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Sharma, G; (2017) An Investigation into Quality of Care at the Time of Birth at Public and PrivateSector Maternity Facilities in Uttar Pradesh, India. PhD thesis, London School of Hygiene & TropicalMedicine. DOI: https://doi.org/10.17037/PUBS.04646087
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ANINVESTIGATIONINTOQUALITYOFCAREATTHETIMEOFBIRTHATPUBLIC
ANDPRIVATESECTORMATERNITYFACILITIESINUTTARPRADESH,INDIA
GAURAVSHARMA
Thesissubmittedinaccordancewiththerequirementsforthedegreeof
DoctorofPhilosophyoftheUniversityofLondon
JULY2017
DepartmentofInfectiousDiseaseEpidemiology
FacultyofEpidemiologyandPopulationHealth
LONDONSCHOOLOFHYGIENE&TROPICALMEDICINE
Researchgroupaffiliation(s):CentreforMaternal,ReproductiveandChildHealth(MARCH)
Funding:MSDforMothers
Page2of248
Declarationbycandidate
I, Gaurav Sharma, confirm that the work presented in this thesis is my own. Where
informationhasbeenderivedfromothersources, Iconfirmthishasbeen indicated inthe
thesis
Signed:………………………………..
Date:7December2017
Page3of248
Abstract
Background:Ensuringhighqualitycareduringlabourandchildbirthisimportanttoeliminate
preventable maternal deaths, neonatal deaths and intrapartum stillbirths. My PhD
investigatesqualityofcare(QoC)duringnormallabourandchildbirth,andexamineswhether
QoCisinfluencedbymanagementpracticesat26publicandprivatesectormaternityfacilities
inUttarPradesh,India.
Methods:First,Iconductedclinicalobservationsoflabourandchildbirth.Iuseddescriptive
statisticsandmultivariateanalysistechniquestodescribeandcomparedifferencesinoverall
QoC,andqualityforobstetricandneonatalcare.Second,Iusedquantitativeandqualitative
methods to describe existing patterns of mistreatment encountered by women. Third, I
describedexistingmanagementpracticesusinga separate surveydatasetand linkedboth
QoCandmanagementdatasetstoexaminetherelationshipbetweenmanagementpractices
andQoC.
Results:QoCwasfoundtobepooratbothpublicandprivatesectorfacilities.Theprivate
sectoroutperformedpublicsectorfacilitiesforoverallessentialcareatbirth,andforboth
obstetricandnewborncare.Allwomenencounteredatleastoneindicatorofmistreatment.
TherewerenosignificantdifferencesbetweenqualifiedandunqualifiedpersonnelforQoC
andmistreatmentlevels.Qualitativeresultssuggestthatinformalpaymentsarewidespread,
maternitycarepathwaysarenon-functional,andtherearepoorhygienestandards.Lastly,I
foundthatmaternityfacilitiesscoredpoorlyonmanagementbestpractices.Overall,Ifound
noassociationbetweentotalmanagementscoresandQoC.
Conclusions:TheresultsofmyPhDstudyindicatethatin2015,inmaternityfacilitiesofUttar
Pradesh,unqualifiedpersonnelprovidedthebulkofmaternitycare,adherencetoevidence-
basedobstetricandneonatalcareprotocolswasgenerallypoorandallwomenencountered
at leastonepracticeofmistreatment. Theseresultssuggesttheneedtocomprehensively
measureandurgentlyimproveQoCatthetimeofbirthinUttarPradesh,India.
Acknowledgements
IamgratefulforalltheguidanceandsupportthatIhavereceivedandthepeoplethatIhave
metinthisjourney.ForapassionatepublichealthdoctorfromNepal,itwasalife-longdream
tocometotheLSHTMandlearnadvancedresearchskills.
Thisworkwouldnothavebeenpossiblewithoutthementorshipofmyexcellentsupervisors.
I am deeply grateful to Professor Veronique Filippi, my primary supervisor, who always
providedmewith timely and insightful guidance, and treatedmewith immense kindness
during the entire process. I am also indebted to Dr. Timothy Powell-Jackson, my co-
supervisor,who provided superbmentorship and guidance throughout this process. I am
gratefultoMs.LovedayPenn-Kekanaforheradviceonthequalitativeaspectsofmyworkand
for many interesting discussions. Dr. John Bradley has been an integral member of my
supervisorypanelandprovidedtimelyguidanceonquantitativeaspectsofmywork.
Iwouldalsoliketoacknowledgemanyotherinspiringacademicswithinthematernalhealth
groupandtheMARCHcentreattheLSHTM,whoseworkhasandwillcontinuetoinspireme.
Inparticular,IhavebenefittedfrommanyinformaldiscussionswithProfessorOonaCampbell
and Iamgrateful toher forgenerouslygivingmetimeandsharingherwisdom. Iamalso
thankfulformyfriends,SchadracAgblaandAnowerHossainforsharingthisjourneywithme,
their encouragement and for always helping me with any statistical problems that I
encountered.
MyPhDworkhasalsobeendeeplyinformedbymypastprofessionalexperiences,andIam
grateful to my previous supervisors and mentors for their encouragement and ongoing
support.MystayinLucknowwouldhavebeenmiserableifitwasnotforMr.BirenThapar
andIamgratefulforhisfriendshipandkindness.
ThisPhDthesisisdedicatedtomyparentsandtomywifeJune.Thankyouforallowingmeto
undertakethis;and,foryourunconditionallove,supportandsacrificesduringthischallenging
process.
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TableofContents
Chapter1.Introduction........................................................................................................................13
1.1. Motivationforthethesis..........................................................................................................13
1.1.1:Thehighandinequitableburdenofmaternalandneonataldeaths..................................13
1.1.2:Relevanceoftheresearchtoongoingglobalefforts.........................................................13
1.1.3:Importanceofcareatthetimeofbirth.............................................................................15
1.1.4:EvidenceonQoCformaternityservicesintheprivatesectorislimited............................16
1.1.5:Managementpracticesatmaternityfacilitiesisanunder-researchedarea......................17
1.2. Purposeofthethesis............................................................................................................19
1.3. Outlineofthesis...................................................................................................................20
Chapter2:Literaturereview................................................................................................................22
2.1:Introduction..............................................................................................................................22
2.2:TheimportanceofqualityatmaternityfacilityinLMICsettings..............................................23
2.3:Qualityofessentialcareatthetimeofbirth............................................................................24
2.3.1:Background........................................................................................................................24
2.3.2:Conceptualisinganddefininghighqualitymaternitycarepathwaysatfacilities..............26
2.3.3:Skilledbirthattendance.....................................................................................................28
2.3.4:Interventionsrecommendedforcareatthetimeofbirth................................................30
2.3.5:Interventionsnotrecommendedforuseduringthetimeofbirth...................................33
2.3.6:Theimportanceofrespectfulmaternitycareduringlabourandchildbirth......................34
2.4:Frameworksofqualityinhealthanddefinitions.......................................................................37
2.4.1:Definitionsofqualityofcareinhealthservices.................................................................37
2.4.2:Elementsofqualityofcareinhealthservices...................................................................38
2.5:FrameworksanddefinitionsofQoCspecifictomaternalandnewbornhealth........................39
2.6:MeasurementofQoCformaternalandnewbornhealthinLMICsettings...............................41
2.6.1:Measuringstructureelementsofqualityofcare...............................................................41
2.6.2:Measuringprocesselementsofqualityofcare................................................................42
2.6.3:Measuringhealthoutcomemeasuresofqualityofcare...................................................47
2.6.4:Summaryofmeasuringqualityofcareinmaternalandnewbornhealth.........................49
2.7:EmpiricalevidenceondeficienciesinQoCduringlabourandchildbirthinIndia.....................49
2.8:Managementpracticesatmaternityfacilities...........................................................................56
2.8.1:Theoreticalconceptsonmanagementpractices...............................................................56
2.8.2:Empiricalevidenceonhospitalmanagementpracticesandquality..................................60
Chapter3:Researchsettingandthecontextforthedoctoralresearch..........................................63
3.1Studysetting...........................................................................................................................63
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3.2:HealthcaresysteminIndia...................................................................................................65
3.3:Maternalandnewbornhealthservicesprovidedatpublicsectorfacilities.........................67
3.4:Maternalhealthprogrammesandpolicies...........................................................................68
3.5:ContextofthePhDresearchwithintheMatrikaproject......................................................70
Chapter4:Roleofthecandidate,fundingandresearchtimeline.......................................................72
4.1:Theroleofthecandidate.........................................................................................................72
4.2:Funding......................................................................................................................................73
4.3:Researchtimeline.....................................................................................................................74
Chapter5:Conceptualframework,aims,objectivesandstudydesign...............................................76
5.1:ConceptualframeworkformyPhD...........................................................................................76
5.2:Aimsofthedoctoralresearch...................................................................................................77
5.3:SpecificObjectives.....................................................................................................................77
5.4:Studydesign..............................................................................................................................78
5.5:Datacollectioninstruments......................................................................................................78
5.5.1:Qualityofcareassessments...............................................................................................78
5.5.2:Surveyonmanagementpracticesatmaternityfacilities...................................................79
5.6:Samplesizecalculations............................................................................................................80
5.6.1:Forclinicalpracticeobservations.......................................................................................80
5.6.2:Theassessmentofmanagementpractices........................................................................81
5.7:Samplingstrategy......................................................................................................................81
5.7.1:Clinicalpracticeobservations.............................................................................................81
5.7.2:Managementsurvey..........................................................................................................82
5.8:Datacollection..........................................................................................................................82
5.8.1:Clinicalpracticeobservations.............................................................................................82
5.8.2:Assessmentofmanagementpractices...............................................................................83
5.9:Studyparticipants.....................................................................................................................83
5.10:Dataanalysis............................................................................................................................83
5.11:Researchethics.......................................................................................................................86
5.12:Datamanagement...................................................................................................................87
Chapter6:Qualityofessentialcareatthetimeofbirth:Findingsfromclinicalobservationsofspontaneouslabourandchildbirthat26publicandprivatesectorfacilitiesinUttarPradesh,India.88
6.1:Introduction..............................................................................................................................90
6.2:Methods....................................................................................................................................91
6.3:Analysis......................................................................................................................................96
6.4:Results.......................................................................................................................................96
6.5:Discussion................................................................................................................................102
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Chapter7:AninvestigationintomistreatmentofwomenduringlabourandchildbirthinmaternitycarefacilitiesinUttarPradesh,India:amixedmethodsstudy..........................................................106
7.1:Introduction............................................................................................................................108
7.2:Methods..................................................................................................................................110
7.3:Analysis....................................................................................................................................113
7.4:Results.....................................................................................................................................114
7.5:Discussion................................................................................................................................126
7.6:Limitations...............................................................................................................................130
7.7:Conclusions.............................................................................................................................131
CHAPTER8:Managementisnotassociatedwithqualityofcareduringlabourandchildbirth:evidencefromacross-sectionalstudyofmaternityfacilitiesinUttarPradesh,India.......................132
8.1:Introduction............................................................................................................................134
8.2:Methods..................................................................................................................................136
8.3:Results.....................................................................................................................................141
8.4:Discussion................................................................................................................................148
8.5:Limitations...............................................................................................................................150
8.6:Conclusions.............................................................................................................................151
Chapter9:Discussionoftheresultsoftheoveralldoctoralresearch...............................................153
9.1:Summaryofkeyfindings.........................................................................................................153
9.1.1:QualityofcarewasgenerallypooracrossthesampledpublicandprivatesectormaternityfacilitiesinUttarPradeshin2015..............................................................................................154
9.1.2:MistreatmentofwomenfrequentlyoccurredatmaternityfacilitiesinUttarPradeshin2015............................................................................................................................................160
9.1.3:OverallmanagementscorewasnotassociatedwithQoCatmaternityfacilitiesinUttarPradeshin2015..........................................................................................................................165
9.2:Plansfordissemination...........................................................................................................167
9.3:Reflections,strengthsandlimitations.....................................................................................168
9.3.1:Forobjective1:QoCduringlabourandchildbirthatmaternityfacilitiesinUP..............168
9.3.2:Forobjective2:MistreatmentofwomenatmaternityfacilitiesinUP...........................173
9.3.3:Forobjective3:ManagementanditsrelationshipwithQoC..........................................176
9.4:Implicationsofthedoctoralstudy..........................................................................................180
9.4.1:Recommendationsforthefutureresearchagenda.........................................................181
9.4.2:Recommendationforprogrammes..................................................................................186
9.4.3:Recommendationsforpolicy...........................................................................................187
Chapter10:Conclusions.....................................................................................................................189
11.Listofreferences..........................................................................................................................190
12.ListofAppendices........................................................................................................................210
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Appendix1:QoCassessmenttoolfornormallabourandchildbirthinUttarPradeshin2015.210
Appendix2:ToolforassessmentofmanagementpracticesinmaternityfacilitiesinUttarPradeshin2015..........................................................................................................................220
Appendix3:Informationsheetsandconsentforms..................................................................230
Appendix4:Ethicalapprovallettersandpermissions...............................................................235
Appendix5:PublishedmanuscriptforChapter6.......................................................................240
Appendix6:Tableshowingfrequencyofmistreatmentbysector............................................248
ListofTables
Table1:Interventionsrecommendedforuseduringintrapartumandpostpartumperiod................31
Table2:Interventionsforintrapartumandpostpartumcarethatdonothaverecommendationsforuse................................................................................................................................................33
Table3:DemographicandhealthindicatorsinUttarPradeshandstudydistricts..............................64
Table4:MaternalandnewborncarestandardsatIndianpublicsectorfacilities...............................67
Table5:Summaryoftheevolutionofqualityinmaternalhealth.......................................................68
Table6:TimelineforthePhD...............................................................................................................74
Table7:IndicesforQualityofCare......................................................................................................95
Table8:Samplecharacteristics............................................................................................................97
Table9:VariationsinessentialcareatbirthacrosspublicandprivatesectorsinUttarPradesh,India....................................................................................................................................................100
Table10:Resultsfromthemultilevelmixedeffectslinearregression..............................................101
Table11:Socio-demographiccharacteristicsofthesamplebytwooveralllevelsofmistreatment.114
Table12:Bivariateanalysisofthesignificancebysocio-demographicfactorsandtheprevalenceofobservedindicatorsofmistreatment.........................................................................................118
Table13:Themesandtheircomposition-clinicalobservationsoflabourandchildbirthatmaternityfacilities......................................................................................................................................120
Table14:Correlationresultsbetweenindependentassessorsratingsformanagementdimensions....................................................................................................................................................142
Table15:Maternityfacilitysamplecharacteristicscategorisedbytheirmanagementscores.........143
Table16:Relationshipbetweenfacilitysamplecharacteristicsandmanagementscores................144
Table17:MixedeffectslinearregressionexaminingtherelationshipbetweenoverallQoCatbirthandZscoreindexfortotalmanagementscoreat26maternityfacilities..................................146
Table18:Mixedeffectslinearregressionexaminingtherelationshipbetweenqualityofcareandzscoresindexesformanagementsub-categoriesfor26maternityfacilities..............................147
Listsoffigures
Figure1:Schematicdiagramofmaternitycarepathwaysfordelivery................................................27
Figure2:WHOQualityofCareFrameworkformaternalandnewbornhealth...................................40
Figure3:Dimensionsofmanagementpracticesatmaternityfacilities...............................................59
Figure4:SchematicrepresentationofthepublichealthsysteminIndia............................................65
Figure5:ConceptualframeworkformyPhD.......................................................................................77
Figure6:StudyflowdiagramfortheassessmentofQoCduringlabourandchildbirth......................93
Figure7:Qualityofcareitemsforobstetricandnewborncarebysectorusingweighteddata........99
Figure8:EstimatedHawthorneeffectacrosssampledobservationsin26hospitalsofUttarPradesh....................................................................................................................................................102
Figure9:Quantitativeresultsshowingtheprevalenceofindicatorsofmistreatmentinpublicandprivatesectormaternityfacilities..............................................................................................116
Figure10:Overallstudyflowdiagram-investigatingtherelationshipbetweenmanagementpracticesandqualityofcareduringlabourandchildbirth........................................................................139
Figure11:Histogramshowingtotalmanagementscoresacrosssampledfacilities(n=33)...............142
Figure12:Graphshowingscoresfortotalandindividualmanagementdomainsatpublicandprivatesectorfacilities...........................................................................................................................142
Figure13:Weightedestimatesofqualityofcareatmaternityfacilitiescategorisedbytheirmanagementscores...................................................................................................................145
Listofabbreviations
AMDD AvertingMaternalDeathandDisabilityProgram
AMTSL ActiveManagementofthethirdstageoflabour
ANC Antenatalcare
ANM AuxiliaryNursemidwife
ARR AnnualRateofReduction
ASHA AccreditedSocialHealthActivists
ASME AdvancedStatisticalMethodsinEpidemiology
BEmOC BasicEmergencyObstetricCare
CEmOC ComprehensiveEmergencyObstetricCare
CHC CommunityHealthCentres
EmOC EmergencyObstetricCare
EmONC EmergencyObstetricandNewborncare
ENAP EveryNewbornActionPlan
EPMM Endingpreventablematernalmortality
IMPAC IntegratedManagementofPregnancy&Childbirth
FIGO TheInternationalFederationofGynaecologyandObstetrics
FRU FirstReferralUnits
JSY JananiSurakshaYojana
LMICs LowandMiddle-IncomeCountries
LSHTM LondonSchoolofHygiene&TropicalMedicine
MARCH CentreforMaternal,Adolescent,ReproductiveandChildHealth
MBA MastersofBusinessAdministration
MET MaternalhealthcaremarketsEvaluationTeam
MCHIP MaternalChildHealthIntegratedProgram
MDG MillenniumDevelopmentGoals
MMR MaternalMortalityRatio
MNCH Maternal,NewbornandChildhealth
MNH MaternalandNewbornhealth
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MOHFW MinistryofHealthandFamilyWelfare
MSD MerckSharpandDohmeCorp.
MICS MultipleIndicatorclustersurvey
NICE NationalInstituteforHealthandClinicalExcellence
NGOs Non-GovernmentalOrganizations
NRHM NationalRuralHealthMission
NMR NeonatalMortalityRate
PHS PublicHealthcareSociety
PhD DoctorofPhilosophy
PDSA PlanDoStudyAct
PCACL-R PerceptionsofCareAdjectiveChecklist
QoC QualityofCare
QPP-I Intrapartum-specificQualityfromthePatientsPerspectivequestionnaire
RMNH Reproductive,MaternalandNewbornHealth
RHFA RapidHealthFacilityAssessments
SARA ServiceAvailabilityandReadinessAssessment
SBA SkilledBirthAttendant
SDGs SustainableDevelopmentGoals
SME StatisticalMethodsinEpidemiology
SPA ServiceProvisionAssessment
SSQ SixSimpleQuestions
UP UttarPradesh
UK UnitedKingdomofGreatBritainandNorthernIreland
UHC universalhealthcoverage
USA UnitedSatesofAmerica
USAID UnitedStatesAgencyforInternationalDevelopment
UN UnitedNations
WHO WorldHealthOrganization
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Chapter1.Introduction
1.1. Motivationforthethesis
Althoughtherehasbeenconsiderableprogressinmaternalandnewbornhealthoverthepast
twodecades,provisionofhigh-qualitycareforwomenoncetheyreachhealthcarefacilities
hasemergedasanimportantchallenge.1Poorqualityofcareatthetimeofbirthhampers
healthoutcomesforwomen,childrenandcommunities;andresearcheffortsshouldidentify
waystoimprovethecurrentstateofaffairs.
1.1.1:Thehighandinequitableburdenofmaternalandneonataldeaths
Maternal andnewbornhealthare important issues for sustainabledevelopment.Withan
estimatedannual210millionpregnanciesand140millionlivebirthsglobally,ensuringthat
everywoman and every newborn across the globe has the right to high quality care is a
formidablechallenge.2Theeraof theMillenniumDevelopmentGoals (MDGs) led togood
progress andmaternal deaths declined by nearly half (44%). However, this progresswas
inconsistentacrossmanypartsoftheworld,andmanycountriescouldnotachievetheMDG
5atargetofa75%reductioninthematernalmortalityratio(MMR).2
In2015,theMMRinhigh-incomecountries(12per100 000livebirths)wasfoundtobe46
timeslowerthanthehighestMMRinsub-SaharanAfrica(546per100 000).2Similarly,the
lifetime risk formaternaldeaths in2015wasmore than100 timeshigher in sub-Saharan
Africa: one in 36 compared to one in 4900 in high-income countries.2 During this time,
inequalitiesalsoworsened.Forexample,in1990thepooledMMRfor10countrieswiththe
highest levels ofmaternalmortalitywas 100 times greater than the pooledMMR for 10
countrieswiththelowestMMRlevels.However,by2013,thisgaphaddoubledto200times
greater.2Thesedatasuggestthatimprovingmaternalhealthisstillanunfinishedagenda.
