complications before and after the interventions in Shrawasti. Second, to identify the specific factors that have contributed to the decrease in maternal postpartum haemorrhage (PPH), newborn deaths, stillbirths, and birth asphyxia. Through these objectives, we aim to elucidate the effective measures and interventions that have been instrumental in improving maternal and neonatal health in Shrawasti.

This retrospective observational study was carried out in the Shrawasti district of Uttar Pradesh. The data collection involved gathering month-wise data over a year from labour room registers at four Community Health Centers (CHCs) - Ikauna, Sirsiya, Malhipur, and Gilaula - and from the Special Newborn Care Unit (SNCU) of the District Combined Hospital (DCH). This comprehensive data included metrics on maternal mortality, neonatal mortality, stillbirths, birth asphyxia cases, and postpartum haemorrhage (PPH) incidents.

Qualitative Data Collection and Analysis:

A significant component of this study was the qualitative data, collected through in-depth interviews (IDIs) with staff nurses and Auxiliary Nurse Midwives (ANMs) at the CHCs and DCH. Informed consent was taken from all the participants prior to in-depth interviews. These interviews delved into practices and attitudes surrounding the administration of uterotonics, documentation, and reporting of asphyxia and PPH cases. A total of 10 interviews were conducted, including 7 with staff nurses and 3 with ANMs.

The interviews were recorded and initially transcribed in Hindi. These transcripts were then rigorously cleaned and translated into English for a detailed qualitative analysis. The English translations were imported into the QDA Miner Lite software for thematic analysis. This process involved identifying relevant codes from the transcripts, which were then grouped into categories and themes. This thematic approach allowed for a nuanced understanding of the effect of healthcare interventions on staff practices and patient outcomes.

Sampling Procedure:

The district of Shrawasti has five blocks, each with a Community Health Centre (CHC). For this study, four CHCs were selected based on their geographic distribution and patient load. The CHC closest to the district hospital was excluded due to its lower delivery rate, ensuring a representative sample from higher patient load centers.

Intervention and Monitoring:

Key interventions were implemented based on the initial findings from data collection and discussions with healthcare officials. These included the safe and responsible use of oxytocin, awareness programs for labour room staff, and strategies to mitigate data underreporting. A second intervention focused on increasing accountability and transparency in healthcare practices, including rigorous monitoring and staff motivation against data underreporting. Continuous assessment of these interventions was carried out to gauge their effectiveness in reducing birth asphyxia and PPH rates.

Data Organization for Intervention Assessment:

The data were systematically organized into four quarters: baseline data from June to August (Q1) before the intervention, September to November (Q2) after the first intervention, December to February (Q3) post the second intervention, and March to May (Q4). This segmentation was instrumental in evaluating the interventions' effect on maternal and neonatal health over time.

Ethical Considerations:

The Institutional Ethical Committee granted ethical clearance for the study (RMCHRC/ACADEMIC/Ph.D./1989B/06/08/2023 dated 05.09.2023).

Status of maternal and Neonatal health before and after the intervention:

The study reports the data collected from both labour room Community Health Centres (CHCs) and the District Hospital of Shrawasti district and the Special Newborn Care Unit (SNCU) of the district hospital. The CHCs are located at Sirsiya, Gilua, Ikauna and Malhipur blocks.

The total deliveries reported from the CHCs and district hospital were 14623. Of the total deliveries, 1012 newborns presented with asphyxia, 731 PPH cases were observed and 431 stillbirths.

The graph shows the decline in the rate of stillbirths, asphyxia and post-partum haemorrhage (PPH) in the total number of deliveries. The baseline represents the data collected before the intervention, from June to August. On the other hand, Q1, Q2, and Q3 represent the three quarters after the intervention: September to November, December to February, and March to May, respectively. Before the start of the intervention, there was a high rate of stillbirths, asphyxia, and post-partum haemorrhage across all surveyed blocks/labour rooms from June to August 2023.

