The results of this intervention show that a system of regular visits to facilities, based on a cycle of assessment, feedback, training and action at public health facilities, backed by policy makers can lead to substantial improvement in adherence to evidence based care practices. Quality of intrapartum and immediate postpartum care is closely linked to better maternal and perinatal outcomes, and our results suggest a potential approach for improving the quality of childbirth services.
Of 17 selected practices, significant improvements were seen in 10 practices. Most importantly, several unnecessary practices reduced significantly, such as augmentation of labour, routine episiotomy and vaginal packing. Similarly, the use of several beneficial practices increased, such as monitoring of foetal heart sounds during labour, use of oxytocin in 3rd stage of labour, and initiation of breastfeeding within one hour after birth.
In terms of perinatal outcomes, the single most significant change was reduction in the rates of routine augmentation of labour, which was practiced in 93% facilities at baseline, and reduced to 45% facilities after the intervention. Convincing providers to avoid routine augmentation of labour was difficult to achieve, since most preferred quick delivery, which reduces the need for monitoring of labour. Most providers also preferred to complete a delivery before their shift change, encouraging them to expedite the delivery process.
There was a significant reduction in the proportion of facilities practicing routine episiotomy for primigravidas, however this change was also challenging to achieve. Providers did not readily give up the practice of routine episiotomy; some doctors vehemently argued with members of the visiting team saying “are you trying to make us dais (traditional birth attendants)?”. Some doctors dismissed all the assembled evidence and said that they would rather go by what they have learnt from their seniors in medical colleges.
Some practices did not show significant improvement -- these included avoidance of lithotomy position for delivery, use of a partograph, hand-washing, use of sterile gloves for delivery, and postpartum check in the ward. Based on our interactions with staff during feedback and training sessions, we surmised that the reasons for not changing a practice were linked to not being fully convinced of the value of changed practice, lack of supplies, fear of being ridiculed by colleagues, or that the practices meant greater time and effort for providers. For example, some providers were convinced about the need to deliver women in an upright position and tried it out only during night duties when other staff was not present and watching. The lack of postpartum monitoring might be related to the fact that women and newborns were routinely discharged 48 hours after delivery without an assessment of the maternal or neonatal condition. Hence introduction of discharge criteria could encourage post partum checks to ensure fitness for discharge. Further, it would be critical to have medical colleges strictly follow and advocate evidence based care practices.Greater monitoring of quality by district level authorities would help to bring about changes in practices such as postpartum monitoring and handwashing.
In our view, the underlying factors through which this intervention improved childbirth practices were: (1) providers understanding the rationale for the necessity of a change and its benefits for maternal or perinatal outcomes, which occurred through orientation of doctors and discussions during repeated facility visits. We found that most changes occurred when senior doctors or senior labour room nurse-midwives took on an active role in encouraging behavior change in their facilities. (2) repeated visits by program staff along with educational materials acted as reminders, (3) endorsement by persons in authority either through office orders or during review meetings, (4) the new practice reduced the workload of staff (for example, avoiding the routine enema or pubic shaving), (5) facilitating the availability of supplies or equipment by program staff, and (6) the on-site training on specific issues was useful to convince providers of the need for change in practices, especially for nurse midwives. Orientation in small groups allowed local clinical staff to openly express their concerns and questions, and discuss issues specific to their facility. One of the most powerful aspects of on-site training was the link between moral and ethical responsibility and adverse outcomes, if evidence based practices are not followed.
Simultaneously, there were some barriers that prevented the improvement of clinical practices: (1) medical colleges as role models – many doctors challenged the evidence, stating that they would do what they had learnt and observed in their medical colleges, (2) the new practice meant greater effort for providers, for example, the monitoring of fetal heart sounds during labour or postpartum checkup would mean more work for providers, and (3) lack of skills or confidence in performing a new practice, for example, many providers expressed that they were not able to conduct a delivery in upright position. A qualitative study in Latin American hospitals has identified barriers to change at level of individual providers, hospitals policies and macro level factors; and suggests that interventions must attempt to bring about sustainable change at all levels [31]. Other studies have also identified that the common barriers to quality improvement are leaders’ and clinicians’ knowledge, attitudes, and practices, and the implementation climate [28]. Medical colleges and professional associations in India have not paid sufficient attention to evidence based childbirth care thus far, and at one time even promoted “programmed labour” which includes routine augmentation [32].