1.1.2:Relevanceoftheresearchtoongoingglobalefforts
In2016,worldleaderswelcomedtheSustainableDevelopmentGoals(SDGs),whichunlike
theMDGs,haveabroaderdevelopment focus.3Goal threeof theSDGs isconcernedwith
ensuring healthy lives for all, and has five health targets including a specific target for
maternalmortality. 3 The targets for reducingpreventablematernalmortality are thatby
2030,allcountriesshouldreduceMMRbytwothirdsandnocountryshouldhaveanMMR
Page14of248
above140.4TheWorldHealthOrganization(WHO)andpartnershavecalledforintensified
action,particularly incountrieswithMMRgreater than420per100,000 livebirths.4 It is
hopedthatwithcollectiveefforts,theglobaltargetofMMRoflessthan70per100,000live
birthsby2030canbeachieved4.Atthenationallevel,twocountries,Nigeriaat19%(58,000
deaths)andIndiaat15%(45,000deaths)contributeduptoonethirdoftheglobalburdenof
maternal deaths in 2015.5 Therefore, both thesepopulous countries have tomake rapid
reductions in maternal mortality if the Global Strategy for Women’s, Children’s and
Adolescents’Health’stargetsaretobemetby2030.6
ThemainstrategyusedtoachievematernalandnewbornhealthtargetsduringtheMDGs
wastoexpandcoverageofsimpleandeffectiveinterventionsproventoworkagainstthemain
causesofdeaths.Successwasprimarilymeasuredthroughincreasedpopulationcoverageof
indicatorssuchasinstitutionalbirths,deliveriesbyskilledattendantsorantenatalcare.7There
wasgoodprogressbetween1990to2013;theproportionofbirthsoccurringwithskilledbirth
attendants(SBA)increasedfrom57%to74%;theproportionofwomenreceivingoneormore
antenatalcare(ANC)visitsincreasedfrom65%to83%;andfourormoreANCvisitsrosefrom
37%to64%.8,9However,increasingcoveragealonewithoutaspecificfocusonQoCmaynot
beoptimalforreasonsoutlinedbelow.7
First,thereisnowincreasingresearchevidencesuggestingthat,despiteincreasedcoverage
of institutional births, associated declines in perinatal and neonatal mortality have been
modestasshownbystudiesinIndia10,11andRwanda.12Inarecentcross-sectionalstudyfrom
Malawi,researchersalsofoundthatpoorhealthfacilityqualitywasassociatedwithhigher
riskofneonatalmortality.13
Second, global monitoring efforts are primarily designed to support global, regional and
nationalcomparisonsofcoverageindicatorssuchasANCvisits,institutionalbirthsandSBA
presenceatdelivery.Theseindicatorstrackuseofhealthcareratherthancontentofcare;
therefore,aqualitygapmayarisedespitetheincreasedpopulationcoverage.14Furthermore,
features beyond SBA and ANC coverage are likely to be important. For example, a high
populationdensityandlongtraveltimesmaycausedelaysinaccesstoemergencyobstetric
Page15of248
care (EmOC), andwomen's underlying health conditions, nutritional status and other life
circumstancesalsoinfluencebirthoutcomes.15
Third,themaincausesofmaternaldeathsin2015werefoundtohaveshiftedawayfromthe
morepreventabledirectcausestoindirectcausessuchasnon-communicablediseasesand
other intractable direct causes such as ectopic pregnancies, embolism and gestational
diabetes. 2 Therefore, there is growing recognition that improvingmaternal andnewborn
healthoutcomesintheSDGerawillrequireanadditionalemphasisonqualityofcareonce
womenreachhealthfacilities.7Iwillelaborateontheseissuesfurtherintheliteraturereview
sectioninchapter2.
1.1.3:Importanceofcareatthetimeofbirth
Despite the focus on promotion of institutional deliveries, the quality of routine care for
normal labour and childbirth has not received enough research and programmatic
attention.15,16Thetimearoundchildbirthhasalwaysbeentheriskiest forwomen inmany
partsoftheworld.16-18Recentestimatessuggestthatclosureofthequalitygapthroughthe
provisionofeffectiveandwoman-centredcareforallwomenandnewbornbabiesdelivered
infacilitiescouldpreventanestimated113,000maternaldeaths,531,000stillbirths,and1·32
millionneonataldeathsannuallyby2020.19
Consensusexistsonaminimumcarepackageof interventions requiredduringpregnancy,
labour and childbirth20. High quality, routine care during labour and childbirth has the
potentialtopreventmanymaternalandneonataldeaths,eitherthroughthepreventionof
complications or by timely intervention prior to the development of complications.21 For
example,oneoftheelementsofroutinecareincludestheuseofapartograph,whichifused
correctly,canalertustothestartofprolongedorobstructedlabour.Similarly,theprovision
ofactivemanagementofthethirdstageoflabour(AMTSL)canreducetheriskofpost-partum
haemorrhage.
Inadditiontothispackageforroutinecare,somewomenandbabiesrequirehigher-levelcare
for complications. Facilities that provide such emergency obstetric and neonatal care are
classifiedasBasicEmergencyObstetricCare(BEmOC)facilitiesorComprehensiveEmergency
Page16of248
ObstetricCare(CEmOC)facilitiesbasedontheprovisionofspecifiedsignalfunctions.22Signal
functions includes clinical capabilities like providing injectable antibiotics, magnesium
sulphate, oxytocics and procedures like assisted vaginal delivery, blood transfusion,
caesareanoperationsandothers.22
However, there are widespread examples in the literature which indicate that a high
proportionofbirthsoccurinfacilitiesthatarenotfullycapableofprovidingtheappropriate
signalfunctionsforobstetriccare.15,23,24,25Forexample,providingassistedvaginaldeliveries,
injectable oxytocics or blood transfusion services are challenging in many resource-
constrainedsettings.16,23
Existingroutinehealthinformationsystemsdonotcaptureinformationonspecificelements
ofcareduringnormallabourandchildbirthfromwomengivingbirthinLMIChospitals.These
individualleveldataonqualityofroutinecareareessentialforimprovementpurposes,but
areonlyavailablethroughdedicatedstudiesandhence,thereislimitedinformationonthis
topic.However,therearecurrentlyongoingeffortsatthegloballeveltodefinemetricsfor
qualityofcareat thetimeofbirth26andonelementsofskilledattendanceatbirth (SAB),
whichmakethisPhDrelevanttotheseongoingglobalefforts.
1.1.4:EvidenceonQoCformaternityservicesintheprivatesectorislimited
The private sector provides a range of health services including maternity care in LMIC
settingsandasIwillshowintheliteraturereviewsection(chapter2),evidenceonqualityof
healthservicesprovidedbytheprivatesector is limited.Theprivatesectorcanvaryfrom
smalltolargefor-profitcompanies,orprivatepracticesformedbyagroupofhealthworkers
orclinicsrunbynationalandinternationalnon-governmentalorganizationsandclinicsrunby
individualhealthworkersandpharmacies.27
Thereareargumentsforandagainsttheroleoftheprivatesectorinprovidingessentialhealth
services.Proponentsarguethattheprivatesectorisalreadyanestablishedproviderofhealth
servicesinmanysettingsandcanmakesignificantcontributionstoexpandefficientandhigh-
qualityhealthservicestounderservedpopulations.28,29Scepticsarguethatsincetheprivate
sectorprioritisesprofitsoverpublichealthimpacts,theyareunlikelytoprovidehighquality
servicesatlowcostsparticularlyinunderservedpopulations.30
Page17of248
Despite these ideological arguments, the size and themarket share of the private sector
acrossLMICsettingsappearstobeincreasing.31,32Although,thepublicsectorstillprovides
themajority of services globally, across the continuumof care, in terms of reproductive,
maternalandnewbornhealth,theprivatesector’scontributionissubstantialandestimates
indicate that 19% of maternity care, 32% of antenatal care, and 22% of family planning
servicesgloballyareprovidedintheprivatesector.33
Therapidgrowthoftheprivatesectorhasdrawnattentiontomanyproblemsthatitoften
shareswiththepublicsector,whichincludeslowstandardsofcare,poorinfrastructure,lack
ofqualifiedstaff,inadequateorpoorequipmentandmedicalmalpractice.31Inaddition,the
abilitytoregulatetheprivatesectorhasalsonotkeptpacewithitsgrowth.Somechallenges
forregulationhaveincludedlackofgovernmentinstitutionalcapacity,thelargesizeofthe
privatesector,lackofresourcesandoften-corruptrelationshipsbetweenstateandprivate
sectoractors.31,34
TheheterogeneityandcomplexityoftheprivatesectorinLMICssuchasIndiaalsomeansthat
high-qualityresearchevidenceonQoCintheprivatesectorislimited.Manypublishedstudies
havefocussedontheincreasingmedicalisationofchildbirthintheprivatesector,especially
givenhighratesofcaesareansectionsamongwomenseekingcareintheprivatesector.24,35-
39However,detailedevidenceonqualityof routinecare fornormalbirths inLMICprivate
sectorfacilitiesislimited.Therefore,furtherresearchtoinvestigatetheQoCfornormallabour
and childbirth in the private sector is important, especially in places like India, where
estimatesindicatethat22%ofalldeliveriesoccurintheprivatesector.40
1.1.5:Managementpracticesatmaternityfacilitiesisanunder-researchedarea
Strongmanagementcompetenciesarethoughttobeessentialtoensurethathealthsystems
canrespondtopopulationneeds.41While,thesecompetenciesareimportantinallsettings,
they seem particularly indispensable in LMIC settings, which are characterised by high
burdensofmaternalandneonatalmortalityandhospitalshereoperateinanenvironmentof
resource-scarcity.41Further,sincehospitalsarethemostexpensive,resource-intensiveand
politicallysensitivecomponentsofhealthsystems,managementpracticesathealthfacilities
seemparticularlyimportant.Inbothpublicandprivatesectorfacilities,goodmanagement
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practices seem essential tomaintain effective hospital operations, hospital performance,
hospitaltargetsandtoensuregoodhuman-resourcemanagement.42-45
AsIwillexplainingreaterdetailintheliteraturereviewsection(chapter2)empiricalevidence
onmanagementpracticesatmaternityfacilitiesinLMICsettingsislimited.Perhapsbecause
management practices are hard to measure quantitatively and because methodological
advancesinmeasurementhavebeenrecent,mostresearchonthistopicoriginatesfromhigh-
income settings.42-45 Consequently, there is limited informationonmanagement practices
anditsrelationshipwithQoCatmaternityfacilitiesinLMICsettings.
Inhigh-incomesettings, large-scaledatacollectioneffortssuchastheWorldManagement
survey(http://worldmanagementsurvey.org/),whichcollectsdatafromover2,000hospitals
inninecountriesexist.Thesemanagementdatacanoftenbelinkedtoroutinelycollected
clinicaldataavailablefromelectronicmedicalrecordsofhospitalsinhigh-incomesettingsand
therelationshipbetweenmanagementandQoCexamined.However,suchdataisgenerally
notavailableinhospitalsinLMICsettings.
Given that management practices have the potential to influence all elements of the
maternitycarepathwayatfacilities,therelationshipbetweenmanagementandQoCneeds
detailedinvestigation.Examiningwhethermanagementpracticeshavethepotentialtodrive
gains in quality in LMIC settings is an innovative and interesting area of research with
significant evidence gaps. In addition, given recent methodological advances, a
comprehensiveassessmenttool,42,43,46 isavailablethatcanbeadaptedandusedtoassess
managementpracticesatmaternityfacilitiesinIndia.
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1.2. Purposeofthethesis
ThecentralpurposeofmythesisistodevelopadetailedunderstandingofQoCduringlabour
andchildbirthat26publicandprivatesectormaternityfacilitiesinUttarPradesh,India.Uttar
Pradesh(UP)isapopulousstatewithlowratesofinstitutionaldeliveriesandfutureprogress
inthisIndianstatehasimportantimplicationsformaternalandnewbornsurvivalinIndia.
To fulfil my research aim, I conducted clinical practice observations and assessed QoC
providedduringlabourandchildbirthfor275mother-babypairsat26maternityfacilities.I
assessedanddescribedoverallqualityofcareatthetimeofbirthandspecificallyqualityof
obstetricandneonatalcareatthesematernityfacilities.IalsoinvestigatedwhetherQoCis
associated with characteristics of the women, characteristics of health workers and
characteristicsofmaternityfacilitiesinthreedistrictsofUttarPradesh,India.
Thereafter, I identified practices that constitute mistreatment of women, assessed and
describedthenature,patternsanddeterminantsofmistreatmentencounteredbywomen
during labour and childbirth at these maternity facilities. I also investigated whether
mistreatmentisassociatedwithsocio-demographiccharacteristicsofwomen,characteristics
ofhealthworkersandcharacteristicsofmaternityfacilities.
AnotherinnovativecomponentofmyPhDistheinvestigationintomanagementpracticesat
maternityfacilities,whichIassessedthroughaseparatesurveywithhealthfacilitymanagers
in Uttar Pradesh. I described existing management practices at maternity facilities and
examinedwhether there is a relationship between quality andmanagement practices at
maternityfacilities
InvestigatingQoCfornormallabourandchildbirthscomprehensivelyincludinganyobserved
mistreatmentisanimportantareaforresearchparticularlysincetherearemanyinformation
gaps related to quality, especially in private sector. Moreover, investigating whether
managementpracticeshavethepotentialtoinfluencequalityofcareisanunder-researched
area.Generatingevidenceontheseimportantquestionscouldsupportqualityimprovement
effortsinmaternalandnewbornhealthinlow-resourcesettings.
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1.3. Outlineofthesis
This is a “research-paper-style” thesis with three prepared manuscripts presented as
chapters.Chaptertwopresentsareviewoftheliteraturerelevanttotheresearchquestions
addressed by my thesis. In this chapter, I provide an overview of why quality of care is
importantatmaternity facilities; introduceconceptsofessentialcareat thetimeofbirth;
maternity care pathways; skilled birth attendance and outline interventions that are
recommendedandnotrecommendedforprovisionofcareatthetimeofbirth.Ialsodiscuss
theconceptsofrespectfulmaternitycare.Thereafter,Idiscussconceptsofqualityofcare,
frameworks,definitionsandmeasurementofQoCinmaternalandnewbornhealthusingthe
frameworkofstructure,processandoutcomes.Thereafter,Ioutlinetheempiricalevidence
ondeficienciesinQoCatthetimeofbirthbasedonmyreviewoftheliteraturefromIndia
using thequalityof care framework. Finally, in the last sectionof the literature review, I
summarisethetheoreticalconceptsandempiricalevidenceonmanagementpracticesand
qualityofcare.
Inchapter3,Idescribethestudysetting,provideanoverviewofthehealthsystem,maternal
andnewbornhealthservicesprovidedatpublicsectorfacilitiesanddiscusstheevolutionof
qualityinmaternalhealthprogrammesinIndia.Ithendiscussmydoctoralresearchwithin
thelargerevaluationoftheMatrikaproject.
In chapter 4, I outline my role in conducting this doctoral research, funding and overall
timelineforthisresearch.Inchapter5,IpresentaconceptualframeworkformyPhD,and
discuss the aim, objectives and design of the studies described in this PhD. Thereafter, I
provideanoverviewofthemethodsusedinthedifferentresearchstudiespresentedinthis
thesis. However,detailedmethods foreachstudyarealsopresented in individual results
chapters(chapters6-8).
Chaptersixpresentsthefirstresearchpaperentitled“Qualityofessentialcareatthetimeof
birth:Findingsfromclinicalobservationsofspontaneouslabourandchildbirthat26public
andprivate sector facilities inUttarPradesh, India.” Addressingobjectiveone, thispaper
describestheoverallqualityofcare,andqualityforobstetricandneonatalcareduringnormal
labourandchildbirthat26maternity facilities inUttarPradesh.Thismanuscripthasbeen
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peer-reviewedandaslightlyshortenedandeditedversionwaspublishedbytheBulletinof
theWHOinaspecialseriesonqualityofcare(publishedinJune2017).47
Chapter seven presents the second research paper entitled “An investigation into
mistreatment of women during labour and childbirth inmaternity care facilities in Uttar
Pradesh, India:amixedmethodsstudy”.Addressingobjective two, thispaper investigates
anddescribethenatureandpatternsofmistreatmentobservedduringlabourandchildbirth
atmaternityfacilities.IaimtosubmitthismanuscripttoReproductiveHealth.
Chaptereightpresentsthethirdresearchpaperentitled“Managementisnotassociatedwith
qualityofcareduringlabourandchildbirth:evidencefromcross-sectionalstudyofmaternity
facilities in Uttar Pradesh, India”. Addressing objective three, this paper describes
managementpracticesatmaternityfacilitiesinUttarPradesh,Indiaanddemonstratesthat
overallmanagementpracticesarenotassociatedwithQoCduring labourandchildbirth in
maternity facilities inUttarPradesh. IaimtosubmitthismanuscripttoHealthAffairsora
similarjournal.
Chapterninesynthesizesthemainfindingsfromthesepapers,discussesmyreflectionsonthe
different studies described in this thesis, and the strengths and limitations of individual
studies. I thendiscuss the implicationsofmyPhD findings for research, programmesand
policy,andproviderecommendations.InChapter10,IpresenttheconclusionsofmyPhD.
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Chapter2:Literaturereview
2.1:IntroductionThischapteraimstoimproveourunderstandingoftheliteratureonqualityofcareatthetime
ofbirthandmanagementpracticesathospitals.Iconductedacomprehensivereviewofthe
literature on quality of care during labour and childbirth and management practices at
hospitalswithafocusonLMICsettings.Asmyresearchobjectivescoveredabroadrangeof
topicsandIwasinterestedinresearchfromarangeofdisciplinessuchaseconomics,hospital
management, and health care administration, itwas not possible undertake a systematic
literaturereview.However,Ihavetriedtoensurethatmyliteraturereviewiscomprehensive
andcoversallkeyaspectsofmanagementpracticesathealthfacilitiesandqualityofcarefor
maternalandnewbornhealth.
To examine the literature on QoC at the time of birth at maternity facilities in LMICs, I
searchedpublishedpapersand the latestWHO,UnitedNations (UN) resourcesandother
reportsexaminingQoCinhealthservicesandspecificallyQoCinmaternalandnewbornhealth
inLMICsettings.SearcheswerecarriedoutinMedlineandgooglescholarbycombiningthe
relevantfree-textandMedicalSubjectHeadings(MeSH)forterms,suchas‘qualityofcare,’
with those for the field of interest (‘maternal health,’ ‘safemotherhood,’ or ‘obstetrics;’
‘newborn’or‘neonatal;’or‘childbirth’or‘intrapartum’or‘intra-partum’or‘hospital’‘health
facility’ ‘maternity facility’; ‘postpartum’ or ‘post-partum’; ‘puerperal’ or ‘puerperium’ or
‘pregnancy’or‘delivery’).InMedline,Iappliedsearchlimitsandrestrictedresultstostudies
fromLMICsettings, involvinghumansubjects,articles inEnglish,publishedduring1980to
2016.Additionalarticlesandreportswereidentifiedthroughwebsearchesoforganisations
workinginmaternalandneonatalhealth,conferencesormeetingreports,andfromexperts
in the field. Additional references were also identified from the reference lists of peer-
reviewedjournalarticlesandpublishedreports.
Forthestudyonmanagementpracticesathospitals,thesearchstrategyinvolvedthreekey
free-text search terms:management, quality of care and hospital setting. Searches were
conductedusingthesefree-textsearchtermsinMedlineandgooglescholar.Inadditionto
thesekeyterms,MedicalSubjectHeadings(MeSH)termswereusedinMedline,whichwere
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‘exploded’toincludeallMeSHsubheadings.Limitswereappliedtorestrictarticlespublished
inEnglish,involvinghumansubjects,between1980and2016.Inaddition,Ialsoconducted
extensive web searches to identify reports produced by management consulting firms,
workingpapersineconomics,hospitalmanagementproducedleadingexpertsinthefieldof
managementandeconomics.Additionalreferenceswerealsoextractedfromthereference
listsofrelevantpublishedmanuscripts,monographsandreports.
In thesubsequentsectionsofchapter2, Iwillpresent thekey findings frommy literature
review.
2.2:TheimportanceofqualityatmaternityfacilityinLMICsettingsDespite the impressive improvements inmaternal and child health during the era of the
MillenniumDevelopmentGoals,approximately5.6millionwomenandbabiesdiedin2015
duringpregnancy, labour,childbirthandtheneonatalperiod.5,48,49 Inordertoachievethe
newmortality targets setout in the SustainableDevelopmentGoals, thereneeds tobea
renewed emphasis in research, programmes and policies that aim to reduce preventable
maternaldeaths,neonataldeathsandstillbirths.50
Formaternalmortality,asindicatedintheintroduction,theglobaltargetfor2030isanMMR
oflessthan70/100,000livebirthswithdifferentsub-targetsforspecificcontexts.4Countries,
dependingontheirbaselinelevelsin2015,shouldeitherreducetheirMMRbyatleasttwo-
thirdsoftheirbaseline,nothaveanMMRgreaterthan140/100,000livebirthsby2030,or
achievereductionsininequalitiesinMMRatasubnationallevel.Thesesub-targetsrequirean
annualrateofreduction(ARR)ofmortalitygreaterthan5.5%inthecountrieswiththehighest
MMRs(MMR>420/100,000).4,50
Forneonataldeaths,theEveryNewbornActionPlansetanabsolutetargetof12orfewer
neonataldeathsper1000livebirthsineverycountryby2030.AnARRof4.3%willbeneeded
toachievetheglobalNMRtarget,butthisvariesconsiderablybetweencountries,with29
countriesneedingtoatleastdoubletheirARR.18,51Forstillbirths,theENAPsetanabsolute
targetof12orfewerstillbirthsper1000totalbirthsinallcountriesby2030.Toachievethis,
aglobalARRof4.2%isneededand56countrieswillneedtodoubletheirARR.52
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Researchers have also demonstrated that it is essential to go beyond ensuring increased
coverageandutilisationofservicestoreducematernalandneonataldeaths.53Asnotedin
theintroduction,studiesfromIndia,MalawiandRwandahaveshownthatgreateraccessto
institutionaldeliverieswasnotassociatedwith reductions inneonatalmortality; a finding
theyattributetopoorqualityofcareathealthfacilities.10,12,13Inamulti-countrystudy,higher
than expected maternal mortality was also found in hospitals in high-mortality, LMIC
countries, despite the availability of essential medicines. This suggest gaps in clinical
managementortreatmentdelaysforhospitalisedwomenwhohadlife-threateningobstetric
complications(maternalnear-miss).53
Recentglobaltrendshavebeenencouragingasupto74%ofdeliveriesarenowconductedby
skilledbirthattendantsandupto63%ofdeliveriesoccurininstitutions.8Withthisincrease
ininstitutionalbirths,higherproportionsofavoidablematernalandperinatalmortalityand
morbidityhavealsomovedintohealthfacilities.53Inaddition,arisingproportionofmaternal
deathsarenowduetoindirectcauses(27.5%),whilethemajorityofmaternaldeaths(over
70%)stilloccurbecauseofcomplicationsthatrequirefacility-basedcare,suchaspost-partum
haemorrhage,hypertensivedisorders,sepsisandcomplicationsrelatedtoabortions.54
Similarly, up to 85% of neonatal deaths are due to complications of preterm birth, birth
asphyxia, intrapartum-relatedneonataldeathsandsevereneonatal infectionsthatrequire
facility-basedcare.55 In2015,estimatesalso indicatedthatoverhalfofthestillbirthsthat
occur,dosoafterthestartoflabouratmaternityfacilities.56
PoorQoCatthetimeofbirthalsocausessignificantphysicalandpsychologicalmorbidities
forwomenwithnegativeconsequencesforthehealthandsurvivalofinfantsandaffectsthe
futurefinancialsecurityoffamilies.57,58Therefore,improvingthequalityoffacility-basedcare
at the time of birth offers tremendous opportunities to reduce maternal and perinatal
deaths.23
2.3:Qualityofessentialcareatthetimeofbirth
2.3.1:Background
Although expanding coverage rather than quality has been the focus of maternal health
programmeshistoricallyinLMICsettings,expertshavearguedthateffortstoimproveQoCat
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institutions have lagged behind efforts to increase demand for institutional maternity
services.7,15,59
Manyfacilitiesinhigh-burdenLMICsettingsareill-equippedtoprovideemergencyobstetric
careparticularlylowerlevelsfacilities.15Acomprehensiveassessmentof86healthfacilities
in sevendistricts inGhana found that thequalityof routineandemergencyobstetricand
newborncarewasgenerallypoorandtherewasalargequalitygapatfacilities.60Similarly,a
cross-sectionalstudyfromNigeriafoundthatonly40%ofprimaryhealthcarefacilitiescould
provideemergencyobstetriccareandthatmostEmOCsignalfunctionswerenotprovided
regularly.61
InIndia,cross-sectionalresearchevidencefrommultiplestateshasfoundthatmostmaternity
facilities have poor EmOC capability and are not able to provide all the basic signal
functions.62-64Theknowledge,skillsandcompetenceofSBAsprovidingmaternityservicesin
institutionswasalsofoundtobedeficientinastudyfromMadhyaPradeshstateinIndia.65
In addition, researchers have also highlighted systemic problems such as bed shortages,
inadequatesupplies,shortagesofskilledstaff,whichisnotconducivetotheprovisionofhigh-
qualityandrespectfulcareatthetimeofbirth.65-67Moreover,manyfacilitiesinLMICsoften
lackbasicrequirementssuchasregularelectricityandcleanwatersupply.15,61,68
Although, skilled birth attendants working within an enabling environment has been
promotedasanessentialstrategytoprovidehigh-qualityintrapartumcare69,manywomen
deliveringat facilities inLMICreportdoingsowithoutskilledbirthattendants. InSenegal,
datafrom2009–14indicatesthat28%ofbirthsinlower-levelfacilitiesand8%inhospitals
occurredwithout skilledbirth attendants.15 In India, studies inRajasthanhave found that
unqualified providers are frequently involved in maternity care provision in institutions,
includinginuptohalfofallobservedcaseswithsignificantdeficienciesinQoCatthetimeof
birth.70,71
Otherstudieshavealsofoundthatskilledbirthattendantsoftendonothavetherequired
skills72 and that numbers of SBAs deployed are frequently not enough which further
exacerbatespoorfacilityEmOCcapability.73Inastudyatninesub-SaharanAfricancountries,
researchersfoundthatskilledbirthattendants lackedadequateknowledgeandskillssince
theirtrainingcurriculadidnotincludetrainingsonmanualremovaloftheplacenta.74Some
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governmentsalsodesignatecadresasskilledbirthattendants,despitethemlackingrequisite
midwiferycompetencies.75,76
AvailableresearchevidencefromfacilitiesinLMICshighlightsmanydeficienciesinessential
careatthetimeofbirth,suchasnon-adherencetorecommendedprotocolsforcare,71,77,78
mistreatmentofwomen79-81andearlydischargefromfacilitieswithoutadequatepostpartum
monitoring.82The2016Lancetmaternalhealthseriesarticulatedthesedeficienciesincareas
“TooLittleTooLate”whichreferstoabsent,delayedorinadequatecareandas“TooMuch
TooSoon”,referringtoover-medicalizationthatresultsinovertreatment.83
Thereasonsbehindpoorqualityofcareatfacilitiesaremulti-facetedandcouldarisedueto
many different reasons such as: lack ofmaterial resources, limited knowledge and skills,
inappropriateapplicationsoftechnology84,inabilityoforganizationstochange85,failureto
align health worker’s incentives and quality improvement efforts to improved health
outcomes.86Giventhemulti-facetednatureofqualityashighlightedabove,ensuringQoCat
thetimeofbirthhasprovedtobechallenging.
