A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

Dominic Montagu, Katie Giessler, Michelle Kao Nakphong, Cathy Green, Kali Prosad Roy, Ananta Basudev Sahu, Kovid Sharma, May Sudhinarset, Dominic Montagu, Katie Giessler, Michelle Kao Nakphong, Cathy Green, Kali Prosad Roy, Ananta Basudev Sahu, Kovid Sharma, May Sudhinarset

Abstract

Background: Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch.

Methods: We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome RESULTS: Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a 'halo' effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed.

Conclusions: This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a 'halo' effect, changing many other aspects of patient-provider interaction at the same time.

Trial registration: QI Phase 1 - NCT04208867 . Retrospectively registered. December 19th, 2019. QI Phase 2 - NCT04208841 . Retrospectively registered. December 23, 2019.

Keywords: Maternal health; Person-centered care; Quality improvement.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Mean adjusted PCMC scores, by survey round and Light Touch/Intensive sites. Scores were scaled to a 100-point scale. All estimates adjusted for age, parity, education, wealth, religion, caste, facility type, delivery provider, ANC visits, and pregnancy complications. Robust standard errors were used
Fig. 2
Fig. 2
Mean adjusted PCMC scores by facility and survey round. Scores were scaled to a 100-point scale. All estimates adjusted for age, parity, education, wealth, religion, caste, facility type, delivery provider, ANC visits, and pregnancy complications. Robust standard errors were used