Precisely, after the intervention, there was a significant decrease in cases of asphyxia in over three-quarters in the five labour rooms of the district. Overall, 74.5% asphyxia, 28.5% stillbirths and 53.8% PPH were seen before intervention Following the intervention, the asphyxia cases decreased to 33.2%, stillbirths decreased to 12.5% and postpartum haemorrhage to 26%.[Fig. 1]

A total of 1045 patients suffering from asphyxia were admitted to the District Hospital in Shrawasti over one year. A total of 317 asphyxia cases were reported before the intervention, between June to August while, except for a rise in the first quarter (38.7%), there was a decrease in asphyxia patients over the next two quarters (18.1% and 12.9%). There was also a noticeable decline in newborn death rates, from 31.3–16.8%. [Fig. 2]

Table 1

Tabular presentation of themes, domains and codes extracted from the in-depth interviews of staff Nurses of selected Labour rooms and SNCU of Shrawasti district
Theme	Domain	Codes
Theme I: Improvements with changing practices	Enhanced awareness	Awareness and changing practices
	Improvement in maternal health
		Reduction in maternal complications
		Improved patient experience
		Improvement in maternal care
	Improvement in neonatal health	Decrease in birth asphyxia and neonatal deaths
	Improvement in neonatal health	Reduction in neonatal complications
	Change in oxytocin administration	Introduction of new practices
		Reduction in fraudulent practices
		Discontinuation of oxytocin
	Improvement in practice and referrals	Natural birth experience
	Improvement in practice and referrals	Improved Practice and referrals
	Changes at the Administrative level	Accountability and Deterrence Measures
Theme II: Effect of training	Increase in knowledge and awareness among healthcare worker	Role and use of oxytocin
		Awareness following training
		Empowerment of ASHA workers
		Improvement in knowledge
		Change in behaviour of healthcare staffs
		Awareness and Change in Staff's Perspective
	Adoption of correct practices	Continuous Training and Reinforcement
		Improved Understanding of Practices
		Changes in clinical practices and medical procedures
	Triage Process	Introduction of triage process
	Triage Process	Improvement of the triage process
	Counselling of patients	Counselling and family education
	Role of stakeholders	Learning from senior staff
		Collaboration with partner agencies
		Effect of external agencies
Theme III: Effect on health care workers	Effect on knowledge and awareness	Staff behaviour change
		Awareness among staff
		Staff behaviour and improvement
		Staff motivation and education
	Effect on practice	Effect on labour room staffs
		Role of ASHA workers
		Team Effect
		Restricting Drug Administration
Theme IV: Effect on Patient's family	Resistance to change among patient and their families	Change in patients their families behaviour
		Patient's behaviour and resistance
		Resistance to change
	Effect on awareness among patients	Patient awareness
		Positive changes in attitude
		Patient empowerment
		Importance of proper care
	Inclination of patients towards pain-killer injections	Patients demanded pain-killer injection
	Inclination of patients towards pain-killer injections	Patient's perception of expediting delivery
Theme V: Documentation and monitoring	Improvement in monitoring	Improved monitoring
		Improved reporting
		Improvement in knowledge of monitoring
	Improvement in documentation	Improved documentation
	Inadequate reporting in before intervention	Lack of documentation
	Inadequate reporting in before intervention	Lack of monitoring in past
Theme VI: Status of maternal and neonatal health before intervention	Limited resources	Handling complications with limited resources
	Status of neonatal health	Neonatal complications
	Status of maternal health	Negative Consequences
		Maternal complications
		Referral for complicated cases
	Status of community	Lack of awareness among community
Theme VII: Injudicious use of uterotonics prior to training	Challenges and risks of using uterotonic drugs	Injudicious administration of oxytocin
		Usage of oxytocin in third stage of labour
		Misuse of Medical Procedures
		Misuse of uterotonic drugs
		Misoprostol administration
		Family demands for oxytocin
	Oxytocin administration	Doctor's influence on oxytocin administration
		Change in oxytocin administration methods
		Patient's disclosure and feedbacks
	Inadequate knowledge about uterotonics	Lack of Knowledge and Practices
		Assumptions about Labor
		Unawareness of Complications

Qualitative Analysis [Table 1]:

Theme I: Improvements with Changing Practices

The theme “Improvements with Changing Practices” and its associated codes reveal a multifaceted transformation in maternal and neonatal healthcare. Enhanced awareness initiatives have led to a significant reduction in maternal complications, thereby improving the overall patient experience in maternal care. This improvement is particularly notable in the reduction of birth asphyxia and neonatal deaths, indicating a positive shift in neonatal health outcomes.

