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. 2018 Oct 8;3(5):e000907.
doi: 10.1136/bmjgh-2018-000907. eCollection 2018.

Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

Ramesh Agarwal  1 , Deepak Chawla  2 , Minakshi Sharma  3 , Shyama Nagaranjan  4 , Suresh K Dalpath  5 , Rakesh Gupta  5 , Saket Kumar  5 , Saumyadripta Chaudhuri  1 , Premananda Mohanty  3 , Mari Jeeva Sankar  1 , Krishna Agarwal  6 , Shikha Rani  7 , Anu Thukral  1 , Suksham Jain  2 , Chandra Prakash Yadav  8 , Geeta Gathwala  9 , Praveen Kumar  10 , Jyoti Sarin  11 , Vishnubhatla Sreenivas  12 , Kailash C Aggarwal  13 , Yogesh Kumar  11 , Pradip Kharya  14 , Surender Singh Bisht  15 , Gopal Shridhar  16 , Raksha Arora  17 , Kapil Joshi  18 , Kapil Bhalla  9 , Aarti Soni  19 , Sube Singh  5 , Prischillal Devakirubai  16 , Ritu Samuel  16 , Reena Yadav  20 , Rajiv Bahl  21 , Vijay Kumar  3 , Vinod Kumar Paul  1 ; QI Haryana Study Collaboration
Collaborators, Affiliations

Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

Ramesh Agarwal et al. BMJ Glob Health. .

Abstract

Background: Low/middle-income countries need a large-scale improvement in the quality of care (QoC) around the time of childbirth in order to reduce high maternal, fetal and neonatal mortality. However, there is a paucity of scalable models.

Methods: We conducted a stepped-wedge cluster-randomised trial in 15 primary health centres (PHC) of the state of Haryana in India to test the effectiveness of a multipronged quality management strategy comprising capacity building of providers, periodic assessments of the PHCs to identify quality gaps and undertaking improvement activities for closure of the gaps. The 21-month duration of the study was divided into seven periods (steps) of 3 months each. Starting from the second period, a set of randomly selected three PHCs (cluster) crossed over to the intervention arm for rest of the period of the study. The primary outcomes included the number of women approaching the PHCs for childbirth and 12 directly observed essential practices related to the childbirth. Outcomes were adjusted with random effect for cluster (PHC) and fixed effect for 'months of intervention'.

Results: The intervention strategy led to increase in the number of women approaching PHCs for childbirth (26 vs 21 women per PHC-month, adjusted incidence rate ratio: 1.22; 95% CI 1.17 to 1.28). Of the 12 practices, 6 improved modestly, 2 remained near universal during both intervention and control periods, 3 did not change and 1 worsened. There was no evidence of change in mortality with a majority of deaths occurring either during referral transport or at the referral facilities.

Conclusion: A multipronged quality management strategy enhanced utilisation of services and modestly improved key practices around the time of childbirth in PHCs in India.

Trial registration number: CTRI/2016/05/006963.

Keywords: cluster-randomised trial; health systems; maternal health; paediatrics.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Conceptual diagram depicting activities during the intervention period. *Skills included those related to care women (general physical examination, obstetric examination, use of photograph and active management of third stage of labour), baby (measuring weight and axillary temperature, breast feeding support and detection of sickness) or both (hand hygiene). DH, district hospital; NHM, National Health Mission; OSCE, Objective Structured Clinical Examination; PHC, primary health centre; SoP, standard operating procedure.
Figure 2
Figure 2
Study participant flow. *The women or the baby may have required referral after delivery. PHC, primary health centre.
Figure 3
Figure 3
Performance of three primary health centres (PHC). Y-axis represents the care score derived from adding the number of 12 childbirth practices received by a patient. Dots represent the care score of individual observed patient. Solid line with shaded area represents the smoothed trend in care score and its 95% CI.
See this image and copyright information in PMC

References

    1. Liu L, Oza S, Hogan D, et al. . Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016;388:3027–35. 10.1016/S0140-6736(16)31593-8 - DOI - PMC - PubMed
    1. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1775–812. 10.1016/S0140-6736(16)31470-2 - DOI - PMC - PubMed
    1. GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1725–74. 10.1016/S0140-6736(16)31575-6 - DOI - PMC - PubMed
    1. Baqui AH, Mitra DK, Begum N, et al. . Neonatal mortality within 24 hours of birth in six low- and lower-middle-income countries. Bull World Health Organ 2016;94:752–8. 10.2471/BLT.15.160945 - DOI - PMC - PubMed
    1. Lawn JE, Blencowe H, Waiswa P, et al. . Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet 2016;387:587–603. 10.1016/S0140-6736(15)00837-5 - DOI - PubMed

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