How performance targets can ingrain a culture of 'performing out': An ethnography of two Indian primary healthcare facilities.

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and 'performing out', whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature. In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of 'performing out' occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of 'performing out' are prevalent. We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system as a whole. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of practice of Bourdieu, encompassing the concepts of field, habitus, and capital. This lens helps illustrate how resource scarcity, unyielding application of unrealistic targets with punitive sanctions for non-achievement, and complex power dynamics lead system actors to manipulate data and create documentation to show the achievement of targets that were not actually met. The practices of 'performing out' are shaped by, and in turn shape, the organisational culture of the facilities, with perverse behaviour becoming part of an entrenched habitus - the 'dispositions' of agents that guide behaviour and thinking. In the longer term, the habituation of 'performing out' contributes to a systemic orientation toward sub-par performance, undermining quality of care.

Ethical considerations of phone-based interviews from three studies of COVID-19 impact in Bihar, India.

Phone-based interviews present a range of ethical challenges, including how to ensure informed consent and privacy and maintain confidentiality. Our paper presents conceptual and practical ethical considerations taken into account across three telephone studies on the impact of COVID-19 conducted following India's nationwide lockdown imposed in March 2020. Two studies captured COVID-19 response impact on primary-level Reproductive Maternal Neonatal and Child Health (RMNCH) services and on provider wellness, respectively. The third study focused on how the gendered experience of COVID-19 and the state's response to control transmission impacted women's lives, focusing on health services, livelihood, entitlements and social change, by interviewing individual women. The ethical challenges as well as the advantages of digital data collection are presented with recommendations for low-resource settings. Ethical considerations included the above challenges as well as avoiding posing unreasonable time burden on the respondents, framing questions with a gendered lens, considering emotional states given contagion concerns and economic uncertainties, and redressing pandemic-induced distress. Using scripted Hindi was challenging in consent-taking, as was protecting household respondents' privacy and confidentiality during lockdown. Unanticipated positive ethical implications of using a telephone approach included providing respondents privacy and catharsis, respondents choosing convenient interview times and affording health providers more privacy than institutional inperson interviews. Internalising empathy, respect and appreciative enquiry are key to establishing rapport in the absence of prior relationships. Institutional Review Board (IRB) time limits on call duration need to be flexible to allow for 'active listening' and empathetic enquiry in surveys on the impact of COVID-19.

"We are nurses - what can we say?": power asymmetries and Auxiliary Nurse Midwives in an Indian state.

In India, nurses and midwives are key to the provision of public sexual and reproductive health services. Research on impediments to their performance has primarily focused on their individual capability and systemic resource constraints. Despite emerging evidence on gender-based discrimination and low professional acceptance faced by these cadres, little has been done to link these constraints to power asymmetries within the health system. We analysed data from an ethnography conducted in two primary healthcare facilities in an eastern state in India, using Veneklasen and Miller's expressions of power framework, to explore how power and gender asymmetries constrain performance and quality of care provided by Auxiliary Nurse Midwives (ANMs). We find that ANMs' low position within the official hierarchy allows managers and doctors to exercise "power over" them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways. Our findings contribute to the empirical evidence, advancing the understanding of gender as a structurally embedded dimension of power. We illustrate how the weak positioning of ANMs reflects their lack of representation in policymaking positions, a virtual absence of gender-sensitive policies, and ultimately organisational power structures embedded in patriarchy. By deepening the understanding of empowerment, the paper suggests implementable pathways to empower ANMs for improved performance. This requires addressing entrenched gender inequities through structural and organisational changes that realign power relations, facilitate more collaborative ways of exercising power, and create the antecedents to individual empowerment.

Childbirth care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys between 1995 and 2014 examining use of care, provider mix and immediate postpartum care content.

BACKGROUND: Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care. METHODS: We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn. RESULTS: Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010-2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured. CONCLUSIONS: Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women's expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers' behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Temporal and regional variations in use, equity and quality of antenatal care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys.