The change in oxytocin administration practices, including the introduction of new protocols and the discontinuation of fraudulent practices, has contributed to a more reliable and safer approach to maternal care. Additionally, there is evidence of improved practice and referrals, fostering a more natural birth experience for mothers while ensuring better healthcare quality.

Verbatim: ANM Malhipur: “Actually, ma'am, initially, we used to administer oxytocin before delivery.”

SN Sirsiya: “When these methods were used, complications such as asphyxia, maternal deaths, fetal deaths, and neonatal deaths significantly decreased."

SN DCH: “The improvement is noticeable, with birth asphyxia cases decreasing from 60–65 to 20–25, and neonatal deaths dropping from 22–23 per month to 6-10-11."

SN Malhipur: “A lot of fraudulent practices were happening, but now, people don't force us. They don't force us to give a pain-killer injection to their patients. They know it's harmful."

At an administrative level, the implementation of accountability and deterrence measures signifies a pivotal change in ensuring responsible practices and discouraging malpractice.

Verbatim: SN Sirsiya: “If anyone misuses oxytocin, MOIC Sir himself has informed us that strict actions would be taken against them. A couple of staff members have had their duties removed, and they were shifted from labour rooms to ANC, as a form of punishment."

These changes collectively highlight a substantial positive effect on both maternal and neonatal healthcare, emphasizing the importance of evolving practices, heightened awareness, and stringent administrative measures in improving overall healthcare outcomes. [Table 1]

Theme II: Effect of Training

Qualitative analysis of the "Effect of Training" theme and its corresponding codes highlights a significant enhancement in knowledge and awareness among healthcare workers. Following training sessions, there's a notable increase in awareness regarding the role and proper use of oxytocin, empowering ASHA workers, and improving the overall knowledge base among healthcare professionals. This includes a heightened understanding of correct medical procedures and clinical practices, indicating the successful adoption of more appropriate and effective healthcare methods.

Verbatim: SN Gilaula: “Earlier, the staff didn't have much knowledge. They used to administer oxytocin even before the delivery, without understanding its implications. We motivated and educated our staff. We explained the benefits and risks. We made them aware of the harm in administering oxytocin before childbirth."

ANM Sirsiya: "After receiving district-level training, we started following the rules more diligently, and maternal deaths decreased."

The introduction of a triage process has significantly improved the efficiency and effectiveness of patient prioritization, reflecting a positive change in the healthcare system's workflow. Moreover, counselling and family education have emerged as crucial components, ensuring patients and their families are well-informed and supported throughout the healthcare journey.

Verbatim: SN DCH: “The new approach involved triage and detailed patient data collection, including FHS (foetal heart sound) monitoring.”

SN Ikauna: “The fear of maternal complications and neonatal death significantly decreased with this approach."

The role of stakeholders, such as learning from senior staff, collaboration with partner agencies, and the influence of external agencies, has been instrumental in shaping the training's effect.

Verbatim: SN DCH: “We now provide counselling to patients and their family members. Earlier, they had misconceptions that the moment they reached the hospital, a drip with medication would be started. Now, everyone knows that it is harmful."

SN Gilaula: “Partner agencies played a significant role in educating us about complications during deliveries and the correct use of oxytocin.”

The collaborative efforts among different entities signify a holistic approach towards improving healthcare practices, incorporating diverse perspectives and resources to enhance the overall quality of care. [Table 1]

Theme III: Effect on Healthcare Workers

There's a noticeable shift in staff behaviour attributed to increased awareness among the workforce. This is evidenced by an enhanced understanding of protocols and practices, leading to substantial improvements in staff behaviour and performance within healthcare settings. Staff motivation and education play a pivotal role in this transformation, fostering a more informed and proactive healthcare workforce. This includes improved adherence to protocols, better utilization of resources, and a more patient-centric approach. The role of ASHA workers emerges as integral, contributing significantly to team dynamics and overall effect. Their involvement in disseminating knowledge and providing support has positively influenced healthcare practices.