While poor quality of childbirth services has been recognized as a major barrier for reduction of maternal and perinatal mortality in different settings [32, 33], successful experiences of improving quality are limited. Many approaches limit themselves to assessing quality without intervening to improve quality. Our intervention attempted to make an impact both at individual and system level. Examples of actions at the individual level were guidance materials, orientation and training programs and feedback to providers, while examples of actions at the system level were feedback to district health officials, who in turn took necessary steps to address the gap. Further, repeated visits to the facility were crucial in maintaining the changes.
Experience from other settings has demonstrated the effectiveness of various approaches to bring about change in evidence based care practices. In an intervention study in Ukraine, training of staff on evidence based guidelines resulted in significant decrease in harmful practices and adherence to protocols [34], mostly by first 3 months of intervention followed by its being sustained. In a study from Turkey, practices to speed up labour (early amniotomy and augmentation with oxytocin) were identified as very common and were linked to financial incentives for a quick delivery [35]. In our study, the social pressure to comply with practices recommended by supervisors and peers played a major role in adopting evidence based procedures. In a pilot study in a single hospital in Karnataka, India, use of a childbirth quality checklist by providers led to significant improvement in quality of care [36]. However, scaling up the approach in greater number of hospitals, coupled with a longer follow-up will demonstrate the effectiveness of this approach. Another study in an Iranian hospital involved building a professional consensus to identify the priority evidence based recommendations and designing new model of care by involving the physicians in the hospital also showed promising results [37].
An overview of systematic reviews of strategies [38] to improve quality of maternal and child care has shown that no single strategy is effective in changing professional practice, and that multiple approaches should be combined to improve quality. The reviewers also conclude that organizational interventions might be important, given the wide prevalence of underlying organizational or system problems.
Limitations
Parijaat was designed as a health system intervention and not as a study, hence there are certain limitations to the data and its interpretation. The government supported intervention did not allow for control facilities to enable comparison. The intervention started at different times in different facilities resulting in somewhat different periods of intervention and visits across facilities. An important tool for assessing the practices was observation of labour and delivery, which depended on whether a woman was in labour at the time of scheduled facility visits. Hence some assessments were based on interviews with women that had delivered on the previous day or two. It is possible that some providers improved their practices in presence of facilitators, which could affect the results of delivery observation. However, to avoid this, facilitators combined the results of observations with those from interviews with postpartum women, which in turn would reflect practices in absence of a facilitator. Although we have only compared data from the first and last visits, we observed that most change was established and sustained within 6 months of initiating the intervention. Hence we feel confident about attributing change to the intervention.
Strengths
Among the strengths of this intervention is the development of assessment tools based on a review (from literature and experience) of childbirth practices in Rajasthan and by building consensus among local stakeholders. Secondly, the intervention was implemented across large numbers of institutions in 10 districts which represented a diversity of settings, hence the feasibility of scaling up is high. These selected institutions conducted the majority of deliveries in their area, hence the intervention has a potential to make an impact on a larger proportion of deliveries. Further, the intervention attempted to make the quality improvement part of the organizational culture by building a professional consensus and providing regular feedback to providers, managers and administrators.
A question that remains is whether changes will last if the system of monitoring visits by project staff were to be withdrawn. Although project teams were accompanied by government staff on about 25% visits, we feel that while practices are likely to be sustained where providers were convinced about the value of change and found it convenient to do so. Reviews of sustainability suggest that quality improvement in health services are likely to sustain if they become part of organizational culture [39, 40]. Other experiences that show that quality improvement efforts need to be repetitive even after reaching a mature phase, and that efforts have to be focussed at all levels from frontline providers to senior leaders within the organization and also involve external structures such as national quality control boards or regulators [41]. It has been shown that continuously monitoring quality indicators significantly improved the quality of care [42, 43]. In a qualitative study of policy makers and program managers in India, poor monitoring of health systems has been identified as an important bottleneck to improving quality of delivery services [44]. Hence we feel that the quality improvement efforts should continue in order to sustain the change, and should be institutionalised through state level regulatory bodies.