Thebulkoftheavailableresearchevidenceonqualityofessentialcareatthetimeofbirth-
mostlyfrompublicsectorLMICfacilities-highlightstheneedtocarefullyexamineexisting
deficiencies inQoC at the time of birth andwork towards improvingQoC in institutions.
ResearchevidenceshowsthatitispossibletoimproveQoCbutinordertodosoitisessential
todefine,measureandthendevelopappropriatestrategiesforqualityimprovement.87,88In
thenextsection,Iwillelaborateonconceptualisinganddefininghigh-qualitymaternitycare
atfacilities.
2.3.2:Conceptualisinganddefininghighqualitymaternitycarepathwaysatfacilities
Thereisconsensusthatinordertoreduceavoidablematernalandneonatalmortality,every
pregnantwomanandnewbornbabywillneedskilledcareatthetimeofbirthwithevidence-
based clinical and non-clinical interventions delivered in a compassionate and enabling
environmentwhich ensures that respect, dignity and equity of care aremaintained.89 In
figure1,Ihaveconceptualisedamaternitycarepathwaythatoutlinesthedifferentwaysin
whichapregnantwomancouldarriveatahospital,eitherattheonsetoflabourorfullyin
labour; her care pathway within the hospital until her discharge from the hospital after
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childbirth.Thisis,insomeways,issimilartowhatothershavereferredtoasthe“gate-to-
gate”approach.90
Figure1:Schematicdiagramofmaternitycarepathwaysfordelivery
A pregnant woman may directly come to the hospital once labour begins or may be
transferredtotheexaminationorlabourroomsfromanotherplacewithinthehospitalsuch
astheoutpatientclinicortheemergencyroom.Uponarrival,thefirststepwillbedetermined
bywhether the labour has actually started.Anobstetric examination to assess change in
uterinecontractionsanduterinecervix (effacementanddilation)willhelptoestablishthe
stageoflabour.Dependinguponthestageoflabour,shemaybetransferredtodifferentareas
ofthehospitalasoutlineinthefigure1.
To implement this maternity care pathway, it is essential that other fundamental
requirementsforprovisionofhigh-qualityservicesareavailable.Forexample,teamsofskilled
andauxiliaryhealthworkersshouldbeavailableatthehospitalround-theclock.Staffshould
adheretorelevantclinicalprotocolsforobstetricandnewborncare.Infectionpreventionand
control measures should be implemented rigorously. Equipment must be accessible and
functional,andsubjecttochecksduringeverydutyshift.Drugsandconsumablesshouldbe
availableround-the-clock.Daily roundsshouldbeconductedbymanagers to identifygaps
andbottlenecks,andthesemustbecorrectedonanurgentbasis.Thetimetakenfromarrival
ofwomanatthehospitaltotheactualreceiptofservicesshouldbeminimisedtotacklethe
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thirddelay.91Specialistback-upwithinthehospitalorreferraltoanotherhigherlevelfacility,
ifneeded,shouldalsobeapartofthematernitycarepathway.15
Itistheoreticallypossiblethatprovisionofsuchamaternitycarepathwayalongwithother
essentialrequirements(staff,equipment,drugs,electricity,waterandothers)andefficient
transferofwomenincaseofcomplications,couldleadtoprovisionofhigh-qualitymaternity
careathospitals.
2.3.3:Skilledbirthattendance
As noted earlier, an important strategy employed to prevent maternal and neonatal
mortality, has been to ensure that skilled birth attendants (SBA), working in enabling
environments,areabletoattendeverychildbirth.69SBAsaredefinedas“anaccreditedhealth
professional such as a midwife, doctor or nurse who has been educated and trained to
proficiency in theskillsneededtomanagenormal (uncomplicated)pregnancies,childbirth
and the immediate postnatal period, and in identification, management and referral of
complicationsinwomenandnewborns.”69
AlthoughSBAsarewelldefined,theenablingenvironmentislesswell-definedbutconsidered
toincludetheavailabilityofequipment,drugsandafunctionalreferralpathway.92Several
studieshaveshownacorrelationbetweenanincreasedproportionofbirthsattendedbySBA
anda reducedmaternalmortality ratio.93-96Modellingsuggests thatacritical thresholdof
40%ofpopulationcoverageofbirthsattendedbyaSBA isessential forany reductions in
maternalmortalityandstillbirths.97
ThecorecompetenciesidentifiedforSBAsincludetheabilitytocommunicateinacaringand
respectful manner and provide holistic “women-centred” care, with the appropriate
knowledge and skills to provide evidence-based obstetric and neonatal care in a timely
manner.80,81,98Unfortunately,researchevidenceindicatesthat,womeninmanysettingsdo
notreceiveappropriateinterpersonalcareandthatSBAsmayoftenhavelimitedskillsand
confidence.72,74,99-101Researchershavealsoreportedthatsomecountriesmayalsodesignate
cadresasskilledattendants,despitethemlackingtherequisitemidwiferyskills.75,76
The indicator- the percentage of births delivered by skilled attendant, assesses progress
towards “skilled attendance at birth”. This indicator was used for the Millennium
DevelopmentGoal(MDG)reports9andtheCountdownto2015report.102Thisindicatorhas
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also been proposed as a core coverage monitoring indicator by the Ending Preventable
MaternalMortality (EPMM) initiative4, the Every Newborn Action Plan (ENAP)103 and the
SDGs6.Reportingofthisindicatoratthepopulationlevelreliesheavilyonnationalhousehold
surveys such as theMultiple Indicator Cluster Surveys (MICS)104 or the Demographic and
Health Surveys (DHS).105 In reality, most population-based surveys only measure births
attendedbyskilledattendantsratherthanthequalityofcaretheyprovideortheenvironment
inwhichtheseSBAswork.Thesequestionsonqualityandtheenablingenvironmentaremuch
hardertoanswerthroughpopulation-basedsurveysandalsovarydependingonthenational
context.
Further,therearemanyissueswiththeSBAindicatoratthecountrylevelsincethereislack
ofclarityintermsofwhichcadreisconsideredaskilledbirthattendantinaparticularcountry.
Forexample,manycountriesdonothaveaformalmidwiferycadreinsteadtheyhaveother
multipurpose workers such as auxiliary nurse midwives that do not undergo specialised
midwifery training. There is also a problem in terms of standardization of names and
responsibilities of different cadres, and task- shifting to less trained providers which
complicates measurement efforts.74 As a result, researchers have found that in many
countriestherearelargegapsbetweenthedefinedstandardsandcompetenciesofSBAand
their ability to manage normal labour and childbirth and other obstetric and neonatal
complications.100
Availability of adequate numbers of SBAs at the national and subnational levels is also
important.The2014updateoftheGlobalHealthWorkforcestatisticsindicatesthatamongst
132countriesforwhichdatawasavailable,64countriesdidnotmeettheminimumcritical
thresholdof23midwives,nurses,anddoctorsper10,000populationneededtoimplement
primaryhealthprogrammes includingmaternity care services.106 In addition, shortagesof
specialistssuchasobstetricians,anaesthetistsandneonatalnursesisalsofrequentinLMIC
settings.16,107
EvenwhenSBAsareavailable,theymaybepoorlydistributedwithinurbanandruralareasor
withinthepublicandprivatesectors.15,107,108Thisisparticularlychallenginginremoteand
ruralareaswherereasonssuchaspoor infrastructure, limitedcareeropportunities, family
reasonslikeschoolingforchildrenandothers,becomesachallengeforSBArecruitmentand
deployment.107,109Asaresultofthesefactors,womenmaynotbeabletoreceivetimelycare
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andendupeitherdeliveringaloneorwithoutappropriatelyqualifiedorskilledattendants,
despitegoingtoinstitutionsformaternitycareservices.15
2.3.4:Interventionsrecommendedforcareatthetimeofbirth
In theirvision forqualityofcare, theWHOandother internationaldevelopmentpartners
envision a future where “Every mother and newborn receives quality care throughout
pregnancy,labour,childbirthandpostnatalperiod”.4,89,110 Recentincreasesininstitutional
birthsacrosstheworld,offerauniqueopportunitytorealisethisvision.However,toachieve
this vision, health workers must apply evidence-based interventions consistently while
providingcare.Adherencetobest-practiceguidelinesforessentialcareatthetimeofbirth,
togetherwitheffectiveimplementationstrategies,111,112havethepotentialtosupporthealth
workersinmakingcorrectdecisionsattherighttimeanduseeffectiveinterventionswhile
providingcare.83
Arecentsystematicreview83publishedasapartoftheLancet2016maternalhealthseries
reviewedallavailableclinicalpracticeguidelinesfortheprovisionofroutineintrapartumcare
and postnatal care and provided up-to date guidance on recommended interventions
identifiedusingarigorousreviewmethodology.83Researchersretained51guidelinesoutof
163 guidelines reviewed, fifteen of them focussed specifically on intrapartum care and
nineteencoveredpostnatalcare.MostoftheretainedguidelineswereissuedbytheWHO,
the International Federation of Gynaecology and Obstetrics (FIGO), and the national
obstetricsandgynaecologysocietiesoftheUSA,Canada,UK,andGermanyandtheremaining
werefromNon-GovernmentalOrganizations(NGOs)inlow-incomesettings.Unfortunately,
mostof the governmental guidelines from low-income countriesdidnotmeet their strict
criteria(researchersusedtheAGREE–IIinstrumentandonlyretainedguidelinesthatreceived
ascoreof6ormore).83Table1belowsummarisestheinterventionsrecommendedforuse
duringintrapartumandpostpartumperiods.
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Table1:Interventionsrecommendedforuseduringintrapartumandpostpartumperiod
Recommendedinterventionsfortheintrapartumperiod1. Respectfulcare,communicationandbirthcompanions
• Offerwomenthepossibilityofbeingcaredforbyamidwife;provideone-to-onecontinuoussupportivecare
• Allowandencouragewomentohaveabirthcompanionoftheirchoice• Treateverywomanwithrespect,provideherwithall informationaboutwhatshemight
expect,askheraboutherexpectations,andinvolveherinthedecisionsabouthercare2. Assessmentsandmonitoringoflabourprogress,andmaternalandfoetalhealth• Performvaginalexaminationevery4hours• Routinelyassessthefrequencyofuterinecontractionsevery30min• Routinely assessmaternal pulse every hour,maternal blood pressure and temperature
every4h,andfrequentlyassesspassingofurine• Considerthepsychologicalandemotionalneedsofthewoman• Offerintermittentauscultationofthefoetalheartratetowomeninestablishedfirststage
oflabourinallbirthsettings(recommendationsincludefrequency,timing,andrecording)• Considerusingapartograph;usea4-houraction line tomonitor theprogressof labour
duringsecondstage• Document the presence or absence of substantial meconium-stained fluid when
membranesrupture(watersbreak)3. Painrelief• Assess the labouring woman's pain level and her desire for non-pharmacological and
pharmacologicalapproachestopainrelief• Encouragewomentoadoptanyuprightpositiontheyfindcomfortablethroughoutlabour• Advisewomenthatbreathingexercises, immersion inwater,andmassagemightreduce
painduringfirststageoflabour,andthatbreathingexercisesandmassagemightreducepainduringsecondstageoflabour
• Ensuretheavailabilityofopioids(e.g.,pethidine,diamorphine)inallbirthsettings;informwomenabouttheirside-effects;ifopioidsareusedforpainrelief,provideanti-emeticsincaseofnauseaorvomiting
• Ensuretheavailabilityofnitrousoxide(1:1mixturewithoxygen)forpainreliefinallbirthsettings;informwomenaboutitsside-effects
• Inobstetricunits,ensuretheavailabilityofregionalanalgesia;informwomenaboutrisksand benefits and potential implications of epidural analgesia during labour; provideregionalanalgesiaforwomenwhorequestit(includingrecommendationsfordrugs,dosing,maintenance, co-interventions, and precautions); ensure intravenous access beforeinitiationofanalgesia
4. Careduringfirst-stageandsecond-stagelabour• Routinehygienemeasurestakenbystaffcaringforwomenin labour, includingstandard
hand hygiene and single-use sterile gloves are recommended to reduce cross-contaminationbetweenwomen,babies,andhealth-careprofessionals
• Allowandencouragewomentodrinkwater,juiceorisotonicdrinks,andeatlightmealsorsnacksduringlabour
• Encourageandhelpwomentomoveandadoptanypositiontheyfindmostcomfortablethroughoutlabourandchildbirth,exceptsupineorsemi-supine
• Informwomenthatinthesecondstagetheyshouldbeguidedbytheirownurgetopush5. Careduringthird-stageandfourth-stagelabour• Informwomenthatactivemanagementofthirdstagepreventspost-partumhaemorrhage
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• Oxytocin(10IU,intravenouslyorintramuscular)istherecommendeddrugforpreventionofpost-partumhaemorrhage
• Ergometrineor600μgoforalmisoprostolcanbeusedasanalternativeifoxytocinisnotavailable
• Delayed cord clamping (done 1–3min after birth) is recommended for all births whileinitiatingessentialnewborncare
• Early cord clamping (<1 min after birth) is not recommended unless the neonate isasphyxiatedandneedstobemovedimmediatelyforresuscitation
• Controlledcordtractionandpalpationshouldbeusedaftercordclampinginsettingswithskilledbirthattendants.
• Encouragewomentohaveskin-to-skincontactwiththeirbabiesassoonaspossibleafterbirth
• Avoidmother–babyseparationbeforethefirsthourfollowingbirth,unlessatthemother'srequest; delay postnatal routine procedures (e.g. weighing, bathing, and measuring);monitortheneonate'sconditionduringskin-to-skincontact.
• Encourageandsupportbreastfeedinginitiationwithinfirsthour.RecommendedinterventionsforthePostnatalperiod
6. Woman-centredrespectfulmaternitycare• Provideindividualised,culturallyandcontextuallyappropriatecare,responsivetochanging
needs,andbasedonindividualcareplan7. Duringpostnatalfacilitystay• Followinganuncomplicatedvaginaldelivery,womenareadvisedtostayatleast24hinthe
facility• Evaluatepost-partumbleeding,maternalbloodpressure,anddocumenturinevoid• Evaluate perineal healing and look for signs of infection to identify and treat puerperal
infectionorsepsis(referwhennecessary)• Providepainrelief• Askwomenaboutheadache,assessbowelmovements,andpromoteearlymobilisationto
preventthrombosis• Facilitate rooming-in (mother and baby should stay in the same room 24 h a day) and
promoteparentparticipationineducationalactivitiesrelatedtonewbornbabies'health• Anti-D immunoglobulin should be offered within 72 h to every non-sensitised Rh-D-
negativewomanfollowingmiscarriageorbirthofapositivebaby• Evaluaterubellaimmunisationandofferimmunisation8. Atdischargefromhealthfacility• Attimeofdischargefromhealthfacility,provide informationaboutdangersignsforthe
motherandbaby,andcounselwomenonadequatenutrition,hygiene,handwashing,andsafesex
• Provideironandfolicacidsupplementsfor3months• Promoteexcusivebreastfeedingfrombirthuntil6monthsofage;observebreastfeeding
techniquebeforehospitaldischarge• Inmalariaendemicareas,advisemothertosleeptogetherwiththebabyunderinsecticide-
impregnatedbednets.9. Organisationandcontentofpostnatalcareafterdischarge• Recommendtwotothreepost-partumvisitsafterfacilitydischarge• Ateachpost-partumvisit,provideinformationaboutdangersignsforthemotherandbaby,
andcounselwomenonadequatenutrition,hygiene,handwashing,andsafesex• Askaboutdyspareuniaandresumptionofsexualintercourse,andrecommendpelvicfloor
exercises• Assessmentalhealthandwellbeingorpost-partumdepressionusingscreeningquestions
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• Exploresocialsupportandassessforsignsofdomesticabuse• Promote excusive breastfeeding from birth until 6 months of age; mothers should be
counselledandprovidedwithsupportforexclusivebreastfeedingateachpostnatalcontact• Inmalariaendemicareas,advisemothertocontinuetosleeptogetherwiththebabyunder
insecticide-impregnatedbednetsSource:Millerat.al(2016)83
2.3.5:Interventionsnotrecommendedforuseduringthetimeofbirth
Havingidentifiedinterventionsrecommendedfortheprovisionofroutineintrapartumand
postpartumcare,Table2belowoutlinestheinterventionsthatdonothaverecommendations
for use, but still continue to be used frequently during provision of intrapartum and
postpartumcare,particularlyinLMICsettings.83,113-116Lackofup-to-dateknowledge,attrition
of skills, low levels of motivation, restrictive institutional policies and health system
bottlenecks canperpetuate theuseof these interventions thatarenot recommended for
providing care during labour and childbirth. 16,117-120 As shown in Table 2,many of these
interventions such as routine use of enemas, prophylactic insertion of intravenous fluids,
administration of oxytocics before delivery, routine episiotomy and others, do not have
evidence of effectiveness.114 Adoption of these ineffective practices into routine care is
harmfulespecially inLMICsettingswithweakhealthsystems,whereservicequality isnot
routinelymonitoredandwherewomenmaynotregularlycometofacilities.
Table2:Interventionsforintrapartumandpostpartumcarethatdonothaverecommendationsfor
use
1. Duringlabourandtheintrapartumperiod• Donotcarryoutaspeculumexaminationifmembraneshavecertainlyruptured.• Donotperformcardiotocographyonadmissionforlow-riskwomeninsuspectedorestablished
labourinanybirthsettingaspartoftheinitialassessment.• Donotperformroutinefetalpulseoximetry.• Donotmakeanydecisionaboutawoman'scare in labouronthebasisof cardiotocography
findingsalone.• Restrictionoffoodandfluidsduringlabour.• Routineintravenousinfusioninlabour.• Repeatedorfrequentvaginalexaminations,especiallybymorethanonecaregiverForpainrelief:• Donotoffertranscutaneouselectricalnervestimulationtowomeninestablishedlabour• Donotofferlidocainespraytoreducepaininthesecondstageoflabour• Donotofferoradvisearomatherapy,yoga,acupressure,acupuncture,orhypnosis,orwater
papulesforpainrelief• DonotoffereitherH2-receptorantagonistsorantacidsroutinelytolow-riskwomen2. Recommendedagainstinterventionsforcareduringfirstandsecondstageoflabour.
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• Donotofferoradviseclinicalinterventioniflabourisprogressingnormallyandthewomanandbabyarewell(includingamniotomyandoxytocinaugmentation,eveninwomenwithepiduralanalgesia).