Verbatim:SN Ikauna “Staff in the labour room started saying that all this (misuse of oxytocin) is happening too much. Gradually, when they saw all these things, they also started noticing."

SN Sirsiya “Regular meetings, training, and reinforcement of these changes improved our practices. Various agencies and professionals trained our staff.”

The effect is not only limited to individual healthcare workers but extends to the team level, signifying a collective change in behaviour and practice. This collaborative effort among healthcare professionals reflects a more cohesive and efficient approach to patient care.

SN DCH“Our team made a significant difference. The agency's visits prompted change. We could not have achieved these improvements without them."

Moreover, there's evidence of a shift towards restricting drug administration practices, indicating a more cautious and regulated approach towards medication usage. This suggests a greater emphasis on patient safety and compliance with established guidelines, driven by the effect of training and awareness initiatives among healthcare workers. [Table 1]

Verbatim: SN Sirsiya “The maternal and newborn care in our area has improved because earlier, the practices were different. We used to administer drugs and procedures without proper understanding. For instance, even when a patient was multi-gravida, we would still use oxytocin, and despite knowing better, we had bad habits. Babies would develop asphyxia, and sometimes even maternal complications were high.”

Theme IV: Effect on Patient’s Family

Resistance to change is observed among some patients and their families, particularly concerning alterations in established healthcare practices. The inclination of some patients towards pain-killer injections, with certain individuals demanding such interventions. It signifies a specific preference among some patients for certain medical interventions, potentially due to a desire for perceived immediate relief.

Verbatim: SN Malhipur “Many times, the patient would get a little angry, threaten to run away from the hospital where they'd have their way."

However, there is evidence of a positive effect on awareness among patients and their families. Increased awareness is evident in patients' improved understanding of healthcare processes, leading to positive changes in attitudes. Patients feel more empowered and informed about the importance of proper care, indicating a willingness to actively engage in their healthcare journey.

Verbatim: SN Ikauna "Patients are benefiting. They come for deliveries without asking for pain-relieving injections. They know it's harmful, and it's showing results."

SN DCH: “After oxytocin is administered and PPH occurs, we observe that a large amount of blood loss occurs. For the next patient, the family sees that blood loss was less, and they also realize that the previous delivery led to more blood loss.”

SN Gilaula: “Patients generally felt happier as complications were minimal with this approach, especially among those with higher education."

This dual dynamic showcases the complexity of implementing new practices and the varying responses among individuals when confronted with healthcare alterations. [Table 1]

Theme V: Documentation and Monitoring

The monitoring and documentation of the usage of uterotonics increased with training. This improved reporting systems, indicating a higher quality of data collection and analysis. A notable improvement in the quality and thoroughness of documentation practices.

Verbatim:SN Ikauna: "We started monitoring and reporting complications regularly, holding monthly meetings, and referring cases appropriately."

Furthermore, the analysis highlights a historical issue of inadequate reporting and documentation practices before interventions were implemented. The lack of documentation and monitoring in the past is identified as a significant gap that has been addressed through the interventions introduced. [Table 1]

Verbatim: SN Gilaula: "Records for administering oxytocin or misoprostol were not maintained before. The records were only maintained after delivery."

SN Malhipur: “ We didn't document the use of oxytocin in patient records."

This acknowledgement suggests a shift from previously insufficient practices towards more comprehensive and reliable documentation and monitoring methods.

Theme VI: Status of Maternal and Neonatal Health Before Intervention

This characterizes the healthcare landscape before interventions were introduced. Limited resources were a significant challenge, particularly in handling complications related to maternal and neonatal health. The healthcare system faced constraints in adequately managing and addressing complications due to resource scarcity.

Verbatim: SN Gilaula: “Earlier, we did not have sanitary pads, so we used cloth or homemade pads when there was bleeding. Now that we have sanitary pads, PPH (postpartum haemorrhage) was seen. People would insist on fundal pressure, which means pressing on the abdomen to expedite the delivery.”