References

    1. Office of the Registrar General & Census Commissioner. MMR Bulletin-2014-16.pdf [Internet]. 2018 [cited 2019 Sep 16]. Available from: .
    1. Montagu D, Sudhinaraset M, Diamond-Smith N, Campbell O, Gabrysch S, Freedman L, et al. Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia. Health Policy Plan. 2017;32(8):1146–1152.
    1. Diamond-Smith N, Sudhinaraset M. Drivers of facility deliveries in Africa and Asia: regional analyses using the demographic and health surveys. Reprod Health. 2015;12(1):6.
    1. Bhattacharyya S, Srivastava A, Roy R, Avan BI. Factors influencing women’s preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis. BMC Pregnancy Childbirth. 2016;16(1). 10.1186/s12884-016-0839-6 [cited 2019 Jan 13].
    1. Sudhinaraset M, Treleaven E, Melo J, Singh K, Diamond-Smith N. Women’s status and experiences of mistreatment during childbirth in Uttar Pradesh: a mixed methods study using cultural health capital theory. BMC Pregnancy Childbirth. 2016;16(1):332.
    1. Kruk ME, Kujawski S, Moyer CA, Adanu RM, Afsana K, Cohen J, et al. Next generation maternal health: external shocks and health-system innovations. Lancet. 2016;388(10057):2296–2306.
    1. Tunçalp ӧ, Were W, MacLennan C, Oladapo O, Gülmezoglu A, Bahl R, et al. Quality of care for pregnant women and newborns-the WHO vision. BJOG Int J Obstet Gynaecol. 2015;122(8):1045–1049.
    1. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reproductive Health. 2017;14(1) [cited 2018 Jul 4]. 10.1186/s12978-017-0381-7.
    1. Raj A, Dey A, Boyce S, Seth A, Bora S, Chandurkar D, et al. Associations between mistreatment by a provider during childbirth and maternal health complications in Uttar Pradesh. India Maternal Child Health J. 2017;21(9):1821–1833.
    1. Sudhinaraset M, Landrian A, Afulani PA, Diamond-Smith N, Golub G. Association between person-centered maternity care and newborn complications in Kenya. Int J Gynecol Obstet. 2019;148(1):27–34.
    1. National Family Health Survey, India. NFHS-4. Mumbai: International Institute for Population Sciences; 2014. Available from: . Accessed 28 Nov 2020.
    1. Sharma G, Penn-Kekana L, Halder K, Filippi V. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reprod Health. 2019;16(1):7.
    1. Singh S, Doyle P, Campbell OM, Mathew M, Murthy GVS. Referrals between Public Sector Health Institutions for Women with Obstetric High Risk, Complications, or Emergencies in India – A Systematic Review. Ho Y-S, editor. PLoS ONE. 2016;11(8):e0159793.
    1. Sudhinaraset M, Beyeler N, Barge S, Diamond-Smith N. Decision-making for delivery location and quality of care among slum-dwellers: a qualitative study in Uttar Pradesh. India BMC Pregnancy Childbirth. 2016;16(1):148.
    1. National Health Systems Resource Center. LaQshya Labor Room Quality Improvement Initiative Guideline [Internet]. LaQysha. [cited 2018 Jul 1]. Available from: .
    1. Srivastava A, Singh D, Montagu D, Bhattacharyya S. Putting women at the center: a review of Indian policy to address person-centered care in maternal and newborn health, family planning and abortion. BMC Public Health. 2018;18(1):20.
    1. O’Neil S, Naeve K, Ved R. An Examination of the Maternal Health Quality of Care Landscape in India. Cambridge: Mathematica Policy Research, 2017. Available from . Accessed 28 Nov 2020.
    1. Semrau KEA, Hirschhorn LR, Marx Delaney M, Singh VP, Saurastri R, Sharma N, et al. Outcomes of a coaching-based WHO safe childbirth checklist program in India. N Engl J Med. 2017;377(24):2313–24.
    1. Barnhart DA, Spiegelman D, Zigler CM, Kara N, Marx Delaney M, Kalita T, et al. Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Utter Pradesh, India. Glob Health Sci Pract. 2020;8(1):38–54.
    1. Robert G, Sarre S, Maben J, Griffiths P, Chable R. Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the ‘productive Ward: releasing time to care’ programme in English acute hospitals. BMJ Qual Saf. 2020;29(1):31–40.
    1. Barnhart DA, Spiegelman D, Zigler CM, et al. Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the Better Birth Trial in Uttar Pradesh. India. Glob Health Sci Pract. 2020;8(1):38–54.
    1. on behalf of the EPOCH trial group. Stephens TJ, Peden CJ, Pearse RM, Shaw SE, TEF A, et al. Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial) Implementation Sci. 2018;13(1):142.
    1. Stephens T, Johnston C, Hare S. Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts? Clin Med. 2019;19(6):454–457.
    1. El-Khani A, Maalouf W, Baker DA, Zahra N, Noubani A, Cartwright K. Caregiving for children through conflict and displacement: a pilot study testing the feasibility of delivering and evaluating a light touch parenting intervention for caregivers in the West Bank. Int J Psychol. 2020;55(S1):26–39.
    1. Gawande AA, Semrau K, Miller K, Lipsitz S, Fisher-Bowman J, Karlage A, et al. Adherence to essential birth practices and perinatal mortality in Uttar Pradesh, India. Int J Gynecol Obstet. 2018;143(Suppl. 3):514.
    1. IHI’s Collaborative Model for Achieving Breakthrough Improvement. [Internet]. Boston: Institute for Healthcare Improvement; 2003 [cited 2019 Sep 29]. (IHI Innovation Series). Available from: .
    1. The Breakthrough Series IHI’s Collaborative Model for Achieving Breakthrough Improvement. Diabetes Spectrum. 2004;17(2):97–101.
    1. UCSF IGHS. UCSF SPARQ PROJECT [Internet]. UCSF SPARQ PROJECT. 2017 [cited 2020 Apr 30]. Available from: .
    1. Afulani PA, Diamond-Smith N, Phillips B, Singhal S, Sudhinaraset M. Validation of the person-centered maternity care scale in India. Reprod Health. 2018;15(1):147.
    1. Phillips B, Kajal F, Montagu D, Kumar A, Kumar V. Is bigger better? Assessment of self-reported and researcher-collected data on maternal health care quality among high-case-load facilities in Uttar Pradesh: a mixed-methods study. Lancet Global Health. 2018;6:S46.
    1. Landrian A, Phillips BS, Singhal S, Mishra S, Kajal F, Sudhinaraset M. Do you need to pay for quality care? Associations between bribes and out-of-pocket expenditures on quality of care during childbirth in India. Health Policy Plan. 2020;35(5):600–608.

Source: PubMed

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