• Discouragethewomanfromlyingsupineorsemi-supineinthesecondstageoflabour.• Donotperformroutineperinealshavingorenemas.• Donotperformperinealmassageinthesecondstageoflabour.• Donotcarryoutaroutineepisiotomyduringspontaneousvaginalbirth.• DonotperformKristellermaneuver.• Administrationofoxytocinatanytimebeforedeliveryinsuchawaythattheeffectcannotbe
controlled.• Sustained,directedbearingdowneffortsduringthesecondstageoflabour.• Massagingandstretchingtheperineumduringthesecondstageoflabour.• Donotperformfundalpressureduringlabour.• Asaroutine,donotmovelaboringwomantoadifferentroomatonsetofsecondstage.• Donotencouragewomantopushwhenfulldilationornearlyfulldilationofcervixhasbeen
diagnosed,beforewomanfeelsurgetobeardown3. Recommendedagainstinterventionsforcareduringthepostnatalperiod• Palpationormeasurementofuterusinabsenceofabnormalbleedingisnotrecommended.• Donotperformmanualexplorationoftheuterusafterdelivery.• Donotperformlavageoftheuterusafterdelivery.• Do not use antibiotics routinely in low-riskwomenwith a vaginal delivery for endometritis
prophylaxis• Aspirinforthromboprophylaxisisnotrecommended.• VitaminAsupplementationforthepreventionofmaternalandinfantmorbidityandmortality
isnotrecommendedSources:WHO1999114,Easonetal.2000115,Nielson1998121;LudkaandRoberts1993116,Milleretal.2016.83
2.3.6:Theimportanceofrespectfulmaternitycareduringlabourandchildbirth
Inrecentyears,researchersandorganizationssuchasFIGO,WHOandothershavehighlighted
theimportanceofprovidinghighqualitycareduringlabourandchildbirthbyusingevidence-
basedinterventionsanddeliveringtheminahumaneanddignifiedmannerwithrespectfor
women’s human rights.80,81,122,123 The Lancet 2014 midwifery series also identified that
womenvalue relevant, timely informationand support, so that theyareable tomaintain
dignityandcontrolduringthebirthingprocess.124
There is often a complex interplay of factors such as those at the individual level (socio-
economicstatus,educational levels,caste), institutional levels (policiesoncompanionship,
clinical guidelines, lack of resources for example: inadequate privacy screens) and at the
healthworkerlevel(deficienciesinknowledge,skillsandincreasedworkloads)thatmayresult
inmistreatmentofwomenatmaternityfacilities.79,80ArecentWHOstatement(2014)on
preventingandeliminatingdisrespectandabusehighlightedtheurgencyofaddressingthis
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issueand recommended that thereneeds tobeagreater researchandaction inorder to
improverespectfulcareduringlabourandchildbirth.123
This growing importanceofensuring respectfulmaternity carehasevolved from research
evidencethathaspreviouslyconceptualisedthisissueasdisrespectandabuse125,obstetric
violence126anddehumanisedcare.127There isnowincreasingresearchevidence indicating
that that this phenomenon occurs in both high80,128-131 and low income settings132-134,
indicatingthatthisisauniversalissue,andnotjustlimitedtoresource-constrainedsettings.
Women’s experiences of maternity care are negatively influenced by factors such as
unhygienic conditions at facilities, any disrespect and abuse they encounter, limited
informationorexplanationsprovidedpriortoconductinginvasiveprocedures,discrimination
and inequitable care provision.81,135 Low cost of treatment, convenience, kindness,
interpersonalqualitiesofthehealthworker,attentionandtimereceived,technicalcapability,
communicationandintegrityareallvaluedqualitiesbywomenwhenitcomestochoosing
healthworkers.136-140
Inalandscapeanalysisfrom2010,BowserandHilldescribedsevencategoriesofdisrespectful
and abusive care during childbirth: physical abuse, non-consented clinical care, non-
confidentialcare,non-dignifiedcare,discrimination,abandonment,anddetentioninhealth
facilities.125Sincethen,researchershaveadvancedthisconceptandproposedadefinitionto
articulate the criteria for determining when an interaction with a health worker or
circumstancesatmaternityfacilitiesthatshouldbeconsideredabusiveanddisrespectful.81,99
Freedmanetal.(2014)proposedthatacomprehensivedefinitionofmistreatmentneedsto
capture the health, human rights and socio-cultural dimensions of mistreatment; while
measurementeffortsneedtocapturewhere,howandwhymistreatmentoccurs.81Further,
measurementeffortsshouldalsobeabletocapturewhethermistreatmentwasintentional
ornot,andtheroleoflocalsocietalnorms(forexample,women’sstatus,patient-provider
dynamics) that influences women’s perceptions of mistreatment in different contexts.81
Giventhisbackground,Freedmanetal.(2014)defineddisrespectandabuseduringchildbirth
as “interactions or facility conditions that local consensus deem to be humiliating or
undignified,andthoseinteractionsorconditionsthatareexperiencedasorintendedtobe
humiliatingorundignified.”99
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In2015,theWHOconductedasystematicreviewandtriedtoestablishtheevidence-basefor
mistreatmentglobally.80Theauthorsreviewed65studies(53qualitativeand12quantitative)
from34 countries and found thatmost studiesuseddifferentoperational definitions and
measurementapproaches.80Amongstthequantitativestudies,onlythreestudiesreporteda
prevalenceofmistreatmentatmaternityfacilities,whichvariedfrom15to98%.80Thisreview
also proposed a typology of items consideredmistreatment and identified the following:
physical, verbal or sexual abuse, stigma and discrimination, failure to meet professional
standardsofcare,poorrapportbetweenwomenandprovidersandhealthsystemconditions
andconstraints.80
However,mistreatmentandpoorqualityofclinicalcarearecloselyinterlinked.83Asthe2016
Lancet maternal health series noted, there are two extremes of maternal health care
provisioninagrowingnumberofLMICs.83Thefirstextremeisassociatedwithover-treatment
ortheroutineover-medicalisationofnormallabourandbirths,whichtheyreferredas“Too
MuchTooSoon”. The secondextreme isunder-treatmentorunderuseof evidence-based
practicessignifiedbytheterminology“TooLittle,TooLate”whichistheunderlyingcauseof
high maternal mortality and considerable morbidity.83 Both over-medicalisation such as
increased use of unnecessary procedures like episiotomies without indications or under-
treatmentsuchasabsenthygienicstandardsatmaternityfacilitiesarealsoagainsttherights
ofchildbearingwomen.141
Therefore, mistreatment of women during labour and childbirth can occur because of
inappropriate care practices, which may include those related to disrespect and abuse
(intentional harmor degradation), over-treatment, or under-treatment. Regardless of the
terminologyused,mistreatmentofwomenfallsunderpoorqualityofcare.Aswomenwho
aremistreatedare less likelytocomebacktofacilitiesforfuturepregnancies,142this isan
importantissuethatneedstobeaddressedurgently.
Inthenextsection,Iwillpresentfindingsfrommyliteraturereviewonqualityofcareinhealth
systemsandqualityasitrelatestomaternalandnewbornhealth.Thereafter,Iwilloutline
approachestomeasurevariouselementsofQoCinmaternalandnewbornhealth.QoCfor
healthsystems includesbroader issuesthanQoC inhealth facilitiesandtheybothrequire
different interventions for improvement. However, since both of these issues are closely
interlinked,itisusefultounderstandthemeaningoftheseconceptsandunderstandtheways
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thattheyoverlaporinteract.Inthesubsequentsection,Iwillthensummarisefindingsfrom
myliteraturereviewontheempiricalevidenceonQoCduringlabourandchildbirthinIndia
usingthequalityofcareframework.
2.4:Frameworksofqualityinhealthanddefinitions
Over the past two decades, numerous frameworks on quality have been conceptualised
basedondifferingnotionsofquality.Sincequalityismulti-dimensional,itiswidelyaccepted
thatthereisnosingleconceptorframeworkofqualityofcare.
Previous frameworks of quality of care for health services have included the perspective
model143focussedonclientandprovider’sperceptionsofquality,thecharacteristicmodel144
whichfocussedonspecificcareelements(safety,efficacy,timeliness,patientcenteredness
etc.)andthesystemsmodels145whichconsideredqualityasaby-productofgoodstructures
andprocessesresultingtogoodoutcomes.
2.4.1:Definitionsofqualityofcareinhealthservices
Historically,manydefinitionshaveexistedforQoCinhealthservices.Earlierdefinitionsseem
to have favoured biomedical outcomes alone. For example, Donabedian (1980) defined
qualityas“theapplicationofmedicalscienceandtechnologyinamannerthatmaximisesits
benefit to health without correspondingly increasing the risk. The degree of quality is,
therefore,theextenttowhichthecareprovidedisexpectedtoachievethemostfavourable
balanceofrisksandbenefits.”146
In1988,RoemerandMontoya-Aguilarmadeadistinctionbetweenassessmentofqualityand
assuranceofqualitybasedonpre-definedsetofstandards.147Theywrote,“Qualityofhealth
careconsistsoftheproperperformance(accordingtostandards)of interventionsthatare
knowntobesafe,thatareaffordabletothesocietyinquestion,andthathavetheabilityto
produceanimpactonmortality,morbidity,disability,andmalnutrition.”147
Anotherdefinitionwhichstressedondecreasingthegapbetweendesiredandactualhealth
outcomeswastheInstituteofMedicinedefinition(1990)whichdefinedqualityofcareas,
“thedegreetowhichhealthservicesforindividualsandpopulationsincreasethelikelihood
ofdesiredoutcomesandareconsistentwithcurrentprofessionalknowledge.”148
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Otherdefinitionshavebeenmorecomprehensive.WilsonandGoldsmith(1998)described
QoC as “the sum of four components: technical quality, resource consumption, patient
satisfactionandvalues”.149Perhaps,thesimplestandmostwell-accepteddefinitionofquality
isGodlee’s(2009),whodefinedqualityas“clinicaleffectiveness,safety,andgoodexperience
forthepatient.”150
2.4.2:Elementsofqualityofcareinhealthservices
Elements of quality of care in health services are generally assessed using Donabedian’s
classicframeworkofstructure,processandoutcomes.146,151AsexplainedbyPeabodyetal.
(2006) in describing elements of quality for health systems, “structure refers to physical
infrastructure,supplies,commodities,resources,financingofhealthservicesandothers.”86
Process refer to “healthworker and client interactionswhich occur during consultations,
examinationorprocedures.” 86Outcomes refer to indicators “thatmeasurehealth status,
mortalityanddisabilityadjustedlifeyearsofthepopulation”.86
Morerecently,theInstituteofMedicine’sreport“CrossingtheQualitychasm:anewhealth
systemforthe21stcentury”broadenedtheconceptofqualitybyexpandingoncontextual
elements of quality to illustrate how improved processes can actually lead to improved
quality152.Accordingtotheirframework,qualityofhealthcaremeansprovisionofservices
thatare:
1. Effective: delivering health care that is adherent to an evidence-base and results in
improvedhealthoutcomesforindividualsandcommunities,basedonneed;
2. Efficient:deliveringhealthcare inamannerwhichmaximizes resourceuseandavoids
waste,deliveringhealthcarethatistimely,geographicallyreasonable,andprovidedina
settingwhereskillsandresourcesareappropriatetomedicalneed;
3. Acceptable/patient-centred:deliveringhealthcarewhichconsidersthepreferencesand
aspirationsofindividualserviceusersandtheculturesoftheircommunities;
4. Equitable: delivering health care which does not vary in quality because of personal
characteristicssuchasgender, race,ethnicity,geographical location,orsocioeconomic
statusand
5. Safe:Deliveringhealthcare,whichminimizesrisksandharmtoserviceusers.
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2.5:FrameworksanddefinitionsofQoCspecifictomaternalandnewbornhealth
Similartoframeworksonqualityofhealthservices,therehavealsobeenmanyframeworks
toassessqualityinmaternalandnewbornhealth.153,154Someoftheseincludesframeworks
thathaveassessedQoC fromclientsperspectives,138 rights–basedapproaches,155provider
needs156andmodelstoovercomedelays.157
Perhaps, themostwidely used frameworkwas developed byHultonet al.153 (2000)who
adaptedtheIOMdefinitionofqualitywhileincorporatingtheconceptsofeffectiveandtimely
accessandofreproductiverights.153Theydefinequalityofmaternalhealthas“thedegreeto
whichmaternal health services for individuals and populations increase the likelihood of
timelyandappropriate treatment for thepurposeofachievingdesiredoutcomes thatare
both consistent with current professional knowledge and uphold basic reproductive
rights.”153
More recently, in 2015, theWHOpublished its vision forQoC formaternal andnewborn
health89.TheWHOvisionwasinformedbyHulton’sframework153andtheIOMdefinition,and
defines QoC as ‘the extent to which health services provided to individuals and patient
populationsimprovedesiredhealthoutcomes.Inordertoachievethis,healthcareneedsto
besafe,effective,timely,efficient,equitable,andpeople-centred.’89
SimilartotheHultonframework153,theWHOframeworkforQoCinmaternalandnewborn
health (Figure2)alsoconceptualisesqualityasbothprovisionofevidence-basedcareand
positiveexperiencesforwomenseekingcare.89Satisfactionofwomenwithmaternitycareis
closelylinkedtowomen’sexperiencesofcareintheQoCframeworkandisassociatedwith
allelementsofstructure,processandoutcomes.Forexample,alackofadequatesuppliesor
skilledpersonalleadstopoorsatisfactionamongstwomen.Similarlyprocessofcareelements
suchasgoodinterpersonalbehaviours,emotionalsupport,andtreatmentwithrespectand
dignityareessentialtoensuresatisfactionwithmaternitycare.89,158Outcomeindicatorsfor
qualityincludethoserelatedtowomen’ssatisfactionandlabourandchildbirthoutcomes.89
However,thereisacomplexrelationshipbetweensatisfactionandQoC.159Itispossiblethat
care receivedbypatients is of high technical quality but inadequate in termsof patient’s
satisfaction.Inaddition,women’ssatisfactionisalsoassociated,atleast,inpart,withlabour
andchildbirthoutcomes.Researchsuggeststhatwomenwhoaredissatisfiedwithmaternity
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servicesalso tendtohavepoorpregnancyoutcomessuchaspoorpostnatalpsychological
outcomes,apreferenceforcaesareansections,negativefeelingstowardstheneonateand
problemswithbreastfeeding.160-162
TheWHOframeworkrecognisesthatqualityisanormativeconcept,therefore,standardsfor
care are needed for assessment and improvement purposes.89 WHO guidelines for both
routineandemergencyobstetricandnewborncarearewell-defined.163TheWHOframework
alsorecognisestheimportanceofrobustinformationsystemstocapturedataonQoC,and
theneedforeffectivereferralsystemsincaseofemergencies.89
TheQoCframeworkis linkedtothesixWHOhealthsystembuildingblocks164of1)service
delivery; 2) health workforce; 3) information systems; 4) medical products, vaccines and
technologies;5)healthfinancingand;6)leadership/governance.Ittherebycreateslinkages
sothatanalyticalworkandimprovementprojectstoimproveQoCcanbetakenusingahealth
systemsapproach.Finally,theframeworkrecognisesthathealthsystemsareplatformsthat
enableaccess tohighQoCandallowsprocesses tooccur, along two importantand inter-
linkeddimensionsofserviceprovisionandexperienceofcareleadingtoimprovedindividual
andfacility-leveloutcomes.89
Figure2:WHOQualityofCareFrameworkformaternalandnewbornhealth
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2.6:MeasurementofQoCformaternalandnewbornhealthinLMICsettings.
GiventherecentemphasisonemphasisonaccountabilityinMNH,165nationalgovernments
anddevelopmentpartnersneedtogenerateorhaveaccesstohigh-quality,representative
dataonQoCtoinformtheirpolicyandprogrammedecisions.166However,measurementof
QoCisoftendifficultgiventhewide-rangingissuesthatqualityencompassesandweaknesses
ininformationsystemsinmanyLMICsettings.
Donabedian’sapproachtomeasuringqualitybyassessingelementsofstructure,processand
outcomesisalsowidelyusedformeasuringQoCinmaternalandnewbornhealth.167These
elementsaredescribedinthesectionsbelowwithaspecificfocusonmeasurementofquality
ofMNHservices.
2.6.1:Measuringstructureelementsofqualityofcare
Dataonstructuralelementsofqualityareperhapstheeasiesttoobtain.Routinemonitoring
dataiscollectedbynationalhealthsystemsormonitoringsystemsofimplementingagencies
andareoftenanobvioussourceofinformationonstructuralelementsofQoC.Forexample,
facility inventoriesofdrugsandsuppliesareoftenavailablethroughlogisticsmanagement
information systems. Serviceutilisationdataon indicators suchasnumberof institutional
births,deliveriesbyskilledbirthattendantsandothersisavailablethroughthenationalhealth
informationsystems.
Potential advantagesof routinedata for structuralmeasures include theiravailabilityata
relativelylow-cost,onacontinuousbasis,dataareoftendisaggregateduptothefacilityor
district level. In addition, routine data provide more detailed information on service
availability and utilisation compared to household surveys.166 However, there are also
limitations with using routine data, for example: many elements of MNH care are not
collected through routine systems,denominators are limited to those in contactwith the
healthsystem,datamayalsobeofpoorquality,incompleteorupdatedinfrequently.166
Giventheseissues,dataonstructuralelementsofQoCtendstobecollectedthroughspecial
surveys or censuses. Readiness which often refers to the availability of necessary drugs,
commoditiesandtrainedhealthworkers,isoftenusedasaproxyforstructuralquality.Some
large-scale facility-based surveys regularly measure structural elements. Some of these
include: the World Health Organization’s Service Availability and Readiness Assessment
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(SARA)168, the DHS Program’s Service Provision Assessment (SPA) surveys,169 and the
MEASUREEvaluation’sRapidHealthFacilityAssessments (RHFA).170Thesesurveyscapture
information on training, supervision, availability of services, tools and guidelines,
infrastructure conditions, availability and storage conditions ofmedications, supplies and
equipment.60,171However,noneofthesemethodsassesscompetencyofhealthworkers.166
SpecifictoMNH,materialssuchasEmOCneedsassessmenttoolkit22,UnitedStatesAgency
for International Development’s (USAID)- Maternal and Child Health Integrated Project’s
(MCHIP)QoCsurveys172haveseparatemodulesonfacilityinventoryassessmentthatcapture
information on infrastructure, availability and conditions of commodities, supplies, and
equipmentrequiredforprovisionofmaternityservices.
However, structural improvements by themselvesmay not improve health outcomes. 151
Therefore,inmaternalandnewbornhealth,measurementofinputsalone,suchasreadiness,
either of facilities (throughmeasurement of signal functions) or of the provider (through
measurement of knowledge and skills) does not provide a comprehensive picture and
therefore,measurementofprocessofcareisimportant.
2.6.2:Measuringprocesselementsofqualityofcare
Theoretically, processes of care can be measured during every health care encounter.
However,insomecases,theprivatenatureofhealthworker-clientinteraction,absenceof
appropriatemeasurementscalesorinstrumentslimitsmeasurementefforts.173Overthepast
decade, therehavebeenmanymethodological advances inmeasurementofprocessesof
care for MNH. There is also robust research evidence, which suggests that measuring
processes of care, as a part of quality improvement efforts can lead to improved health
outcomes.88,111,174ThismakesprocessmeasurementapreferredapproachtoassessQoCfor
maternalandnewbornhealth.
Below Idiscussnineapproaches tomeasureprocessesof care formaternalandnewborn
health such as standardizedpatients, clinical vignettes, reviewofmedical records, audits,
simulations or clinical skills and drills, direct clinical observations, video filming and
satisfactionsurveys.Allmethodshavetheirownadvantagesanddisadvantages.86,175
Standardized patients are a popular method to assess processes of care and have been
employedbyanumberofstudiesinAsiaandAfricatomeasureQoCforchildhoodillnesses
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such as diarrhoea, acute respiratory infections,176 and sexually transmitted infections177.
Standardized patients are trained actors, often from local communities, who make
unannouncedvisitstoahospitalandpresentsymptomsofasimulatedcondition.178These
patientscompleteanassessmentchecklistonprovidersclinicalactionsafterthevisit.175Since
this methodology employs cases that are standardised and predetermined, it allows for
qualitycomparisonsacrossdifferenttypesofprovidersandcontexts.179
Someproponentsofstandardizedpatientsarguethatthatsincehealthworkersdonotknow
the true identity of standardized patients, their behaviours approximates that of “real-
patients”andhence,healthworkersarelesspronetoHawthorneeffect.180Hawthorneeffect
isaphenomenonwherebyhealthworkersbecomeawarethattheyarebeingobserved,and
thereafter,exertadditionaleffortwhich isachange intheiractualbehaviour.181However,
predictinghealthworker’sbehavioursinreallifeiscomplex.Forexample,healthworkersmay
providebettercaretosomeonetheyknowpersonallyorprovidediscriminatorycaretoother
patients.Moreover,thesesimulatedpatientsarenotsuitableforassessingQoCforinvasive
proceduresorconditionslikechildbirththatcannotbesimulatedbyactors.
Clinicalvignettesweredevelopedformeasuringqualitywithinagroupofproviders86,179,182
and theyhavebeenused to studyQoC fora rangeof conditions, including formeasuring
EmOC capability65 and intrapartum decision-making of midwives.183 Vignettes can be
administeredeitheronpaper,bycomputer,orovertheInternet.86Whenclinicalvignettes
areusedtoassessmanyproviders,eachproviderisgiventhesamecaseorthesamesetof
cases.86Healthworkersfollowthatparticularwrittenclinical-case,respondtoquestionsthat
replicatecertaincomponentsofapatient’svisit, forexample-history-taking,examination,
orderingofinvestigationsorprescribingatreatmentplan.86Thequestionsareopen-ended
and include interactive responses that simulate a patient’s visit and evaluate the health
workersknowledge.Healthworkers’performanceisassessedagainstacriteriaformanaging
theparticularcondition.184
Vignetteshave severaladvantages, suchasallowingcomparisonbetweenhealthworkers,
andcomparisonbeforeandafterimplementationofanewpolicy.86Theyarealsocheap,easy
toadministerandeasytoanalysewhichmakesthemuseful.86However,researchershave
argued that health worker’s behaviours during an actual consultation is not accurately
captured by vignettes, and that knowledge does not always translate into actual clinical
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practice.185Therefore,althoughvignettesareausefulqualityassessmenttool,theyareoften
incompletewhenusedin isolation,andshouldbeusedwithothermethodssuchasdirect
observationsofclinicalpractice.185186
Recordreviewsareoneofthemostfrequentlyusedmethodstoevaluateclinicalqualitysuch
asforemergencycaesareansections.187Theirmainadvantagesarethatmedicalrecordsare
availableaftereveryhealthcareencounterand theyareeasilyobtained. However,often
whenmedicalrecordsarehandwritten,theymaynotbelegibleormayhavebeenwrittenfor
otherpurposes likeobtainingpayments,ormedico-legalreasonsratherthantodocument
details of procedures.86 Their utility is perhaps greater in high-income settings where
electronicmedicalrecordsareroutinelyused.Incontrast,suchsystemsdonotexistinmost
low-resourcesettingsandthereisofteninconsistency1andpoorclinicaldocumentationfor
indicatorsof interestsuchaspartographuse, timingofoxytocin,orbloodtransfusionand
others.