The status of maternal and neonatal health before interventions showed negative consequences, primarily manifested through complications. Complications arising from childbirth or related issues were relatively common.

Verbatim: ANM Malhipur"We also administered misoprostol, instructing patients to insert it vaginally to expedite dilation."

SN Sirsiya: "Neonates often faced complications; they wouldn't cry or express distress."

ANM Sirsiya: “complex cases, we referred patients to the district hospital."

Furthermore, the status of the community portrayed a lack of awareness among its members regarding maternal and neonatal health.

Overall, the qualitative findings indicate a challenging healthcare landscape characterized by limited resources, higher instances of complications among mothers and newborns, and a lack of community awareness regarding maternal and neonatal health issues before the implementation of interventions. These issues underscore the critical need for targeted interventions and improvements to enhance the overall healthcare outcomes for mothers and newborns in the community. [Table 1]

Theme VII: "Injudicious Use of Uterotonics before Training"

It focuses on the difficulties and potential dangers associated with the administration of uterotonic drugs. It highlights the risks involved in using these drugs without adequate training or guidelines, which might lead to complications during labour or childbirth. It addresses the inappropriate or incorrect use of oxytocin, a common uterotonic drug. It encompasses instances such as using oxytocin during the third stage of labour or its misuse, possibly due to a lack of knowledge or adherence to medical procedures. [Table 1]

Verbatim: SN DCH: "The misuse of oxytocin and misoprostol was prevalent. The practice was to induce delivery as quickly as possible, using these drugs to speed up the process."

SN DCH: "Improper use of oxytocin, higher levels of postpartum haemorrhage, and increased complications led to staff revising their practices.”

It was observed that various aspects related to the administration of oxytocin, including the influence of doctors on its usage, changes in administration methods, and patient disclosure and feedback concerning the use of this drug during childbirth.

Verbatim: SN Gilaula: "Patients sometimes disclosed that they were given injections or pills before delivery. We inquired, and their input was invaluable."

SN Ikauna: "We identified instances where patients were given injections before delivery, which we didn't know earlier."

The inadequate knowledge and practices related to uterotonic drugs, encompasses assumptions about labour, lack of awareness regarding complications, and insufficient understanding about the appropriate use of these drugs among healthcare providers.

Verbatim: ANM Malhipur: “When we started our jobs, we had no idea about how to conduct deliveries. We used to administer oxytocin, thinking it would induce deliveries. We didn't know the correct dosages or when to administer it.

SN Sirsiya: "We assumed that when a woman was in pain, it meant she was in labour, and we administered oxytocin."

SN Gilaula: “We were unaware of complications such as postpartum haemorrhage (PPH) and didn't know how to handle them. We thought it was normal for women to experience complications during delivery."

SN DCH: “The improvement is noticeable, with birth asphyxia cases decreasing from 60–65 to 20–25, and neonatal deaths dropping from 22–23 per month to 6-10-11."

SN Sirsiya: “The change in birthing practices led to a substantial decrease in birth asphyxia and neonatal deaths."

The observations emphasize the critical need for comprehensive training, guidelines, and awareness programs to ensure the judicious and safe use of these medications, reducing risks and improving maternal health outcomes.

The comprehensive study on maternal and neonatal health in Shrawasti district highlights the importance of the effect of interventions on healthcare practices. Specifically, the decline in asphyxia cases from 74.5–33.2%, stillbirths from 28.5–12.5%, and PPH from 53.8–26% showcases the effectiveness of the interventions in improving maternal and neonatal health. The significant reduction in adverse health events in the post-intervention phase is largely aligned with the transformative effect of the interventions on multiple fronts, including enhanced knowledge and awareness regarding uterotonics usage among healthcare workers, improved training, behavioural shifts among healthcare workers, and a more informed patient population.

