Strengthening the Use of Partograph in High Caseload Public Health Facilities in India through an Integrated Quality Improvement Approach.

BACKGROUND: The effective implementation of evidence-based practices including the use of partograph to improve maternal and newborn outcomes is critical on account of increased institutional delivery. However, despite clear guidelines, partograph use in India is not widely practiced. MATERIALS AND METHODS: Quality improvement (QI) efforts along with training and mentoring were operationalized in a total of 141 facilities across 26 high priority districts of India. Assessments were conducted across baseline, intervention period, and end line. These included reviewing the availability of partograph and staff competency in filling them at baseline and end line, as well as reviewing monthly data for use and completeness of filling. The monthly data were tabulated quarter wise to study trends. Competency scores were tabulated to show the difference across assessments. RESULTS: An overall upward trend from 29% to 61% was seen in the practice of partograph use. Simultaneously, completeness in filling up the partograph increased from 32% to 81%. Staff competency in filling partograph improved considerably: proportion of staff scoring low decreased over the intervention period from 63% to 2.5% (P < 0.0001), and the proportion scoring high increased from 13% to 72% (P < 0.0001) from baseline to end line. CONCLUSION: The integrated approach of training, mentoring, and QI can be used in similar settings to strengthen partograph use.

Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn, and reproductive health-care services in Uttar Pradesh, India: a quasi-experimental study.

BACKGROUND: How to harness the private sector to improve population health in low-income and middle-income countries is heavily debated and one prominent strategy is social franchising. We aimed to evaluate whether the Matrika social franchising model-a multifaceted intervention that established a network of private providers and strengthened the skills of both public and private sector clinicians-could improve the quality and coverage of health services along the continuum of care for maternal, newborn, and reproductive health. METHODS: We did a quasi-experimental study, which combined matching with difference-in-differences methods. We matched 60 intervention clusters (wards or villages) with a social franchisee to 120 comparison clusters in six districts of Uttar Pradesh, India. The intervention was implemented by two not-for-profit organisations from September, 2013, to May, 2016. We did two rounds (January, 2015, and May, 2016) of a household survey for women who had given birth up to 2 years previously. The primary outcome was the proportion of women who gave birth in a health-care facility. An additional 56 prespecified outcomes measured maternal health-care use, content of care, patient experience, and other dimensions of care. We organised conceptually similar outcomes into 14 families to create summary indices. We used multivariate difference-in-differences methods for the analyses and accounted for multiple inference. FINDINGS: The introduction of Matrika was not significantly associated with the change in facility births (4 percentage points, 95% CI -1 to 9; p=0·100). Effects for any of the other individual outcomes or for any of the 14 summary indices were not significant. Evidence was weak for an increase of 0·13 SD (95% CI 0·00 to 0·27; p=0·053) in recommended delivery care practices. INTERPRETATION: The Matrika social franchise model was not effective in improving the quality and coverage of maternal health services at the population level. Several key reasons identified for the absence of an effect potentially provide generalisable lessons for social franchising programmes elsewhere. FUNDING: Merck Sharp and Dohme Limited.

Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India.

OBJECTIVE: To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. METHODS: Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother-neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. FINDINGS: The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother-neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. CONCLUSION: In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh.

Cash transfers, maternal depression and emotional well-being: Quasi-experimental evidence from India's Janani Suraksha Yojana programme.

Maternal depression is an important public health concern. We investigated whether a national-scale initiative that provides cash transfers to women giving birth in government health facilities, the Janani Suraksha Yojana (JSY), reduced maternal depression in India's largest state, Uttar Pradesh. Using primary data on 1695 women collected in early 2015, our quasi-experimental design exploited the fact that some women did not receive the JSY cash due to administrative problems in its disbursement - reasons that are unlikely to be correlated with determinants of maternal depression. We found that receipt of the cash was associated with an 8.5% reduction in the continuous measure of maternal depression and a 36% reduction in moderate depression. There was no evidence of an association with measures of emotional well-being, namely happiness and worry. The results suggest that the JSY had a clinically meaningful effect in reducing the burden of maternal depression, possibly by lessening the financial strain of delivery care. They contribute to the evidence that financial incentive schemes may have public health benefits beyond improving uptake of targeted health services.

Protocol for the evaluation of a social franchising model to improve maternal health in Uttar Pradesh, India.

BACKGROUND: Social franchising is the fastest growing market-based approach to organising and improving the quality of care in the private sector of low- and middle-income countries, but there is limited evidence on its impact and cost-effectiveness. The "Sky" social franchise model was introduced in the Indian state of Uttar Pradesh in late 2013. METHODS/DESIGN: Difference-in-difference methods will be used to estimate the impact of the social franchise programme on the quality and coverage of health services along the continuum of care for reproductive, maternal and newborn health. Comparison clusters will be selected to be as similar as possible to intervention clusters using nearest neighbour matching methods. Two rounds of data will be collected from a household survey of 3600 women with a birth in the last 2 years and a survey of 450 health providers in the same localities. To capture the full range of effects, 59 study outcomes have been specified and then grouped into conceptually similar domains. Methods to account for multiple inferences will be used based on the pre-specified grouping of outcomes. A process evaluation will seek to understand the scale of the social franchise network, the extent to which various components of the programme are implemented and how impacts are achieved. An economic evaluation will measure the costs of setting up, maintaining and running the social franchise as well as the cost-effectiveness and financial sustainability of the programme. DISCUSSION: There is a dearth of evidence demonstrating whether market-based approaches such as social franchising can improve care in the private sector. This evaluation will provide rigorous evidence on whether an innovative model of social franchising can contribute to better population health in a low-income setting.