Auditssuchasnear-missaudits,maternalandperinataldeathreviewshavealsobeenused
extensivelytoidentifyandaddressdeficienciesinprocessesofMNHcare.90,188-193Auditshave
beendefinedas:‘thesystematicandcriticalanalysisofthequalityofmedicalcare,including
the procedures used for diagnosis and treatment, the use of resources and the resulting
outcome and quality of life for the patient.194 193 Audits often combine information from
different sources, whichmakes them superior to othermethods such as record reviews.
However, it is important toensure that thepurposeofconducting theauditasa learning
exercise aimed to improve clinical practices is communicated effectively for them to be
acceptedathospitals.193
AvarietyofstudieshaveusedauditstomeasureandimprovequalityinMNHandevidence
indicates that under certain contextual conditions audits can be feasible, effective and
acceptable.90,192,193195However,likerecordreviews,auditsareretrospectiveandrequirea
trainedhealthworker toundertakedetailedabstractionof records fromdifferent sources
whichmakeitatimeconsumingendeavour.175
Clinicalskillsanddrillsapproachesliketheobstetricemergencyskillsanddrillsmethodshave
been used extensively to maintain health workers’ competence in managing obstetric
emergenciesthathealthworkersmaynotalwaysencountersuchaseclampsiaorpost-partum
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haemorrhage.196,197 In these skills and drills approaches, participants are given clinical
scenarios,andareinstructedtodemonstrateclinicalskillsonmannequinsorothersimulators.
Simulation-based-trainingisconsideredtobeaproactiveapproachtoreduceerrorsandrisk
inobstetricsandaimstoprovideparticipantsarangeoftransferrableskillstoimprovetheir
actual clinical performance. 196 However, these methods have mostly been used for
educationalpurposes rather than formeasuringquality, 198 and simulators canalsobea
costlyinvestment,particularlyforuseinLMICsettings.
Clinicalpracticeobservationsaredirectobservationsofcareprocessesastheyhappenand
areanestablishedmethodforevaluationofQoC.1,86Theygenerallyutiliseexternalobservers
andareseparatetoongoingsupervisionandmentorshipduringregularclinicalpracticewhich
mayinvolveobservations.Fromanethicsstandpoint,itisessentialthatbothhealthworkers
andpatientsareinformedpriortothestartofclinicalobservations.Thismayoftenintroduce
a bias referred to as Hawthorne effect.181 Clinical practice observations and standardized
patients are thought to be gold-standardmethods to assessQoC 1,86,179 but they are not
suitableforoutcomesthatareinfrequentorconditionsthatcannotbesimulatedbyactors,
forexample:neonatalresuscitationormaternalcomplicationsofpregnancy.Theyarealso
resource-intensiveandthereforemaynotbesuitableforfrequentorroutinemonitoringof
quality.
Clinical practice observations have been utilised by various studies to examine quality of
obstetricandneonatalcareinmanyLMICsettings.70,71,78,199-201TheAvertingMaternalDeath
and Disability (AMDD) programme of the Columbia University, which initiated the needs
assessment of emergency obstetric and newborn care22, USAID/ MCHIP QoC surveys172,
HelpingBabiesBreatheprogrammeforneonatalresuscitation202andassessmenttoolsfrom
the Gaala study203 have specific sections onmeasuring processes of care during routine
labourandchildbirth.Theyalsohavespecificsectionsonintrapartumandimmediatepost-
partum care including aspects of woman-centered respectful maternity care. These
instruments been used in multiple countries and are based on globally recognised best
practicessuchastheWHO’scareinnormalbirthandIntegratedManagementofPregnancy
&Childbirthmanuals.114,204
SomeexcitingrecentadvancesinmeasuringQoChaveincludedtheuseofvideo-filming205
which is suitable for rarer outcomes, events that unfold over a shorter period of timeor
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involve a series of steps such as neonatal resuscitation or observation of oxytocin use.
However,thecostsofclosed-circuitcameras,ethicalandsensitiveissuesaroundtheuseof
videofilming,consentprocedures,dataanonymizationanddatamanagementneedscareful
consideredpriortousingsuchvideofilmingmethodsinLMICsettings.
Clients’experiencesincludingsatisfactionwithcareisgenerallyassessedusingcross-sectional
surveys.Donabedian(1980)definedusersatisfactionas“patient’sjudgmentonthequality
and goodness of care”146. Linder-Pelz and Struening (1985) have argued that satisfaction
comprisesof“multipleevaluationsofdistinctaspectsofhealthcarewhicharedetermined(in
some way) by the individual’s perceptions, attitudes and comparison processes.”206 As
highlightedbythesedefinitions,theconceptofsatisfaction ismultidimensional207andany
evaluation of satisfaction is likely to be influenced by individual women’s personal
preferences,theirexpectations,theculturalandsocialcontextandactualcarereceivedby
them.208
Althoughsatisfactionisconsideredtobeimportantforfutureutilizationandchoiceofhealth
facility,209 further research is needed to fully understand the mechanism through which
womenperceivesatisfactionwithmaternityservices.210-212Surveystomeasuresatisfaction
have been criticised for limitations such as measurement errors and inability to assess
changesovertime.Forexample,surveysmayoftenuseasingleitemtoassesssatisfaction
withcareignoringthemulti-dimensionalnatureofsatisfaction.208,210,213Researchindicates
multipledeterminantsthatinfluencewomen’ssatisfactionsuchasstaff-womaninteraction,
informationexchange,involvementindecisionmaking,controlduringthebirthingprocess,
painrelief,andbirthenvironment.214-216,210,217Detailedinformationonthesedeterminantsis
notalwayscollectedinsatisfactionsurveys.
Someresearchershavealsoarguedthatsurveysonsatisfactionwithmaternitycarearenot
groundedinconceptsandtheory.218,207Othershavealsonotedthathighlevelsofsatisfaction
are frequently reported in surveys which questions the reliability and validity of existing
measurement tools.Oftendata fromsatisfactionsurveysshowsa lackofvariabilitywhich
questionstheabilityofsurveystodiscriminate.211Lastly,measuresofsatisfactionreported
inresearchstudiesoftendonotalwaysdifferentiatebetweentheactualexperienceoflabour
andchildbirth(suchaspainormistreatment)andtheoverallexperienceofcareduringthe
hospitalstay.208,219,220
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Arecentsystematicreviewthataimedtoidentifyexistinginstrumentstomeasuresatisfaction
with labour and childbirth found that there were only a small number of validated
instruments.208 Based on a detailed review of the literature, researchers identified all
availablemulti-itemscalesofsatisfactionofcareduringlabourandchildbirthandassessed
whether psychometric information (such as information on questionnaire construction,
reliabilityandvalidity)wasavailable.Basedontheirfindings,researchersrecommendedthat
for a detailed investigation of satisfaction with maternity care, the Intrapartum- specific
Quality from thePatientsPerspectivequestionnaire (QPP-I)was themostappropriate. 218
Othershorterinstrumentsfoundtohavegoodreliabilityandvaliditywerereportedtobethe
SixSimpleQuestions(SSQ)161andthePerceptionsofCareAdjectiveChecklist(PCACL-R).221,222
However, research evidence examining the extent towhich these instruments have been
usedinLMICsettingsishardtoobtain.
Although, measuring satisfaction with maternity services has been discussed under
measuringprocessesofcare,Iwillnotmeasurewomen’ssatisfactionwithmaternitycareas
apartofmyPhD.
2.6.3:Measuringhealthoutcomemeasuresofqualityofcare
Outcomemeasuresareindicatorsofthehealthstatusofthegroupofpatientsusingfacilities
andofbroaderpopulations,however,measuringhealthoutcomesalone,isnotnecessarily
idealformeasuringqualityofcareforthreereasons.
First,apatientmayreceivepoorqualitycarebutmayrecovercompletelyormayreceivehigh
quality carebut stillmaynot recover.Second,adversehealthoutcomessuchasmaternal
deathsand/ormaternalcomplicationstendtoberare.86Third,inhealthfacilities,casefatality
and complication rates are influenced by the case mix of patients using facilities which
complicatesanalysisandinterpretationefforts.
Atthepopulation levelandwiththeaimofassessinghealthsystemquality,therearefive
opportunities to collectdataonoutcomes suchasmaternalmortality.These includedata
fromdeathregistrationsystems,routinedatafromhealthfacilities,censuses(onceeveryten
years), specialised surveys and surveillance efforts.223 Other composite methods such as
ReproductiveAgeMortalityStudies(RAMOS)alsoexist,whichdrawuponacombinationof
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these methods. 73 Essentially, in these studies researchers aim to identify all deaths of
reproductive age woman and then ascertain cases of maternal deaths and identify the
circumstancesbehindthesematernaldeath.95,223 However,it isgenerallyacceptedthatin
LMICcountrieslackingcompletevitalregistration,noapproachisguaranteedtogiveprecise
population-basedestimates, inparticularasmaternaldeath isstatisticallya relatively rare
event.
Somecommonproblemsassociatedwithreportingofmaternalmortalityaremisclassification
andunderreportingofmaternaldeaths.Misclassificationmayoccur incaseswheredeaths
areassociatedwithinducedabortion(especiallywhereitisillegal);earlypregnancydeaths
(resultingfromectopicormolarpregnancy),wherethepregnancymayhavebeenunknown
to the woman or her family; indirect maternal causes (malaria, anaemia, tuberculosis,
hepatitis,orcardiovasculardisease).Itmayalsohappenifdeathsoccursometimeafterthe
endofchildbirth,especiallyincaseswherethedeathoccursinanon-obstetrichospitalwards,
forexample, inan intensivecareorotherspecializedunits.224Underreportingofmaternal
deathsinLMICsettingsisalsothoughttooccurbecauseoflimitedincentivestoreportvital
events,differentialunder-reportingofdeathsbysexandinaccurateclassificationofmaternal
deathsashighlightedearlier.223
Measuringmaternalhealthoutcomeswithcertaintyatthepopulation level, thereforecan
requireresearchstudiesconductedonavery largescale,whichmakesthemanexpensive
endeavour.
However, depending on the research question, studies frequently measure outcomes to
assesstheeffectivenessofclinical interventionsorprogrammaticapproaches in improving
maternalhealthatthehealthfacilitylevel.Forexample,arecentlarge-scaletrialknownas
theWOMANtrialenrolledover20,000womenacross21countries,examinedtheeffectof
Tranexamicacidonriskofmortalityfrompost-partumhaemorrhage(outcome)andfound
that Tranexamic acid reduced death due to bleeding in women with post-partum
haemorrhage with no adverse effects.225 Similarly, Dumont et al. (2013) conducted a
pragmatic cluster randomised trial and investigated the impact of a multi-faceted
intervention(trainings,auditcycles,maternaldeathreviews,refreshertrainings,certification
andothers)onreducinghospital-basedmaternaldeath(outcomemeasure)in46hospitalsin
Senegal and Mali. 226 Their results showed that that this multi-faceted intervention was
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successfulinreducingmaternaldeaths(oddsratio[OR]0.85;95%CI0·73to0·98,p=0.029)
inprimaryreferralhospitals.226
However,itisimportanttonotethatwhilemeasuringoutcomesatthehealthfacilitylevel
suchasmaternaldeathsorcomplications,researchershavetobecarefulininterpretingtheir
findingsbecauseof issuessuchasmisclassificationandunderreporting (describedearlier),
but also larger health system factors that influence maternal and perinatal outcomes in
facilities.
2.6.4:Summaryofmeasuringqualityofcareinmaternalandnewbornhealth
Measurementofstructurealone,suchasreadiness,eitheroffacilities(throughmeasurement
ofsignalfunctions)oroftheprovider(throughmeasurementofknowledgeandskills)does
not provide a comprehensive picture. Similarly, a focus on clinical outcomes alone is not
enough, as most pregnancies are uneventful, complications may occur, and negative
outcomesmayalsooccurinthepresenceofgoodclinicalcare.Therefore,measurementof
QoCinobstetricsneedstofocusontheprocessesofcareandshouldincludebothtechnical
quality as well as experiences of care that women receive while seeking institutional
maternitycare.
2.7:EmpiricalevidenceondeficienciesinQoCduringlabourandchildbirthinIndia
This section will present the findings of my literature review on QoC during labour and
childbirthatmaternityfacilitiesincludingrelevantliteratureonhealthsystemsissuesinIndia.
Ihaveusedtheframeworkofstructure,processandoutcomestosummarisethefindingsof
myliteraturereviewrelatedtoQoCduringlabourandchildbirthinIndia.Additionaldetails
ontheIndianhealthsystemareprovidedinthestudysettingsection.
2.7.1:ForstructuralelementsofQoCinIndia
This sectionwill discussdeficiencies in structural elementsofquality, bothat the levelof
healthsystemsandathealthfacilitiessincetheyarebothintegraltotheprovisionofhigh-
qualitymaternitycareatfacilities.
AlthoughthereseemstobeashortageofclinicalworkforceacrosseveryIndianstate,this
situationisparticularlyacuteinstateswithpooresthealthindicatorssuchasUttarPradesh,
which also has the lowest density of healthworkers.227,228 Data from the IndianNational
SampleSurvey(2011-2012)estimatedthatthedensityofdoctors,nursesandmidwivesof6.4
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per 10,000 population was significantly below theWHO benchmark of 22.8 workers per
10,000population.227
Overall,theIndianpublichealthsystemisknowntosuffersfromstaffshortages,imbalances,
mal-distribution, poor work environments, low personnel productivity, numerous vacant
posts, high staff turnover, loss of qualified personnel to private sector, andmigration of
workerstourbanareas229,whichmakehumanresourcesshortagesasignificantconcern.The
distributionofqualifiedhealthworkersinthecountryalsoseemstobeskewedinfavourof
urbanareas;77.4%ofthequalifiedworkforcelivesinurbanareas,whereas31%oftheIndian
population is urban.227 Moreover, there aremany challenges to recruiting and retaining
qualifiedstaffinthepublicsectorespeciallyinruralareas.228
India’shealthworkforcealsoincludesdoctorstrainedinIndiansystemsofmedicinesuchas
Ayurveda, Yoga, Unani, Sidha and Homeopathy which are collectively known as AYUSH
providersandtheyofferhealthcarethroughbothpublicandprivatesectorfacilities.230
ApartfromAYUSHpersonnel,therearealsoalargenumberofinformalmedicalpractitioners
commonlyreferredasregisteredmedicalpractitioners(RMPs).TheseRMPsareoftenthefirst
point of contact, particularly for the rural population and the urban poor. Although they
practiceallopathicmedicine,RMP’softendonothavetherequiredformalqualificationsor
licensetodoso.230DetailedinformationonRMP’squalificationsandskillsarehardtoobtain,
however,onestudyestimatedthatanaverage25%ofRMP’sclassifiedasallopathicdoctors
reportednomedicaltraining(42%inruraland15%inurbansettings).231 AnotherstudyinUdaipurdistrict,inthestateofRajasthanfoundthat41%ofprivatepractitionerswhocalled
themselvesdoctorshadnomedicaldegree,18%hadnomedicaltrainingatalland17%had
notevengraduatedfromhighschool.232
Theseunregisteredprivate“doctors”areconsideredtoprovideasubstantialproportionof
maternalandnewborncare,althoughasmentionedearlier,disaggregateddataontheirshare
of themarket ishard toobtain.However,available research suggests that these informal
providersoftenhavestrongprofessionalnetworkswithqualifiedprivatesectordoctors(or
theprivatepracticesofpublicsectordoctors),pathologylaboratories,andprivatefor-profit
hospitalsandtheymakereferralstotheseplacesinreturnforcommissionsonprocedures,
diagnostics,medicinesandconsultations.233
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Furthermore,Indiaalsohasotherpractitionersoftraditionalmedicinesuchasherbalistsand
faithhealers, traditional birth attendants (dais), andotherswhoare also involved in care
provision.Asaresult,availableresearchevidencesuggeststhatthereisahighrelianceon
unqualifiedpersonnel,particularlyinruralareas.230
Specifictomaternitycare,thereisnoformalmidwiferycadreinIndia.234Aneedsassessment
reportby JohnsHopkinsProgramforInternationalEducationinGynaecologyandObstetrics
(Jhpiego)Indiain2015estimatedthattherewasadeficitofovertwomillionnurses,withover
18%posts of staff nurses and auxiliary nursemidwives at primary and community health
centresreportedtobevacant.235 Jhpiego(2015)alsoreportsthatthetrainingcurriculaof
nursesinIndiadidnotmeettheinternationallydefinedcompetenciesforSBA.235Inaddition,
61% nursing institutions were reported as unsuitable for conducting competency-based
trainings.234
ResearchershavealsoreportedthatinsomestatesofIndiathereisalackofnationallyagreed
minimum standards for drugs, supplies and equipment that results in procurement of
resourcesofvariablequality.16Inaddition,poorhospitalinfrastructureandstrictinstitutional
policies (for example, not allowing nurses to give injectable/s or not allowing birth
companionsinlabourrooms)alsohampertheprovisionofhighqualitycareatthetimeof
birth.
ThehealthfacilityenvironmentinIndiaalsoappearstohavemanystructuralconstraints.For
example, a facility survey fromUttar Pradesh (2009) reported that cleanwaterwas only
availablein57%andessentialdrugsandsupplieswereonlyavailablein29%ofprimaryhealth
centresandregularelectricitysupplyisamajorchallenge236.Agapanalysisoffirstreferral
units(FRU)inUttarPradeshconductedbytheUPgovernmentandpartners(November2013)
foundthatonefifthofhigherlevelfacilitiessuchasdistricthospitalsandmedicalcollegesdo
nothaveadequatespaceallottedforlabourrooms.237Thisstudyreportedthatcomparedto
higher-levelfacilities,greaterproportionsoflowerlevelfacilitiesperformedpoorlyformany
structural indicators. For example, just 35% of Community Health Centres (CHC) had
appropriate handwashing areas with elbow-operated taps, 16% had functional and clean
toiletsattachedtothelabourroom,31%hadtheadequateavailabilityofessentialequipment
andsuppliesand31%ofCHCshadsufficientnumberofbeds.237Thesedataindicateindicates
significantstructuraldeficienciesatmaternityfacilitiesinUttarPradesh.
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Othercross-sectionalevidence from Indianstudies suchas inMadhyaPradesh,whichhas
similar indicatorstoUttarPradesh,hasfoundthat86%ofdeliveriesoccur inpublicsector
facilitiesthatareunabletoprovidetherecommendedBEmOCsignalfunctions.62Inthisstudy,
researchers reported that amongst 29 facilities that could perform caesarean operations,
nonecouldperformalltheBEmOCfunctions.62Capacitytoprovidesignalfunctionssuchas
parenteralanticonvulsants,manualexplorationoftheuterus,removalofretainedproducts
of conception and assisted vaginal deliverieswere particularly problematic.62 In addition,
researchers reported that CEmOC services were more likely to be available in a greater
proportion of private-sector facilities compared to public sector facilities, just one in six
public-sectorfacilitiescouldprovideallCEmOCservices.62
OtherstructuralconstraintsdocumentedinIndianmaternityfacilitieshaveincludedlimited
triaging mechanisms, limited availability of round-the clock services, weak referral and
transportationservices,limitedonsitebloodtransfusionandanaesthesiaservices;allofwhich
indicatethattherearesignificantstructuralchallengesfortheprovisionofhigh-qualitycare
atthetimeofbirthinIndia.16,238-240
2.7.2:ForprocesselementsofQoCinIndia
MostoftheavailableresearchevidenceonprocessmeasuresofQoCduringnormallabour
andchildbirthinIndiaemergesfromcross-sectionalstudiesinthepublicsector.Information
onQoCfromtheprivatesectorisscarce.Availableresearchevidenceindicatespoorquality
of maternity care as shown by high rates of labour augmentation, routine conduct of
episiotomies,non-adherencetoactivemanagementofthirdstageoflabour,limiteduseof
partograph or foetal heart rate monitoring, early discharge from the hospital, limited
preparedness for neonatal resuscitation, poor initiation of breastfeeding, and inadequate
thermalcareofneonates.241-244
Evidencefromaquantitativestudyin2007inRajasthanfoundthatupto85%ofalldeliveries
wereaugmented,67%ofwomenweresubjectedtostrongfundalpressureandmorethan
halfofpostpartumwomenweredischargedbefore24hours(nationalguidelinesrecommend
48hours).243Similarly,anotherobservationalstudyfoundthatfoetalheartratemonitoring
was not performed regularly, preparedness for neonatal resuscitation was minimal,
episiotomy;perineal-shavingandenemawerecommon.244Theauthorsalsoreportthatthe
presenceofSBAsduringchildbirthatfacilitiesdidnotguaranteethereceiptofskilledcareby
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themother and her newborn, and that unqualified attendants are frequently involved in
maternitycareprovisioninfacilities.244
Someresearchershavearguedthatlimitedknowledgeofmaternitycarepersonnelisbehind
thepoorQoCatfacilitiesinIndia.65Forexample,anIndianstudyutilisingclinicalvignettes,
foundthataslittleas20percentofnursesworkingasSBAsappearedcompetentinmanaging
eclampsiaandhaemorrhage,andonly10%seemedcompetentinperformingacorrectinitial
assessmentofwomenwithpregnancycomplications.65Twocross-sectionalstudieshavealso
reportedthatANMs,nursesandmedicalofficers(doctors)didnothavetherequiredskillsand
werenotconfidentinprovidingbasicEmOCservicesincludingstabilisationpriortoreferral.245,246
Researchers have also found overuse of prophylactic antibiotics during labour in India
irrespectiveofthetypeofdelivery.247Thisoveruseofantibioticswithoutproperindications
isthoughttobeduetohealthworkers’beliefsregardingpoorhygieneandinfectioncontrol
standards at maternity facilities and their own assumptions of poor personal hygiene of
womenthatcomefordeliveries.247
Stanton et al. (2014) conducted an observational study in two Indian states, and found
widespread non-adherence to existing protocols on uterotonic drug use at public sector
facilities.242Theyfoundthatthatlabouraugmentationratesrangedfrom78.6%(Karnataka)
and99.1%(UttarPradesh),correctuseofoxytocicsforpostpartumhaemorrhagevariedfrom
6%–8.8%inUttarPradeshand41.2%–76.4%inKarnataka.Activemanagementofthethird
stageoflabourwasfoundtobeperformedcorrectlyinlessthan10%ofdeliveriesinboth
districtsandthatstorageofuterotonicsatroomtemperaturewascommon.242
OtherqualitativeresearchevidencefromIndia66,239hasdescribedsituationswherelabouring
women were mistreated (shouted at or slapped), cases where women were not given
adequateinformationabouttheproceduresbeingdone,birthsoccurringinhospitalswithout
a health professional in attendance, and cases where post-partum women were not
monitoredorsupportedafterchildbirth.66,239
Evidence from various Indian states has also revealed poor routines in care, such as
inappropriate monitoring during labour and childbirth, use of harmful and unnecessary
practices,limitedpreparednessandwidespreadstaffshortagesathealthfacilities.66,67,70,71,78
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Thereisalsosomeresearchinformationonwhousesprivatesectorfacilities.Cross-sectional
research evidence indicates that socio-demographic factors are a key determinant for
choosingprivatesectorformaternitycare.40Theeffectofeducationseemstobeimportant,
with one study finding a positive effect in India.248 Other factors such as ethnicity and
caste/tribestatuswerefoundtobenegativelyassociatedwiththeuseofprivatefacilitiesin
India.248Cognitionwhichmeansprovider–clientinformationexchangewasidentifiedasthe
mostimportantdeterminantforservice-utilisationinsouthAsia.239Womenwhoattendeda
greaternumberofANCvisitsweremorelikelytousetheprivatesectorduringchildbirth.248
However, there is also contradictory evidence on whether obstetric complications could
promptwomen to seek care inaprivate sector. 40,249Ahigher socio-economic statusand
urbanresidencewasassociatedwithgreateruseofprivatesectorfacilitiesformaternitycare
inIndia.248
Most published studies from India (and specifically from Uttar Pradesh ) have not
comprehensively measured QoC during labour and childbirth, most have employed
qualitative methodologies, were conducted in the public sector, examined home-based
childbirth practices70 or focus on specific issues such as PPH management77, labour
augmentationwithoxytocin,250,251neonatalcordcare,breastfeedingorthermalcare.252Asa
result, there is limited descriptive information from robust studies that comprehensively
measureQoCduringlabourandchildbirth.ThisisespeciallytruefortheprivatesectorinIndia
whichprovidesapproximatelyaquarterofmaternitycareservicesinIndia.253,254However,
available evidence from the private sector does indicate that there is increasing
medicalisationofchildbirthdrivenprimarilybycaesareansinprivatesectorhospitalsinsouth
AsiaincludinginIndia.25,39
2.7.3:HealthoutcomemeasuresofqualityofcareatthetimeofbirthinIndia
Giventheincreasingglobalattentiontowardsimprovingmaternalandnewbornhealth(MNH)
in India and effective advocacy by grassroots organizations, there appears to be lot of
momentumaroundimprovingMNHinIndia.TheGovernmentofIndia,throughtheNational
RuralHealthMission’seffortsandtheJananiSurakshaYojanaprogrammehasbeensuccessful
inincreasinginstitutionalbirthsfrom41%in2004to73%in2012.255
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However,thereislimitedavailabilityofinformationonfacility-basedoutcomemeasuressuch
ashospitalmortalityrates,obstetriccase-fatalityrates,near-misseventsornever-eventsin
UttarPradesh.Thisinformationcouldnotbeobtainedfromexistingroutinedatasourcesat
healthfacilitiesandthesearescarceinthepeer-reviewedliterature.