The qualitative findings unearth several themes that elucidate the multifaceted transformation in healthcare practices and its effect. "Improvements with Changing Practices" showcases the positive shift resulting from enhanced awareness initiatives and revised oxytocin administration practices. This change has significantly reduced complications, leading to a more natural birth experience while ensuring better healthcare quality. Moreover, the implementation of accountability measures at an administrative level highlights a shift towards responsible practices, deterring malpractice. Furthermore, themes like "Injudicious Use of Uterotonics before Training" and "Status of Maternal and Neonatal Health Before Intervention" underscore the challenges faced due to limited resources, inadequate awareness, and improper use of medications; before the training was conducted. These findings reinforce the critical necessity for targeted interventions and improvements to enhance healthcare outcomes in the community.

A growing body of literature has established the adverse effects associated with the intrapartum use of oxytocin in obstetric practice. These effects include hyperstimulation, uterine rupture, perineal tears, and foetal distress.^15–17 The studies from several districts of rural areas of Uttar Pradesh focuses on the prevalence of home births in rural areas of Uttar Pradesh, India, where untrained practitioners administer oxytocin injections to hasten labour without proper monitoring or medical supervision.^18–20 Thus, establishing protocols for oxytocin use in obstetrics is very essential.

A study conducted in rural Karnataka between 2007 and 2009 revealed that oxytocin was being misused for labour augmentation. The study enrolled 642 pregnant women, with 501 deliveries occurring in healthcare institutions and 99 at home. The findings suggest that oxytocin is being overused in both government and private healthcare settings, highlighting the necessity for adherence to clinical protocols and guidelines to ensure safe motherhood.²¹ The study complements the comprehensive study on maternal and neonatal health in Shrawasti district, which resulted in significant reductions in adverse outcomes like stillbirths, asphyxia, and post-partum haemorrhage through enhanced awareness initiatives, revised administration practices of oxytocin, and accountability measures at administrative levels.

A retrospective study revealed a considerable incidence of labour dystocia (LD), especially among primiparas, and highlighted associations between oxytocin use, LD, and delivery outcomes. An observational analysis of 1,263 electronic antenatal and delivery records randomly selected from the NU Hospital Group register in western Sweden evaluated the factors associated with LD among 5,702 deliveries between 2000 to 2001. Oxytocin was used in 55% of deliveries, primarily in primiparas (72.8%). Also, the frequency of Caesarean section (CS) was higher among women treated with oxytocin compared to those not given oxytocin, especially in primiparas. Neonates in the oxytocin group had a higher incidence of acidaemia compared to those not in the oxytocin group.²²

The theme "Effect of Training" emphasizes the significant enhancement in knowledge and awareness among healthcare workers, leading to better understanding and adherence to correct medical procedures. The introduction of triage processes, counselling, and family education have all contributed to improved healthcare practices. Similarly, a study was conducted in India to assess the practices and barriers faced by healthcare providers while providing maternal and newborn healthcare. The study collected quantitative and qualitative data from 56 facilities and 125 healthcare providers. The results showed that uterotonics were often used to augment labor, even in facilities not equipped for certain procedures. Primary barriers included a lack of awareness of guidelines, inadequate training, and reliance on traditional practices. The study highlighted the need for comprehensive training, improved guideline awareness, regular supervision, and addressing traditional practices to enhance the quality of maternal and newborn healthcare in India.²³

In corroboration with the above-mentioned studies, the study conducted in Karnataka highlighted the need for standardized guidelines, enhanced training, and improved community education to ensure the safe and appropriate utilization of uterotonics during labour and delivery. The study examined uterotonic use during childbirth in two districts of Karnataka; Bagalkot and Hassan. Formal healthcare providers used oxytocin primarily to augment labour and prevent postpartum haemorrhage (PPH), while informal practitioners commonly administered oxytocin to enhance labour in community settings. Decision-making regarding uterotonic use varied. Family members believed uterotonic injections were used to increase pain and expedite delivery, pressuring healthcare providers to administer these medications.²⁴

The effect extends to healthcare workers themselves, with a noticeable shift in behaviour and performance, indicating a more informed and proactive workforce. Additionally, the theme "Effect on Patient's Family" portrays varying responses among patients and their families, showcasing an increased awareness and willingness to engage in healthcare decisions. However, challenges persist, including resistance to change among some patients, which underscores the importance of continuous education and community engagement.