BACKGROUND: Egypt has seen substantial decreases in maternal mortality and reached near universal coverage for antenatal care (ANC). The objective of this paper is to describe the changes over time (1991-2014) in the use of ANC in Egypt, focusing on sector of provision (public versus private), and the content and equity of this care, to inform future policies for improving maternal and newborn health. METHODS: We used Demographic and Health surveys (DHS) conducted in Egypt in 1995, 2000, 2005, 2008 and 2014 to explore national and regional trends in ANC. To assess content of care, we calculated the percentage of ANC users who reported receiving seven ANC components measured in DHS in 2014. RESULTS: During the period under consideration, the percentage of women in need of ANC who received facility-based ANC increased from 42 to 90%, the majority of which was private-sector ANC. The mean number of ANC visits among ANC users increased over time from 7.5 (95% confidence interval [CI] = 7.1-7.9) in 1991-1995 to 9.7 (95%CI 9.6-9.9) in 2010-2014. In 2010-2014, 44% of women using public ANC reported eight or more visits compared to 71% in private ANC. In the same period, 24% of ANC users received all seven care components. This percentage ranged from 10% of women reporting fewer than four ANC visits to 29% of women reporting eight or more. The poorest ANC users received all seven measured components of care less often than the wealthiest (20% versus 28%, p-value< 0.001). CONCLUSIONS: Egypt's improvements in ANC coverage were characterized by decreasing reliance on public services and a rising number of ANC visits. However, despite rising ANC coverage, less than a third of women received the seven essential ANC components measured at least once during pregnancy, with differences between poorer and wealthier women. Policymakers need to ensure that high ANC coverage translates into equity-focused interventions targeting ANC quality. Further research needs to support this effort by assessing the determinants behind poor quality of ANC and evaluating potential interventions.

First assessment of phytoplankton diversity in a Marrocan shallow reservoir (Sidi Abderrahmane).

In order to find effective measures to control a Moroccan shallow reservoir (Sidi Abderrahmane), a better understanding of phytoplankton composition, abundance, spatial and temporal distribution it is necessary. Trophic level and the stability status were assessed upon the basis of Shannon diversity index (H'), species richness (S), and evenness (J) index. Statistical tests were used to evaluate the different relationships between phytoplankton and the concentrations of several physico-chemical parameters, and the main soluble nutrients. In surveys, the samples were taken fortnightly from May 2011 to December 2012. 64 taxa belonging to seven groups of phytoplankton were identified, including Bacillariophyceae (25 taxa), Chlorophyceae (22 taxa), and Cyanophyceae (9 taxa). Aulacoseira granulata, Nitzschia palea, Scenedesmus acuminatus, and Oscillatoria sp, were the main contributors to the dissimilarity in temporal distribution. Phytoplankton population never reached a monospecificity situation. Shannon and evenness indices were between (0.0001 < H' < 0.15; 0.003 < J < 0.085) and manifested a young phytoplankton community with high multiplying power. There were significant correlations between total phytoplankton (r = 0.015, p < .01) and water temperature. Significant negative correlations were observed between transparency and Cyanophyceae (r = -0.208, p < .05) and between the number of species and transparency (r = -0.206, p < .05), orthophosphorus (r = -0.377, p < .01), and nitrates (r = -0.301, p < .01). A negative correlation was found between Orthophosphorus and Chlorophyceae (r = -0.377, p < .01). Similar correlations were also observed with nitrates and Chlorophyceae (r = -0.297, p < .01), Silica and Bacillariophyceae (r = 0, p < .01) and total phytoplankton (r = -0.372, p < .07). The underwater light condition, as indicated by Secchi depth fluctuations, hydraulic process conditions (short residence time, short outflow/inflow ratio) were shown to be the limiting factors in regulating the density of phytoplankton. With reference to Palmer pollution index, test results indicated an oligotrophic or mesotrophic reservoir. The data presented provide the first contemporary account of the level of algal diversity present, the prominent environmental conditions and trophic status of Sidi Abderrahmane reservoir waters.

Hospital practice versus evidence-based obstetrics: categorizing practices for normal birth in an Egyptian teaching hospital.

BACKGROUND: Little is known of common normal labor hospital practices in Egypt or of their relationship to evidence-based obstetrics. This study documented facility-based practices for normal labor and delivery in Egypt for the first time by categorizing 44 practices observed in a busy obstetric teaching hospital according to the World Health Organization (WHO) Technical Working Group on Normal Birth classification of normal birth practices. METHODS: A multidisciplinary approach combined directly observing practices that were applied to individual laboring women and their newborns, observing ward activities, interviews, and focus groups. One hundred seventy-five normal births were observed in their entirety, over 28 days and nights, by medically trained observers using an observation checklist that documented 537 variables for each woman. Mothers were interviewed postpartum, and findings were shared with practitioners for their feedback. Observed practices were categorized according the 1999 WHO classification of 59 practices for normal birth, depending on their usefulness, effectiveness, or harmfulness. RESULTS: There was infrequent use of beneficial practices that should be encouraged and an unexpectedly high level of harmful practices that should be eliminated. Some beneficial practices were applied inappropriately, and practices of unproved benefit were also documented, some of which are potentially harmful to childbearing mothers and their babies. CONCLUSIONS: Hospital practices for normal labor were largely not in accordance with the WHO evidence-based classification of practices for normal birth. The findings are worrying, given the increasing proportion of hospital-based births in Egypt and the country's improved but relatively high maternal and neonatal mortality rates. Obstacles to following evidence-based protocols for normal labor require examination.