Available population-based outcome measures illustrate the high burden of maternal,
neonatalandperinatalmortalityinIndia.TheMDG5atargetforIndiawastoreducetheMMR
to 109 maternal deaths per 100,000 live births by 2015.256 However, despite impressive
progress, with declines inMMR from 437 to 178 per 100,000 live births (a 59% decline)
between1990and2012,IndiacouldnotachievetheMDG5atargets.Furthermore,national
estimateshidestrikingdisparitiesbetween Indianstates.Forexample, theMMRinAssam
was found tobe328per100,000compared toUttarPradesh,where theMMRwas240,
considerablyhigher than states likeKeralawhere theMMRwas just 66per 100, 000 live
births.253Availableresearchevidencealsoindicatesthatthemajorcausesofmaternaldeaths
inIndiawereduetodirectobstetriccausessuchas-haemorrhage(38%),sepsis(11%),unsafe
abortion(8%),hypertensivedisorders(5%)andobstructedlabour(5%)257,althoughdataon
causesofdeathafter2003isnotavailable.
For neonatal mortality, in 2013, India had the highest burden globally with 0.75 million
neonatal deaths. 258 Currently, theNMR stands at 28 per 1000 live births.259 The annual
burdenofneonataldeathsreducedfrom1.35millionin1990to0.75millionin2013258with
rapidaccelerationofNMRdeclines(33%)between2000-2013comparedto17%declines
between1990and2000.260InIndia,themaindirectcausesofneonataldeathin2015were
prematurity(43.8%),birthasphyxia/trauma(18.9%)andsepsis(13.6%)261whichsuggeststhat
careatthetimeofbirthisansignificantconcern.
Forstillbirths,in2015,Indiahadthehighestratesintheworldwithapproximately592,100
stillbirths,contributingupto22.6%oftheglobalburden.52Ahospital-basedstudyhasfound
thatpregnancy-inducedhypertension,eclampsia,abruptio-placenta,birthasphyxia,andpre-
term labour are the underlying causes contributing to stillbirths in India.262 Researchers
suggestthatpoorqualityofantenatalandintrapartumcarearetheleadingcausesformost
preventablestillbirthsinIndia.262,263
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2.7.4:SummaryoftheliteraturereviewonQoCinIndia.
Theprevioussectiondiscussedthefindingsofmyliteraturereviewandestablishedacasefor
investigatingtheQoCatthetimeofbirthinIndia.
Insummary,thefindingsofmy literaturereviewhighlightedthatthebulkoftheavailable
evidenceonqualityofessentialcareduringlabourandchildbirthinIndiaemergesfromthe
public sector. Most identified studies did not examine care at the time of birth in a
comprehensive manner. The literature review on structural aspects of QoC identified
deficiencies relatedto inadequatehumanresources, limited functioningofEmOCfacilities
andinadequateprovisionofrecommendedsignalfunctions.Ialsofoundproblemsrelatedto
limitedsuppliesofessentialdrugsandcommodities,gapsinknowledgeofhealthworkersand
widerinfrastructuralconstraints.
The literature review on process aspects of QoC identified deficiencies related to non-
adherencetoevidence-basedprotocolsformaternalandneonatalcareandmistreatmentof
womenatmaternityfacilitiesinIndia.Inparticular,researchevidenceonqualityofmaternity
careprovidedintheprivatesectorandresearchstudiesthathavecomprehensivelyaddressed
careatthetimeofbirthwerefoundtobelimited.
Outcomedeficienciesidentifiedwererelatedtoalackofinformationfromhealthfacilitieson
outcomeindicatorsofQoCsuchasinformationonobstetriccasefatalityrates,near-misses
ornever-events.Overall,populationbasedoutcomemeasuresshowhighratesofmaternal
mortality,neonatalmortalityandstillbirthsinIndia.AllofthesefindingssuggestthatQoCat
thetimeofbirthisanextremelyimportantconcernforIndia.
2.8:Managementpracticesatmaternityfacilities
2.8.1:Theoreticalconceptsonmanagementpractices
Management capacity has often been identified as a critical bottleneck for poor health
indicators in LMICs264 but their potential in improving QoC at hospitals has not been
extensively studied. TheWorld Health Organization (2005) defines goodmanagement as
“providingdirectionto,andgainingcommitmentfrompartnersandstaff,facilitatingchange
andachievingbetterhealthservicesthroughefficient,creativeandresponsibledeployment
ofpeopleandotherresources.”264
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In hospitals, management competencies are needed to identify and prioritise problems,
developappropriateplans,effectivelyutiliseavailableresourcesandtrackprogresstowards
achievement of institutional goals.264 Theoretically, it seems likely that if resources are
available,amanagerwhounderstandstherequirementsnecessarytoprovidehigh-quality
maternitycarepathways(figure1)willputinplaceappropriatesystemsandproceduresto
supporthigh-qualityclinicalcareandrespectfulmaternityservicesatinstitutions.
Itappearsthatmostofthetheoreticalconceptsaroundmanagementcomefromthebusiness
sector,whichhasbeenprogressivetotestinnovativemanagementstrategiesandquantify
the impact ofmanagement practices inmonetary terms rather than gains in quality. The
notionthathealthserviceswillbemoreeffectiveifstaffwithmanagerialcompetenciesare
employedataseniorleveliswellestablished,andappearstohavebeeninfluencedbymany
factors.265First,itisthoughtthateffectivecost-containmentathospitalswillnotbeachieved
withoutdrawinghealthworkersintoaframeworkofaccountability.Second,thereisabelief
thatmodernmanagementpracticessuchasthoseemployedinthebusinesssectorcouldbe
appliedtohospitalstoincreasetheirproductivity.Third,funders(whetherpublicorprivate)
requireaccountabilityforthelargesumsofmoneytheyinvestintohealthinstitutions.Fourth,
theprocessesandtransactionscreatedbyhospitalssuchascontracting,costingandbilling
arethoughttobetterdealtbyprofessionallytrainedmanagersandfifth,thereisabeliefthat
goodmanagementpractices could lead tobetter returnson investment through financial
earningsandcostsavings.265
However,inhospitalsunlikeotherorganizations,managersneedtounderstandnotjustthe
operational,human, institutionalandstructural factorsbutalso issuesaroundclinicalcare
provision,patientsafetyandmedicalerrors.266,267Thesefactorsmaketheroleofahospital
managerparticularlychallenging.Moreover,atpublic-sectorhospitalsinLMICsettings,there
aremorefundamentalbarrierstoprovidinghighQoCthatareoftenbeyondthecontrolof
individual managers. Some of these include limited availability of essential drugs,
commodities,irregularelectricitysupply,infrastructuraldeficienciesandlackofskilledhuman
resourcesasdescribedinprevioussections.16
Basedonmyreviewoftheliteratureonmanagement,qualityofcareandhospitalsetting,
managementpracticesathospitalshavebeenconceptualisedasoperationsmanagement,
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performance management, target management and people management.42-45 These
practicesareillustratedinfigure3andfurtherdetailsareoutlinedbelow.
1. Operationsmanagement:Operationsmanagement refers to thedesign,management,
andimprovementofsystemsthataffectahospital’sperformance.Areviewofoperations
managementliteratureidentifiesthefollowingbestpracticecategories:“leansystems”
to eliminate waste and non-value-added activities, planning and control systems and
qualitymanagement systems. 268-273 Goodhospitaloperationsare supported ifhealth
workersadheretoclinicalguidelinesandcarepathways274thatfacilitateefficientpatient-
flowthroughthehospital275andbyimprovingqualityofclinicaldocumentation.276Bloom
etal.andDorganetal.havealsoproposedthatefficientlayoutofpatientflow,focuson
continuous improvementandoptimalutilizationofresourcesarealsooperationalbest
practices. 277,43 In the Indian context, although government guidelines on operational
standardsexist,thereislimitedresearchexaminingwhethertheseoperationalstandards
arefollowed.278,279
2. Targetsmanagement:Performancetargetsaretoolsdesignedtoimproveaccountability,
transparency and performance of health facilities.280,281 Effective target management
referstosettingrealistic,well-defined,time-boundandspecifictargetsformaternitycare
servicesatfacilities.282Bloometal.andDorganetal.suggestthatbestpracticesintarget
managementrequirestargetstoincludeoperationalandfinancialdimensionsandhave
short and long-term timeframes. 43,277 The introduction of targets and performance
contractsisthoughttoencouragebetterhospitalperformance283andthatincentivestend
tobemoreeffectivewhenlinkedtoinstitutionaltargets.284
3. Peoplemanagement:Humanresourcesatmaternityfacilitiesarecomprisedofteamsof
medical,paramedicalandauxiliarystaffresponsibleforvariousindividualfunctionswith
anaimtoprovidehigh-qualitycontinuityofcaretopregnantwomanfromthetimeof
admission to discharge from the facility.16 To a large extent hospital performance,
dependsontheknowledge,skillsandmotivationsofindividualsresponsibleforproviding
services.285Astudyof61hospitalsinEnglandfoundapositiveassociationbetweengood
humanresourcepractices(specifically,performanceappraisal)andpatientmortality.286
Evidencefromhigh-incomecountriessuggeststhatincentivesandteam-basedworking
increasesjobsatisfaction287,employeemotivation,retention288andcauseslessstress289.
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Systemsof training, supervision and career development are also thought to improve
retentionofhealthworkers.290,291Bloometal.277andDorganetal43suggestthatgood
practices forpeoplemanagement includea structuredapproach to recruit, retainand
managehealthworkers.Theyalsosuggestthateffectiveincentivesystemsarelinkedto
performanceappraisalsandshouldbalancebothfinancialandnon-financial incentives.
Merit-based promotions rather than by tenure or seniority are also considered best
practices.277However,inLMICsettings,humanresourcesystemsarenotasdeveloped,
andpeoplemanagementisoftenchallenging.Forexample,inthepublicsector,decision-
making on recruitment, positing and transfers is usually centralized and adequate
supervisionisanon-goingchallenge.292
Figure3:Dimensionsofmanagementpracticesatmaternityfacilities
4. Performance management: Performance management allows managers to identify
deficiencies in serviceprovision293 and if doneeffectively, is thought to improve care-
processes and clinical outcomes.294,295,296Researchers have argued that multiple
performanceindicatorsarerequiredtomeasurehospitalperformanceaccurately.297-299
According to Scott et al., an effective performance monitoring system is based on
evidence-basedclinicaldecision-making(throughguidelines,protocolsandpathways);it
incorporates systems for process evaluation (audits, feedback, clinical indicators and
processmeasures);andsupportsindefining,implementingandmonitoringappropriate
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indicatorstomeasurequalityimprovement.274ThereisrobustevidencefromaCochrane
systematic reviewthat supports theeffectivenessofauditsand feedback in improving
professionalpracticeandhealthoutcomes.195
2.8.2:Empiricalevidenceonhospitalmanagementpracticesandquality
Although it is generally accepted thatmanagement practices influence quality of care at
hospitals, empirical evidence examining this relationship is limited.300 Perhaps, because
managementishardtomeasureusingquantitativemethodsandmethodologicaladvancesin
measurement have been recent, there is limited evidence to support these claims,
particularlyasthereisadearthofstudiesfromLMICsettings.
The bulk of the peer-reviewed literature consists of non-empirical articles such as case
studies, opinion-pieces, editorials but these often lack empirical data examining the
relationshipbetweenmanagementandqualityofcare.301,302303Manyresearchershavenoted
thisasanimportantevidencegap.300,304-306Theonlysystematicreviewwhichexaminedthe
role of hospital managers in quality and patient safety found limited and inconsistent
evidence on this relationship.300 The modest evidence that exists does suggest that
managers’ time spent, engagement andwork specifically on quality assurance influences
indicatorsofclinicalqualityandpatient-safetypositively.300Managerialactivitiesthoughtto
improvequalityincludeactivitiessuchasestablishinggoalsandstrategiestoimproveQoC,
setting thequality agenda,promotingaquality improvement cultureandprocurementof
institutionalresourcestoensurequalityofcare.300
Thepastdecadehasseena rise in the innovativemeasurementefforts thathave tried to
quantify therelationshipbetweenmanagementandQoCoutcomes.Mostof this research
stems from the field of health economics and are primarily from studies in high-income
countries.42,46,300Notableamongstthese,isthepioneeringworkbyBloometal.(2010)who
initiallystudiedmanagementpracticesacrossmanufacturingfirmsinnumerouscountries.307
ThisworkhassincebeenreplicatedinthehealthsectorandthetoolsdevelopedbyBloomet
al.(2010)havenowbeenusedformeasuringmanagementpracticesindiversehealthsystem
contexts suchas inhigh-income (Australia,Canada, France,Germany, Sweden,UK,USA),
upper-middleincome(Brazil)andlower-middleincomecountries(India).43,282,308,309
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These research efforts have employed a telephone-based interview methodology and
assessedmanagementpracticesunderfourkeydimensionsdescribedearlier:measuresof
hospitaloperations,measuresofhospitalperformance,measuresoftargetsmanagementat
hospitalsandmeasuresofpeoplemanagementathospitals.44,310,311
Thesemeasurementeffortshaveuncoveredsomeinterestingresults.Forexample,inacross-
sectionalstudyatcardiacunitsinUSA,managementpracticesweresignificantlyassociated
withmortalityaswellasprocessofcaremeasures.312Inanotherstudyatsubstanceabuse
clinics in the USA, researchers have found a strong association between management
practicesandclientdaystotreatmentandincreasedrevenuegeneratedattheseclinics.313
Similarly,inUKhospitals,managementpracticeswerefoundtobestronglyassociatedwith
both health outcomes (improved survival rates after acute myocardial infarction) and
financialindicators.310
OtherstudiesthatconductedsecondaryanalysisofdataconductedasapartoftheWorld
ManagementSurveyefforts(http://worldmanagementsurvey.org/),whichcollectsdatafrom
over 2,000 hospitals in nine countries have found that hospitals with more effective
management practices provide higher quality care.46,42,311 One of these studies which
restrictedanalysistodatafromhospitalsintheUSAandEnglandfoundthatwhenhospital
boardspaidmoreattentiontoclinicalquality,managersweremorelikelytopayattention
to clinical quality and that hospital boards which used clinical quality measures more
effectivelyhadhigherscoresontargetmanagementandoperationsmanagement.46
Bloomet.al’stoolhasalsobeenusedinIndia,whereitwasadministeredtomanagersof
3,892privatesectorhospitalsasapartofadescriptivestudy.44InIndia,theresearchersfound
that the average total management scores in Indian hospitals were poorer compared to
hospitals in other high income countries but this study did not examine the relationship
betweenmanagementscoresobtainedbyhospitalsandQoCoutcomes.44
However, it is important to note that the majority of research studies examining the
relationshipbetweenmanagementpracticesandQoCweredoneinhigh-incomecountries,
mostly in the private sector and none of them specifically focused on examining the
relationship between management practices and quality of maternity care provision.
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Therefore,examiningwhether there isa relationshipbetweenmanagementpracticesand
QoCofferedduringlabourandchildbirthinmaternityfacilitiesisakeyevidencegap.
Given thewide application of the Bloomet al.’s study instrument, the standard research
methodologyusedacrossmultiplecountrieswhichsupportscomparabilityandthe limited
time-frameofaPhD,thistoolappearspromisingforadaptationanduseatmaternityfacilities
inUttarPradesh,India.
Chapter3:Researchsettingandthecontextforthedoctoralresearch
3.1Studysetting
Uttar Pradesh (UP) is India’smost populous statewith approximately 200million people
(about17%ofthepopulationof India) livingacross its18divisionsand75districts.314The
population ispredominantlyrural (77%).Eightcities inUttarPradeshcontainmorethan1
millionpeople(Kanpur,Lucknow,Ghaziabad,Agra,Varanasi,Meerut,AllahabadandBareilly).
Seventy-fivepercentof thepopulation lives in rural areasandabout33% livesbelow the
povertyline.Theper-capitaincomeofUPwasUS$522comparedtoIndia’saverageofabout
US$1,097in2010-11.314UPhasconsistentlybeenrankedwithinthebottomthirdamongst
allIndianstatesontheHumanPovertyIndexsince1981,andhaspoorhumandevelopment
indicators compared to other Indian states.314 The overall literacy rate is 70%,with 60%
femaleliteracycomparedtoanationalaverageof74%and65%,respectively.315
The religiousandcastecharacteristicsofUttarPradeshshowthestrongpresenceofboth
Hindu and Muslim populations, and of Scheduled Caste groups (marginalised groups).3
Approximately80%ofthepopulationofUttarPradeshisHindu,withtheremaining20%being
Muslim.Itisestimatedthatabout21%ofthepopulationbelongtosocalledScheduledCaste
communities.253,316
In2010-2011,UttarPradesh’smaternalmortalityratio(359per100,000livebirths)wasthe
secondhighest in the country.317 Neonatalmortality (45per1,000 livebirths) and infant
mortalityrates(63per1000livebirths)arethehighestinthecountry.318Thetotalfertility
rateof3.8isthehighestinIndia,althoughcontraceptivecoverageisincreasing.319Anaemia
(85%inchildrenand51%inwomen)andmalnutritionaresignificantconcernswithahigh
percentageofchildrenunderweight(42%),wasted(20%)andstunted(52%).320
MydoctoralstudywasconductedinthreedistrictsofUttarPradesh:KanpurNagar,Kanpur
DehatandKannauj.WithKanpurasitscapital,KanpurNagardistrictisthemostpopulatedof
the studydistrictswith4.6millionpeople.KanpurDehatandKannaujdistrictsarealmost
exclusivelyruralwith90%and83%ofthepopulationresidinginruralareasandapopulation
of1.8millionand1.7millionrespectively.TheproportionofMuslimpopulationislowerin
KanpurDehat(10%)thaninKannauj(17%)andKanpurNagar(16%).KanpurDehathasthe
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highestproportionofScheduledCastecommunities(26%)whileKannujhas19%andKanpur
Nagarhas18%.253
Despitegovernmentschemestoimproveratesofinstitutionalbirths,54%ofdeliveriesoccur
athomeinUttarPradesh(57%inKannauj,40%inKanpurNagarand52%inKanpurDehat).
Ofthehomedeliveries,11%,53%and29%wereconductedbyskilledhealthpersonnelin
Kannauj,KanpurNagarandKanpurDehat,respectively.253
Table3highlightsimportantReproductive,MaternalandNewbornHealth(RMNH)indicators
inKannauj,KanpurNagarandKanpurDehatascomparedtotheUP-stateaverage.Kanpur
Nagarispredominantlyurban,withhigherliteracyandlowermortalityratesthanthestate
average.Bycontrast,KannaujandKanpurDehataremoreruralwithlowerlevelsofliteracy
andhighermortalityratesclosertothestateaverage.Specifically,Kannaujdistrictfaresthe
worstacrossmostoftheseRMNHindicatorscomparedtotheothertwostudydistricts.315
Table3:DemographicandhealthindicatorsinUttarPradeshandstudydistricts
Indicator UttarPradesh
Kannauj KanpurNagar
KanpurDehat
Population(inmillions) 199.8 1.7 4.6 1.8
Ruralpopulation(%) 78 83 34 90
Literacy(%) 57 61 71 65
Fertility(lifetime) 3.3 3.7 2.6 3.2
Maternalmortalityratio(per100,000) 345 267 267 267
Underfivemortality(per1,000) 94 99 52 97
Infantmortalityrate(per1,000) 71 78 36 65
Neonatalmortalityrate(per1,000) 50 55 24 43
CurrentuseofmodernFPmethodsamongcurrentlymarried(women(%)
31.8 23.2 39.7 38.6
Unmetneedforfamilyplanningamongcurrentlymarriedwomen(%)
29.7 43.2 23.7 25.0
ANC3+visit(%) 29.6 14.5 51.0 32.3
Institutionalbirthrate(%) 45.6 42.4 59.7 47.7
DeliveryathomeconductedbySBA(%) 21.8 11.2 53.2 28.6
Motherreceivedpost-natalcheck-upwithin48hours(%)
68.4 48.8 66.5 72.7
Newbornwascheckedwithin24hoursofbirth(%) 68.2 49.9 71.7 74.4
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Newbornbreastfedwithinonehourofbirth(%) 32.9 27.0 41.0 47.0
Sources:Census2011315andAnnualHealthSurvey2011316
Note:TheMMRestimatesaregroupedbystatesduetosamplesizelimitationsandthethreedistrictshavethesameMMRgrouping.