A study conducted as part of the Oxytocin Initiative Project investigated the use of uterotonic medications during childbirth in Uttar Pradesh and Karnataka, India. The research included 140 interviews with healthcare providers and mothers. The study found that uterotonic use for labour augmentation was common in both health facilities and community settings, which deviated from established guidelines. The lack of knowledge among community members regarding the adverse effects of incorrect uterotonic use was evident. ANMs associated uterotonic use with risks of prolonged labour and fetal health, sometimes using it without proper indications. Financial pressures were also influential, with some providers admitting to administering uterotonics to ensure monetary compensation.

The current qualitative analysis also addresses the historical issues of inadequate documentation and monitoring practices, highlighting the need for improved reporting systems and comprehensive documentation to ensure a higher quality of data collection and analysis. It is emphasized that the training not only improved clinical outcomes but also addressed systemic issues such as documentation deficiencies, inadequate training, and the inappropriate use of medications. The shift towards more informed, accountable, and patient-centric practices emphasizes the success of the interventions in shaping a more effective healthcare system.

In conclusion, the interventions have shown promising results in improving maternal and neonatal health outcomes in the Shrawasti district. The findings emphasize relationship between misuse of oxytocin and birth asphyxia, PPH, still birth, newborn deaths in health facilities. Lack of knowledge and awareness in service providers and care seekers are major road blockers in addressing this issue. Assessment of the financial burden on families and society because of this negligence and ignorance need to be done by district and disseminate the information as one of tool to create awareness in society. Joint efforts of administration and health department in a drive form can address this issue to great extent in which measures like capacity building and sensitization of care providers, awareness of care seekers, rigorous monitoring and prompt referral can be included.

Ethics approval and Consent to Participate:

The ethical clearance was obtained from the Institutional Ethical Committee, Rama Medical College (RMCHRC/ACADEMIC/Ph.D./1989B/06/08/2023 dated 05.09.2023). The informed consent was obtained prior to the in-depth interview from all the participants.

Availability of Data and Materials: The datasets generated and/or analysed during the current study are available in the Figshare repository, (https://figshare.com/s/4ee7db3a98cb5e409f97)

Consent for Publication:

We give the consent for publication of the research manuscript

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest:

The authors have no competing interests to declare.

Acknowledgement: We are thankful to the administration and healthcare officials at the Shrawasti district for their support in the research project.

Authors contribution:

SY: Conceptualization, methodology, software, investigation, resources, data curation, writing review and editing, visualisation, supervision, project administration.

SA: Conceptualization, methodology, writing review and editing, visualisation, supervision, project administration.

PL: software, formal analysis, writing original draft, writing review and editing

MK: Conceptualization, project administration, supervision

AG: Conceptualization, methodology, supervision

The final manuscript is read and approved by all authors.

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No competing interests reported.

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Assessing the Effect of Integrated Health Interventions on Maternal and Neonatal Health Outcomes in an aspirational district of Uttar Pradesh: A mixed method study

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Abstract

Figures

Introduction

Methodology

Qualitative Data Collection and Analysis:

Sampling Procedure:

Intervention and Monitoring:

Data Organization for Intervention Assessment:

Ethical Considerations:

Results

Status of maternal and Neonatal health before and after the intervention:

Qualitative Analysis [Table 1]:

Theme I: Improvements with Changing Practices

Verbatim: ANM Malhipur: “Actually, ma'am, initially, we used to administer oxytocin before delivery.”

Theme II: Effect of Training

SN Ikauna: “The fear of maternal complications and neonatal death significantly decreased with this approach."

Theme III: Effect on Healthcare Workers

Theme IV: Effect on Patient’s Family

Theme V: Documentation and Monitoring

SN Malhipur: “ We didn't document the use of oxytocin in patient records."

Theme VI: Status of Maternal and Neonatal Health Before Intervention

Verbatim: ANM Malhipur"We also administered misoprostol, instructing patients to insert it vaginally to expedite dilation."

SN Sirsiya: "Neonates often faced complications; they wouldn't cry or express distress."

ANM Sirsiya: “complex cases, we referred patients to the district hospital."

Theme VII: "Injudicious Use of Uterotonics before Training"

Discussion

Conclusion

Declarations

References

Additional Declarations

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