3.2:HealthcaresysteminIndia
ThehealthsysteminIndiaismixedandconsistsofthepublicsector,theprivate-for-profitand
theprivatenot-for-profitsector.Thepublichealthsystemisthree-tieredincludingprimary,
secondary and tertiary level facilities (Figure 4)321. The private-for-profit sector is
heterogeneousandvariesinsizeandcapacity,dependingoncontextofthedistrictwhereas
theprivatenot-forprofitsectorisrelativelysmall.
Inthepublicsector,thesub-centreistheprimaryunitinruralareasandoftenthefirstpoint
ofcontactwherewomengotoreceiveantenatalcareservices.Insomeinstances,maternity
servicesarealsoavailableat sub-centres, if auxiliarynursemidwife (ANM), femalehealth
worker (cadre) or staff nurses are available.At thenext level areprimaryhealth centres,
which although, envisioned as round-the-clock BEmOC sites, may not always provide
maternity services. Community health centres (CHCs) are sites where obstetricians and
paediatriciansareavailableandtheymayfunctionattheBEmOCorCEmOClevel.Firstreferral
units (FRUs) are upgraded CHCs, sub-district hospitals, district hospitals and specialist
hospitalsthatshould,inprincipal,provideCEmOCcare.322
Figure4:SchematicrepresentationofthepublichealthsysteminIndia
Source:https://doi.org/10.1371/journal.pone.0159793
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Inurbanareas,therearedispensaries,urbanhealthcentresandurbanhealthposts,which
provideantenatalcareandreferralservices.Someurbanhealthcentreshavebeenupgraded
toprovidematernityservices.Atthenextlevelarematernityhospitalsandothersecondary
and tertiary level hospitals that provide both BEmOC and CEmOC services.323 There are
medical colleges inmost districts that provide specialised tertiary care services including
CEmOCservices.
Healthworkersinthepublicsectorarepaidaregularmonthlysalarydependingontheirgrade
andlevelofexpertise.Thesesalariestendtobelowerthanearningsintheprivatesectorand
hencethesejobsarenotaslucrative.Inrecenttimes,therehavemanyinnovativeschemes
toattracthealthworkerstothepublicsectorsuchasadditionalmonetaryincentivesifthey
work in rural areas, educational incentives, promotion and career enhancement
opportunitiesandinnovativepublic-privatepartnershipschemes.However,thedistinction
betweenprivateandpublicsectorprovidersisnotstraightforwardashealthcareworkersin
publicsectorsmayalsohavetheirownprivatepracticeswheretheyworkaftertheirregular-
workinghoursinthepublicsector.
Qualifiedhealthworkers providingmaternity care services at institutions includedoctors,
nurses, auxiliary nursemidwiveswho receive 5 years, 3 years and 2 years of pre-service
training respectively. Thesequalifiedhealthworkers are regulated, and legally allowed to
provideinstitutionalservices.However,inIndia,asdescribedpreviously,availableevidence
indicatesthatthedistributionofqualifiedhealthworkersisinequitable:77.4%ofthequalified
healthworkforcelivesinurbanareas,although,just31%oftheIndianpopulationisurban.227
Also,researchevidencesuggeststhatthereisahighrelianceonunqualifiedpersonnelinrural
areasincludingathospitals.70,230Inaddition,thereisnoseparatemidwiferycadreinIndia
and it is thought that a serious human resource shortages exist throughout the health
system.228
Intheprivatesector,thereisextremeheterogeneityoffacilitiesinIndia.Anestimated75%
ofprivatehealth facilitiesaremicro-enterprisesandtherestaremediumto largemedical
establishments.324 In my study, private sector maternity facilities were either private-for
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profitorNGOownedfacilitieswithbasicemergencyobstetriccare(orhigher)capability.The
majorityofprivatesectorhospitalsandbedsarelocatedinurbanareasandareoperatedby
qualifiedandregisteredprivatesectordoctorsornurses.325Generally,largerprivatesector
facilitiestendtoberegisteredwithpublicauthoritiesandtherefore,intheoryhavesomelevel
ofregulationandmonitoring.Dependingonthetypeoffacility,healthworkersintheprivate
sectorearnafixedmonthlysalaryorreceivefee-for-services.
3.3:Maternalandnewbornhealthservicesprovidedatpublicsectorfacilities
UndertheumbrellaoftheNationalRuralHealthMission,Indianpublichealthstandardshave
beendefinedthatprescribeuniformstandardsforMNHservicesabovethePHClevel.These
standardsareshowninTable4.TheyemphasizeSBA,EmONCcapabilityandefficientreferral
capacityatfacilities.326Privatesectorfacilitiesarealsoencouragedtoprovidesimilarstandards
ofMNHservicesbutdetailedinformationonadherencetothesestandardsbyprivatesectoris
notavailable.
Table4:MaternalandnewborncarestandardsatIndianpublicsectorfacilities.
Level2:Institutional(BasicLevel) Level3Institutional(ComprehensiveLevel)PHC-Basic Obstetric and Neonatal Care (round-the
clockservicesatPHCs,CHCsotherthanFRUs)FRU-Comprehensive Obstetric and Neonatal Care
(DH,SDH,RH,CEmOC,selectedCHCs)
StandardsforintrapartumcareAllinLevel1(deliverybySBAorhomedeliveryoratCHCs,PHCsnotfunctioninground-theclockplus:Availabilityoffollowingservicesroundtheclock• Episiotomyandsuturingcervicaltear• Assisted vaginal deliveries like outlet forceps,
vacuum• Stabilisation of patients with obstetric
emergencies,e.g.eclampsia,PPH,sepsis,shock• Referrallinkageswithhigherfacilities
All in Level 2 plus availability of following servicesroundtheclock:• Managementofobstructedlabour• SurgicalinterventionslikeCaesareansection• Comprehensive management of all obstetric
emergencies, e.g. Eclampsia, Sepsis, PPH,retainedplacenta,shock.
• In-housebloodbank/bloodstoragecentre• Referral linkageswithhigher facilities including
medicalcolleges
EssentialnewborncareasinLevel1plus• AntenatalCorticosteroidstothemotherincase
of pre-term babies to prevent RespiratoryDistressSyndrome
• ImmediatecareofLBWnewborns(>1800grams)
EssentialnewborncareasinLevel2plus• CareofLBWnewborns<1800gm.
PostnatalandNewbornCareAllinLevel1plus
• 48 hours stay post-delivery and all postnatalservices for zero and third day tomother andbaby.
• Timely referral of women with postnatalcomplications.
AllinLevel2plus• Clinical management of all maternal
emergencies such as PPH, Puerperal Sepsis,Eclampsia, Breast Abscess, post-surgicalcomplication, shock and any other postnatalcomplicationssuchasRHincompatibilityetc.
• Newborn Care as in Level 2 plus in districthospitalsthroughSickNewbornCareUnit
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• Stabilisation of mother with postnatalemergencies, e.g. PPH, sepsis, shock, retainedplacenta
• ReferrallinkageswithhigherfacilitiesNewbornCareasinLevel1plus:• Stabilisationofcomplicationsandreferral• CareofLBWnewborns>1800gm.• Referral services for newborns that are <1800
gm.andothernewborncomplications• Managementofsepsis
• Managementofcomplications• CareofLBWnewborns<1800grams.• Establishreferrallinkageswithhigherfacilities
3.4:Maternalhealthprogrammesandpolicies
Maternalandnewbornhealth in India fallsunder the remitof theMinistryofHealthand
FamilyWelfare(MoHFW).SinceIndiaobtainedits independencein1947,therehavebeen
significant shifts with regards to programmes and policies on reproductive andmaternal
health. The evolution of quality in maternal health and major programmatic efforts for
maternal newborn health are highlighted in Table 5.327 Although, previous policy and
programmeeffortswerefocussedonexpandingcoverage,since2000,thereappearstohave
beenaconsiderableemphasisonQoCforMNH.
Asmentionedearlier,despiteimpressiveprogress,withdeclinesinMMRfrom437to178per
100,000livebirths(a59%decline)between1990-91and2010-12, Indiacouldnotachieve
MDG5atargets.256Since2000,theGovernmentadoptedthreemajorpolicies-theNational
PopulationPolicy(2000)328,theNationalPolicyforEmpowermentofWomen(2001)329and
theNationalHealthPolicy(2002)330,allofwhichhaveaspecificfocusonqualityinMNH.
Table5:Summaryoftheevolutionofqualityinmaternalhealth
Timeperiods Keyevents1947-60 • Focusonexpansionofservicesinunderservedareas
• Limitedhealthsectorfunding• Launchofverticaldiseaseeradicationprogrammeswithfirstfive-yearplan• Maternalandchildhealthpriorityareawithexpandedprogramminginfirst
five-yearplan• Noevidenceofeffortonqualityassurance-focusrestrictedtoequityand
humanresources1960-80 • Adoptionoftarget-basedfamilyplanningapproach;pressureformeeting
targetsdamagescommunitymaternalandchildhealthservices• ForcedsterilizationsduringEmergency(1975-77)leadtoneglectofmaternal
healthcareservices• Qualityconcernsrestrictedtoequityandqualityofhumanresources
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• AlmaAtadeclaration(1978)renewsfocusonprimaryhealthandinspiresconcernforqualityinhealthcare
1980-90 • Verticalprogrammesonimmunizationandmaternalhealthlaunched• Qualityscopelimitedtoequity,humanandphysicalresourcesand
effectiveness;noactionstrategies1990-2000 • StructuralAdjustmentProgrammeleadstoriseinprivatesectorhealth
investmentinIndia• ReproductiveandChildHealthprogrammeintroducesintegratedmaternal
andchildhealth,familyplanningandreproductivehealthservices• EffortstoensureessentialobstetriccareandEmOCthroughstrengthening
healthfacilitiesandtransportfacilities,improvingfirstreferralunitsandbloodtransfusionservices
• Qualityconcernsvoicedincreasinglybutnoactionstrategiesformulated2000-present • NationalPopulationPolicy(2000)outlinesReproductiveandChildHealth
strategyandsetsspecificmaternalandinfantmortalityreductiongoals• Qualityfocusintenthandeleventhplanswithstrategiesforquality
assuranceandappraisal• NationalRuralHealthMissionlaunched,leadingtoexpandedfundingand
decentralizedprogrammeimplementationo Emphasisonfacilitybirthso Focusonskilledbirthattendance(SBA)o InfrastructurestrengtheningforbasicandcomprehensiveEmOC
throughreformsundertheNRHMo CapacitybuildingforSBA-trainingofnurse-midwivesforSBA,task
shifting–generalphysicianstrainedforanaesthesiaforEmOCandforCaesareansection
o Raisingdemandforfacilitybirths-theJSYcashtransferprogramofferingincentivestowomenandtoASHAs
• Qualityfocusandactionstrategiesinbothprogrammesalongwithregularmonitoringandfeedbackmechanisms
• QualityinitiativesincludeIndianPublicHealthStandardsforqualityassuranceinprimarycare;QualityAssuranceCommitteesatdistrict/StatelevelandassistancetostatesbyNationalAccreditationBoardforHospitalsandHealthcareProviders(NABH)forqualitycertification
Source: Srivastavaetal.(2013),Chaturvedietal.(2015)
In2006,theMoHFWinitiatedaconditionalcashtransferprogrammeknownastheJanani
SurakshaYojana(JSY)thatpaysacashincentivetowomenattendinginstitutionsforbirth.
TheJSYhasbeenaleadingprogrammeoftheNationalRuralHealthMission(NRHM)ofthe
GovernmentofIndia.331Themonetaryincentivesforwomendiffersbasedonthecontextof
individualstates.Inlowperformingstates,theJSYprogramprovidesacashincentiveofINR
1400andINR1000(equivalent£12-17)towomengivingbirthinapublicoraccreditedprivate
healthfacility.Inhigh-performingstates,thecashincentiveisabouthalfofthatamountand
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is restricted to women living below the poverty line and those from marginalised
communities.332
TheNRHMhasalsoappointedcommunityhealthworkersknownasAccreditedSocialHealth
Activists(ASHAs)ineveryIndianvillage.333Motivatingpregnantwomen,accompanyingthem
toinstitutionsforchildbirthandarrangingsuitabletransportationtohospitalsfallsunderthe
responsibilitiesoftheASHAs,whoreceiveINR600(equivalent£7)forthesetasks.
Intheinitialyears,JSYbenefitswererestrictedtowomenabove19yearsofageandtowomen
withparityofuptotwo,butduetooppositionfromadvocacygroups,theserestrictionswere
laterremoved.Therewerealsootherconditionsthatwomenhadtofulfillsuchascompleting
allantenatalcarevisitswhichwaslaterremovedsinceitwasnotfeasibletomonitorthis.A
mandatary48-hourpostpartumstayathospitalswasalsoaconditionforobtainingpayments
butthishasalsonotprovedpracticalsincemanywomenprefertobedischargedearly332and
vacatingbedsforotherclientsisanimportantpriorityespeciallyinhigh-volumefacilities.The
JSYisoneofthelargestconditionalcashtransferprogrammesintheworld,withanestimated
80millionbeneficiaries.Despitecontributingtoremarkableincreasesininstitutionalbirths,
resultsfrommanyevaluationshavenotfoundassociateddeclinesinmortality.10,11,64
3.5:ContextofthePhDresearchwithintheMatrikaproject
MyPhDresearchbenefittedfromfundingbyMSDforMothersobtainedbyLSHTMacademics
leading the external evaluation of Matrika project funded by MSD for mothers and
implemented by two NGOs – Pathfinder International (lead) and World Health Partners
(partner)inUttarPradesh.
The aim of the Matrika project was to increase access to, and use of, basic emergency
obstetriccareandfamilyplanningservices.ItoperatedinKanpurNagar,KannaujandKanpur
DehatdistrictsofUttarPradesh.TheprojectworkedtowardsthreeobjectivesbetweenMarch
2013toMay2016;(1)Establishasocialfranchisenetworkofprivateprovidersandfunctional
referral centres offering affordable antenatal care, emergency obstetric care, and family
planningservices;(2)Strengthencapacityofandlinkagesbetweenruralprivateandpublic
sectorhealthproviderstoofferhighqualityservices;and(3)Improvecommunityawareness,
demandandlinkageswithmaternalhealthservicesamongruralpopulations.
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TheoverallimpactevaluationofMatrikausedquantitativeandqualitativeresearchmethods
toassesstheimpactoftheprojectonawiderangeofstudyoutcomes,coveringhealthcare
utilisation,qualityofcare,patientexperience,healthybehaviours,healthstatusandfinancial
strain.Thefindingsfromtheimpactevaluationshowedthatthemulti-facetedprojectdidnot
haveameasurableimpactonthevastmajorityofoutcomes,withtheexceptionofasmall
effectonrecommendeddeliverycarepractices.Notably,Matrikawasfoundtohavenoeffect
on antenatal care (ANC) utilisation, ANC content of care, or ANC knowledge and
preparedness.
TheMatrikaevaluationwasledbyDr.TimothyPowell-Jackson,Ms.LovedayPennKekanaand
Dr.AndreiaSantosatLSHTMandwasdoneincollaborationwithanIndianresearchagency
calledSambodhiResearchandCommunications(KultarSingh,PareshKumarandDr.Kaveri
Halder)based inNewDelhi, India.MyPhD researchworkwasdonealongside theoverall
impact evaluation and contributed some important information to the impact evaluation.
Apartfromreceivingregularguidancefrommyco-supervisorDr.TimothyPowell-Jackson,
andguidancefromMs.LovedayPenn-Kekanaontheanalysisofqualitativedata,noneofthe
other academics involvedwith the largerMatrika impact evaluation provided substantial
inputsonmyPhD.Iconceivedandexecutedallaspectsofthethreeseparateresearchstudies
describedinchapterssix,sevenandeightofthisthesis.
Chapter4:Roleofthecandidate,fundingandresearchtimeline
4.1:Theroleofthecandidate
IamamedicaldoctorfromNepalandgraduatedfromtheKathmanduUniversityin2004.I
thenreceivedfurthertraininginpublichealthfromtheUniversityofAberdeengraduatingin
2007. After that, I went back to Nepal and worked in a variety of positions with non-
governmentalorganizations,bilateraldonorsandUNagenciesinNepalandothercountries
in southAsia and south-eastAsia. The focus ofmyprofessional career has been towards
improvingmaternalandnewbornhealthinresource-constrainedsettings.
InSeptember2013,IjoinedtheLSHTManddevelopedmyPhDresearchideaonQoCduring
labourandchildbirth,afterdiscussionwithseveralacademicsattheLSHTM,myfuturecareer
interests and the scope to conduct this work within the Matrika evaluation. Prior to
finalisation of the protocol, I undertook a preparatory field-visit, designed all the data
collectiontools,finalisedtheresearchmethodologyandsubmittedanethicsapplicationfor
thestudy.IwrotemydoctoralresearchprotocolthatwasapprovedbyLSHTMexaminersas
apartofmyupgradingdocument.
IlivedinLucknow,UttarPradesh,Indiaforapproximatelysevenmonthsleadingallresearch
activitiesrelatedtothePhD.Duringthattime,I initiatedcontactwithgovernmentofficials
from National Rural Health Mission and obtained the necessary permissions prior to
approaching hospitals. I coordinated and managed relationships with local partners at
Sambodhi,PathfinderandWorldHealthPartners. I finalisedall thestudy instrumentsand
providedoversighttothe:I)translationofthetoolsintoHindi;ii)pretestingofthetools;and
iii)developmentofthedatacollectionmechanisms.
Iconductedapilotstudytofinalisetheoveralllogisticsforthestudy.Icarriedoutsampling
asdescribedintheprotocolandmadesiteselectionvisitstomosthospitalsinthethreestudy
districts.Iprovidedmanagerialandtechnicaloversighttotheprimarydatacollectionefforts
andkeptallpartnersinformedoftheprogress.Idevelopedatrainingmanualusingclinical
training skills methodology and conducted the trainings myself to ensure that field-
researchersweretrainedtocompetencyovera5-daytrainingperiod.Iensuredthatthedata
werecheckedregularlyforqualityandconsistencyduringtheentiredatacollectionphase.I
travelledtoallthetwenty-sixhospitalsnumeroustimesduringdatacollectionandmanaged
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all logisticalandadministrative issues. Iwasresponsible fordeploying14-fieldresearchers
andthreefield-supervisorsduringthistime.
For themanagement survey, I adapted a pre-existing tool so that it was relevant to the
contextofUttarPradeshandledathree-dayorientationprogrammetofield-researcherson
management.Ipilotedthemanagementsurveyinstrumentatonehospitaloveraday,made
required changes to the tool after piloting and then finalised the survey instrument. I
conductedall the interviewswithmanagersat thirty-threehospitalsmyself,prepared the
transcripts,enteredthedata,ensureddataqualityandconsistency.
Duringmy time in Uttar Pradesh, I also provided regular updates tomy supervisors and
incorporated their feedback into the on-going work. I was responsible for all the data
cleaning,dataanalysisandinterpretationofalltheworkinthisthesis.Iwrotethefirsttwo
draftsofall thethreepapersthathavebeen includedasresultschaptersandIhavebeen
managingtheprocessofcollaboratingwithallmyco-authorsandsupervisors.
IwashiredasaresearchassistantbyMETfordoingthisworkinUttarPradeshandpaida
monthlysalaryforthedurationofthefieldwork.Inaddition,theQoCtoolsthatIdeveloped
were used for subsequent studies in Uganda and in Rajasthan, where I conducted the
trainings.AsapartofmycontractwithMET,IalsosubmittedapreliminaryreportonQoCand
managementpracticesatmaternityfacilitiesinUttarPradeshtoMSDformothers.Although,
my research provided important information to the largerMatrika evaluation, I was not
involvedinotheraspectsofthelargerimpactevaluationstudy.
4.2:Funding
Funding for this research was obtained from Merck Sharp & Dohme Corp. (“MSD”), a
subsidiaryofMerck&Co.,Inc.,Kenilworth,NJ,USA,throughitsMSDforMothersprogramme.
Fundingwasusedforgeneral financialsupport,salaries, travelandoverheadcostsandall
datacollectionactivities.Non-financialsupportwasreceivedfromSambodhiResearchand
Communications,NewDelhi,Indiawhoprovidedtwo-researchassistants’pro-bonothatwere
involvedinthemanagementsurvey.MSDhadaroleinthedesign,collection,analysisand
interpretationofdata,inwritingofthethesisorthemanuscriptscontainedinthisthesisorin
thedecisiontosubmitthemanuscriptsforpublication.
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4.3:Researchtimeline
ThissectionprovidesatimelineofactivitiesinvolvedinconductingmyPhDresearch,which
startedwhenIenrolledintoLSHTMinlateSeptember2013.Asmentionedearlier,overthe
courseofmyPhDwork,IspentapproximatelysevenmonthsinUttarPradesh.Furtherdetails
onthetimelineofthePhDarepresentedintable6below.
Table6:TimelineforthePhD
Year Month Activities
2013-2014
September2013-Dec2014
• Preparatoryreadingandformativeresearch• Finalisedresearchtopic• Conceptnotefinalisation• ExploratoryvisittoIndia• Tookrelevantmodules:Extendedepidemiology,Statistical
MethodsinEpidemiology,AdvancedStatisticalMethodsinEpidemiology,Datamanagement
• Researchinstrumentdevelopment• Submittedforlocalethics• Upgradingdocumentfinalisedandupgradingseminar
2015
Jan–April2015
• Preparatoryworkforfieldworkbegins.• TranslationofdatacollectiontoolsintoHindiandback-
translation• Conductedfurtherpretestingandformativeresearchto
finalizetools.• SubmittedtoLSHTMethics• Resubmissiontoethics
May–July2015
• TravelledforfieldworktoUttarPradesh.• MeetingwithlocalpartnersatPathfinderandWHP• MeetingwithMoHandhospitalauthorities• Conductedpretestingofthetoolsandtrainingmanual• ConductedapilotstudyforQoCassessments:3daysat
publicsectorand4daysatprivatesectorusing2observersforprivatesectorand4forpublicfacility
• Amendmentsoftoolsbasedonresultsofthepilotstudy• PilottestedthedataentrysoftwareinCS-pro• Regularcommunicationwithsupervisors.• DatacollectionbeginswithclinicalobservationsandQoC
studyends.
2015
Aug-Oct2015 • SiteSelectionforthemanagementsurvey• Trainingtofieldresearchers• Pilotstudyatonepublicsectorhospitalx1day• Amendmentofthedatacollectioninstrument• Datacollectionanddataentrybegins.
Oct-Dec2015 • Datacleaningandpreliminaryanalysis
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• SubmittedreporttoMSDformothers
2016 Jan-Dec2016 • Dataanalysisandwritingup• Finalizedpaper1• Finalisedpaper3
2017 Jan-July2017 • Dataanalysisandwritingup• Resubmissionofpaper1-acceptedatBWHO• LearntqualitativeanalysisusingNVIVO• Finalizedpaper2-submittedatRHjournal• Finalisedfirstdraftofpaper3• Finalisedthesisandsubmitted
Chapter5:Conceptualframework,aims,objectivesandstudydesignThis chapterprovidesanoverviewof theconceptual framework,aims,objectivesand the
studydesignofmyPhDstudy.ThefirstsectionoutlinestheconceptualframeworkofmyPhD
andtheaimandobjectives.Ithendiscussthestudydesignwithsectionsonthedevelopment
of the data collection instruments, sample size calculations, sampling strategy, study
participants,dataanalysis,ethicalissues,anddatamanagement.
5.1:ConceptualframeworkformyPhD
A conceptual framework is the composition of various concepts developed from the
theoretical underpinnings to guide and better explain the proposed research work. The
conceptualframeworkformyPhD(Figure5)wasdevelopedtoassessQoCfornormallabour
andchildbirthatpublicandprivatesectormaternityfacilities(BEmOCorhigher)inUP,India
andcombinestheDonabedianQoCcausalchainmodel(structure,processandoutcome)145
withtheHulton239andWHOframework89.
Atthelevelofmaternityfacility,QoCcomprisesofclientsexperiencesofcareandclinicalcare
provision239.Experiencesofcaredependuponinterpersonalaspectsofcarereceivedduring
thelabourandbirthingprocesssuchasensuringprivacy,allowingabirthcompanion,freedom
tochoosebirthingposition,righttoinformation,respectforchoiceandpreferences,freedom
fromdiscrimination and others.334 Clinical care provision or adherence to evidence-based
practices depends upon numerous factors such as organizational factors, financing,
infrastructure,healthworkforce,existingqualityimprovementmechanismssuchauditsand
feedbackmechanisms.174ThiscorrespondstostructureinDonabedian’sframework;i.e.the
contextinwhichcareisprovided.145
ThesecondboxintheframeworkrelatestomyoperationaldefinitionofQoCwhichisthe
applicationofevidence-basedguidelinesandrespectfulmaternitycarepracticesbymaternity
care personnel. This corresponds to theprocess element in Donabedian’s framework.145
Finally,thelastboxcorrespondstooutcomessuchasimprovementsinclinicaloutcomes335
(reduction of maternal, neonatal deaths, disability and complications) and positive client
experiences.157Although,acomprehensiveconceptualframeworkhasbeenpresented,my
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doctoral research focuses on assessment of selected structure and process measures.
OutcomemeasurementwasbeyondthescopeofthisPhDstudy.
Figure5:ConceptualframeworkformyPhD
5.2:AimsofthedoctoralresearchUltimately, my doctoral research aims to provide policymakers, public health managers,
academics and clinicians with novel information about QoC during normal labour and
childbirthinUttarPradesh.IwillalsoexaminewhethermanagementpracticesinfluenceQoC
at26publicandprivatesectormaternityfacilitiesinU.P,India.
5.3:SpecificObjectives1. TodescribeQoCfornormallabourandchildbirthat26maternityfacilitiesandtoexamine
whetherQoC isassociatedwithcharacteristicsof thewomen,characteristicsofhealth
workersandcharacteristicsofmaternityfacilitiesinthreedistrictsofUttarPradesh,India.
2. To investigate and describe patterns of mistreatment encountered by women during
labour and childbirth at 26 public and private sectormaternity facilities and examine
whethermistreatment isassociatedwithsocio-demographiccharacteristicsofwomen,
characteristicsofhealthworkersandcharacteristicsofmaternityfacilities.
3. To assess and describe existing management practices at 33 maternity facilities and
examinewhetherthereisarelationshipbetweenQoCandmanagementpracticesat26
maternityfacilitieswhereclinicalobservationshadtakenplace.
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Inadditiontoadvancingtheevidence-baseonthesetopics,Ihopethatthedatacollection
instrumentsdevelopedinthisstudywillbeusefulformeasuringandimprovingQoCinlabour
andchildbirthinhigh-burdensettingsofsouthAsiaandsub-SaharanAfrica.
5.4:Studydesign
Thisthesisusescross-sectionaldatasetsfromtwoseparateresearchstudies.Overaseven-
monthperiod, I led twoprimarydatacollectionefforts in threedistrictsofUttarPradesh,
India.Toaddressobjectiveoneand two, I conductedclinicalpracticeobservationsof275
mother-newbornpairsat26publicandprivatesectormaternityfacilitiesutilisingastructured
tool designed to assess QoC during normal labour and childbirth including aspects of
mistreatmentofwomenatmaternityfacilities.
To address objective three, I conducted a separate cross-sectional survey by interviewing
hospitalmanagersat33maternityfacilitiesbyusingapreviouslytestedsurveyinstrument
thatwasadaptedtothecontextof ruralUttarPradesh. These33maternity facilitiesalso
includedthe26facilitieswhereclinicalobservationshadtakenplace.
5.5:Datacollectioninstruments
5.5.1:Qualityofcareassessments
Fordevelopingtheclinicalpracticeobservationtools,Ireviewedavailableguidanceonbest
practicesinmanagementofnormallabourandchildbirth.TheseincludedtheWHOguidelines
for care during normal labour and childbirth,204,336NICE guidelines for intrapartum care, 5
AMDDEmONCneedsassessmenttools22andresearchinstrumentsfromtheGaalastudy337.
Ialsoconductedexploratoryvisitstothestudysitesinordertounderstandthesocio-cultural
factors, maternity-facility context, health worker characteristics, facility caseloads and
existingmaternitycarepathwaysathealthfacilities.Afterreviewingtheavailableliterature,
andlearningfromthefieldvisits,Idevelopedanearlyversionofthestudyinstrumentsthat
underwentpeer-reviewsbyIndianandLSHTMresearchers.
Ialsopre-testedthesetoolswithfield-researchersinLucknow,UPandmaderelevantchanges
afterpre-testing.Apilotstudywasalsoconductedtotestthefeasibilityofmethodsanddata
collectionproceduresover3daysinasampleofpublicsectorfacilitiesand4daysinasample
ofprivatesectorfacilitiespriortofinalizingtheclinicalpracticeobservationtools.
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Overall, the QoC assessment tool has three sections. The first section is a screening
questionnairethatcapturedmedicalandobstetrichistoryfromclientcaserecordstoensure
participants fulfil case definitions for normal labour and childbirth. Normal labour and
childbirthwasdefinedaslaboursthatarespontaneousinonset,low-riskatthestartoflabour
withasingletonpregnancy,inavertexpresentation,withagestationalagebetween37to42
completedweeksofpregnancy.Thesecondsectioncapturedinformationondemographic,
socio-economicandeducationalstatuswhichwasadaptedfromtheNationalFamilyHealth
Survey questionnaire (2014-2015).338 The third section included modules that captured
provisionoftechnicalinterventionsandrespectfulmaternitycareprovisionfromthetimeof
admission of women up to one-hour post-partum. This section was developed based on
reviewofWHOIntegratedManagementofPregnancyandChildbirth(IMPAC)guidelinesand
NICEguidelinesforcareduringnormallabourandchildbirth.204,339TheentireQoCassessment
toolisavailablefromappendix1.
5.5.2:Surveyonmanagementpracticesatmaternityfacilities
Iadaptedandusedamanagementsurveytoolthathaspreviouslybeenusedformeasuring
managementpracticesindiversehospitalsettingsincludinginIndia282,308,309andtailoreditto
be applicable to the context of health facilities in rural Uttar Pradesh. Essentially, this
interview-based tool assessed management practices at hospitals through four key
managementdomainsasdescribedpreviously.Questionswerestructuredbutopen-ended.
Ascoringgrid(between1to5)wasusedbyinterviewerstogivescoresforresponsestoall
questionsdependingonhow closely answersmatcheddescriptors for eachquestion. The
entiremanagementassessmentinstrumentisavailablefromappendix2.Briefly,operations
managementandperformancemanagementsectionsofthetoolassessedhowwellmodern
managementtechniqueswereappliedatmaternityfacilities,whethersystemsforcontinuous
improvementexisted; andwhether facilityperformancewas regularly trackedwithuseful
indicators.Targetmanagementsectionassessedwhetherappropriatetargetshadbeenset,
whethertheypushedmaternity facilitiesto improvetheirperformance,andwhetherthey
were communicated, effectively throughout the hospital. People management section
assessedwhethertherewasanemphasisongoodhumanresourcepractices.42,277,307,310
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5.6:Samplesizecalculations
5.6.1:ForclinicalpracticeobservationsTheprimary focusonmystudy is toexamine thequalityofnormal labourandchildbirth,
whichisthecommonesteventatanymaternityfacility.Clinicalobservations,therefore,were
themostappropriatemethodtoassessprocessesofcare. Samplesizecalculationswere
doneinthecontextofadefinedevaluationwithearmarkedfundsfordatacollection.Sample
sizeestimationwasdictatedbylogisticalfeasibilityofobtainingnecessarycasesforclinical
observationsandresponseratesat individualpublicandprivatesectorfacilities.Obtaining
goodresponseratesandadequatenumberof‘normalvaginalbirth’caseswasfoundtobe
particularlychallengingintheprivatesector.ToensurethatIfollowedascientificapproach
forestimatingtherequirednumberofclinicalobservationsatmaternityfacilities,Iconducted
powercalculationsforimportantindicatorsofinterestsuchasActiveManagementofThird
StageofLabour(AMTSL),partographandoxytocinuse.
For calculating the required numbers of observations, I used themethodology of cluster-
randomisedtrials,withclustersdivided into1)Publicsectorfacilitiesand2)Privatesector
facilities.Thetotalnumberofclustersrequired,denotedby!,iscalculatedusingthefollowingequation340which ismultipliedbytheconstant(4/3)toaccountfortheapproximately3:1
ratioofpublic(n=18)andprivatefacilities(n=7).341
! = 1 + (&' ( + &))( ,- 1 − ,- / + ,0 1 − ,0 / + 1((,-( + ,0()
(,- − ,0)(×2× 43…… . (1)
Where,&' (isthelevelofsignificanceand&) ispower,,0and,-aretheproportionsofuseofevidencebasedpracticesatfacilitiesinbothsectors,/isthenumberofclinicalpractice
observationsateachhealthfacilityand1isthecoefficientofvariation,ameasureofvariation
betweenheathfacilities.
ForActiveManagementofThirdstageoflabour:TherecentStantonet.alstudyfoundthat
AMTSLwaspracticed in10%of all births inpublic sector facilities in similarneighbouring
districtsofUP.242Theaboveformulashowsthat,assumingacoefficientofvariationof0.25,
thenif10observationseachareconductedat18publicsectorfacilitiesand7privatesector
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facilities,thestudywillhave80%powertodetectdifferencebetween10%useofAMTSLin
publicsectorfacilitiesand28%useofAMTSLinprivatesectorfacilities.
Partographuse:Arecentcross-sectionalstudydonein44publicsectorfacilitiesinasimilar
neighbouringstateofIndiafoundthatpartographwasusedin11%ofallbirths.243Usingthe
aboveformula,assumingacoefficientofvariationof0.25,thenif10observationseachare
conductedat18publicsectorfacilitiesand7privatesectorfacilities,thestudywillhave80%
powertodetectdifferencebetween11%partographuseinpublicsectorfacilitiesand30%
partographuseinprivatesectorfacilities.
Useofoxytocics: Iyengaret.al’s study inaneighbouringstateofUttarPradeshfoundthat
oxytocin was given in 57% of all childbirths243. Using the above formula and assuming a
coefficientofvariationof0.25,thenif10observationseachareconductedat18publicsector
facilitiesand7privatesectorfacilities,thestudywillhave80%powertodetectadifference
betweentheuseofoxytocinin57%ofpublicsectorfacilitiesand88%oxytocinuseafterthe
birthofthebabyinprivatesectorfacilities.
5.6.2:Theassessmentofmanagementpractices
The assessment ofmanagement practices atmaternity facilities was purposive. Separate
samplesizecalculationswerenotdoneforthemanagementsurvey.Instead,I interviewed
managersatallthefacilitieswhereclinicalpracticeobservationshadtakenplace.
5.7:Samplingstrategy
5.7.1:Clinicalpracticeobservations
Iusedamultistagesamplingmethod.Theinitialsamplingframeincluded59facilitiesinUttar
Pradesh thatprovidedmaternity services:all29of the largerpublic facilities listedby the
IndianDepartmentofHealthi.e.facilitiesthatreportedatleast200deliveriespermonth342
and in theorywere round-the clockBEmOC sites. In addition, I also identified30private
facilities that, in theory, provided continuousmaternity care. The private facilities were
identifiedbykeyinformantsfromSambodhiResearchandCommunications(Lucknow,India),
anorganizationthathasworkedinhealthresearchinthestudydistrictsforseveralyears.47
In thesecondstageofsampling, Iattemptedtoselectsixpublic facilitiesperdistrict.This
includedarandomselectionoffourcommunityhealthcenters,onemedicalcollegeandone
districthospitalperdistrict.SinceKanpurDehatdidnothaveamedicalcollege,Ihadtoselect
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anadditionaldistricthospital.Weinvitedthe18selectedpublicfacilitiesandall30private
facilitiestoparticipateinourstudy;however,13facilities–allprivate–refusedtoparticipate.
Among the nine private facilities that agreed to participate, no deliveries occurredwhile
observerswerepresent.TheobservationaldatathatIanalyzedthereforecamefrom18public
and eight private facilities. Further details on the sampling strategy and the study flow
diagramareprovidedinchapter6andfigure6andpublishedelsewhere47.
5.7.2:ManagementsurveyA purposive sampling technique was utilized and all maternity facilities where clinical
observationshadtakenplacewereselectedforthemanagementsurvey.Allselectedfacilities
had complex organizational structures, defined as facilities with separate administrative,
information,therapeutic,diagnosticandsupportservicesandgreaterthanfivepostnatalcare
beds.Ireceivedabetterresponserateandwasabletointerviewmanagersat33facilities
whereasclinicalobservationscouldonlybeobtainedin26maternityfacilities.Thesampling
strategyforthemanagementsurveyisillustratedinFigure10inchapter8.
5.8:Datacollection
5.8.1:Clinicalpracticeobservations
At health facilities, female observers with nursing or midwifery backgrounds visited
admissions, emergency, labour roomand postnatalwards to identify pregnantwomen in
latentphaseoflabour(regularuterinecontractionswithcervicaldilatationlessthan4cm),
whoarelikelytoundergonormalvaginaldeliveries.Theyprovidedinformationsheetsand
consentformstothesewomenandobtainedaninformedconsentfollowingethicalconsent
procedures. After obtaining informed consent, they collected background information on
women’smedicalandobstetrichistoryfromtheircaserecordstoensurethatshewaseligible
forparticipationinthestudy.Theyprospectivelyobservedcareprovidedtothesepregnant
womenduringtheentiredurationoflabourandchildbirthuptoonehourpostpartum,using
a structured, paper- based, clinical observation toolwithout interfering in any aspects of
clinicalcareprovision.Accompanyingfamilymembersorcompanionswerealsoapproached,
consent takenanddetailed informationondemographic, socio-economicandeducational
characteristic of women was collected from them, to minimise distress to the labouring
woman.
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5.8.2:Assessmentofmanagementpractices
Iestablishedtelephonecontactwithfacilitymanagersearlyonandsetupappointmentsto
ensureahighresponserate.Themanagementsurveywasconductedasafollow-upactivity
to the QoC assessments. Interviews were presented as confidential conversations about
management experiences and challenges and did not cover sensitive issues, for example
financialearningsofthehospital.Theparticipantswerenotawarethattheywerebeingrated
fortheirresponsestothemanagementquestionnaire.Alltheinterviewsweredouble-scored;
whileIconductedalltheinterviews,anotherresearcheralsoscoredthemindependently.
5.9:Studyparticipants
Clinicalpracticeobservationsoflabourandchildbirth:Studyparticipantsincludedpregnant
womenwithspontaneous,uncomplicatedlabouroperationallydefinedaswomenwithlow-
risk, gestational agebetween37and42 (+0)weekswith singletonpregnancywith vertex
presentation admitted to facilities who consented to participate in the study and their
newborns.
Assessment of management practices at maternity facilities: Study participants for the
managementsurveyincludedadministratorsorclinicalleadersat33maternityfacilities(10
privateand23publicsector).
5.10:Dataanalysis
Inthissection,Ihavesummarisedthedataanalysisplanformydoctoralstudy.However,the
individualresultschapters(chapters6to8)describethemethodsandtheanalysisplanfor
eachobjectiveingreaterdetail.
The data obtained from clinical practice observations (for objective 1 and 2) and the
management survey (objective 3) were coded either as binary, continuous or categorical
variables. Both QoC and management datasets were double entered. Frequencies were
calculatedforallvariables,andoutliersorerrorsinthedatasetwereidentified.Incasesthere
wereinconsistencies,Iwentbacktothepaper–basedquestionnairesandverifiedtheentered
data. After crosschecking for data accuracy and completeness, I conducted appropriate
statisticalteststoanswerthestudyobjectivesusingSTATA14(StataCorp.LP,CollegeStation,
UnitedStatesofAmerica).
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Forobjective1:
Foreveryclinicalobservation,Iassessed42clinicalitemsrelatedtoQoCduringlabourand
childbirth. Each item was coded as 1 if completed, and 0 otherwise. I finalised a
comprehensiveframeworktoassessQoCduringlabourandchildbirth,bymappingthese42
clinical items into17overall essential carepractices.Nineof these clinical practiceswere
related to obstetric care and eight clinical practiceswere related to neonatal care. Some
practiceswerebasedonasingleitem(e.g.,earlyinitiationofbreastfeeding).Otherpractices
werebasedonmultipleitems(e.g.ActiveManagementofThirdStageofLabour). Further
detailsonthedevelopmentoftheQoCindicesusingduringanalysisareprovidedinchapter
six.
Iappliedprincipalcomponentanalysistodataonownershipofacommonsetofassets,and
thereby,generatedquintilesofwealthstatusforindividualwomen.343Ialsoappliedweights
using data on facility caseload of normal deliveries, the idea being to correct
underrepresentationoffacilitieswithfewercases.
DescriptiveanalyseswasconductedatthelevelofindividualwomenusingSvycommandin
STATA to account for clustering of patients within facilities. Prevalence, proportions,
frequencies, andmeanswere calculated for covariates disaggregatedby public or private
sector.Summaryscoresforobstetriccare(ninepractices),newborncare(eightpractices)and
anoverallessentialcareatbirth index(17practices)werecalculatedasthepercentageof
practicescompletedperwoman(i.e.thenumberofpracticesdonedividedbythenumberof
practicesmeasuredwithintheQoCdomain).
For investigating whether QoC was associated with characteristics of the women, health
workersandhealth facilities, Iusedatwo-level linearmixedeffectsmodelwitharandom
effectat the facility level toaccount forclustering.344Theexposurevariablewaspublicor
private sector and the explanatory variables were women’s characteristics (parity, age,
referral status, caste, wealth, time and day of admission), health worker characteristics
(deliverybyqualifiedpersonnel,dutyhours)andfacilitycharacteristics(volume).Ialsoadded
a dummy variable for each observer in the regression model to mitigate biases across
observers.
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Forobjective2:
I analysed quantitative data on 15 potentially harmful interventions obtained from
quantitativechecklistusedduringclinicalobservationsof275normallabourandchildbirthin
maternity facilities. I also used qualitative data obtained from open-ended observers’
commentsrecordedattheendofeveryclinicalobservation.
Forthequantitativeanalysis,eachitemofmistreatmentwascodedas1ifobserved,and0
otherwise. An aggregate score for mistreatment was calculated for every woman, which
rangedfrom0-15.Descriptiveanalyseswerecarriedoutatthelevelofindividualwomento
describe patterns ofmistreatment that occurs atmaternity facilities. I then conducted a
bivariateanalysistoexaminetherelationshipbetweenindicatorsofmistreatmentandsocio-
demographic characteristics of women. Means, proportions and a summary total
mistreatmentscorewerecalculatedforallcovariates.Chisquaretestswereusedtoassess
whether there was a significant difference amongst the use of practices considered
mistreatment and the relevant co-variates. Since, this paper was conceptualised as a
descriptivepaperwrittentodocumentandexplainthecontextandreasonsformistreatment,
I did not conduct any advanced regression analysis. Instead, I used qualitative insights
obtainedfromobserver’scommentstofurtherexplainquantitativedataonmistreatment.
For analysing the qualitative data obtained fromobservers’ comments, I used a thematic
approach to data analysis using Nvivo 11 software (QSR International). Comments that
summarisedsimilarfindingsacrossobservationswereusedasexamplestodescribedifferent
themesofmistreatment.
Forobjective3:
Two separate analyses were done to address objective three. First, to analyse the
determinantsofmanagementpracticesat33maternityfacilities,Icalculatedtotalscoresfor
overall management, operations management, performance management, target
managementandpeoplemanagementatmaternityfacilities.Ithencategorisedthesampled
maternityfacilitiesbasedontheirmanagementscoresandconductedadescriptiveanalysis
ofthedeterminantsofmanagementpracticesatmaternityfacilities.
Second,toinvestigatetherelationshipbetweenmanagementandQoC,ImergedtheQoCand
managementdatasets,whichmeantthatdatawereanalysedatthelevelof275individual
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women. I then calculated Z scores for overall management and specific management
dimensionstostandardizethesemanagementscores.Aswiththeearlieranalysis,Iapplied
samplingweightssothatequalweightsweregivenforobservationsateachfacility,thereby,
correctingforunderrepresentationoffacilitieswithfewercases.Therelationshipbetween
QoC (outcome) and total management and specific management Z scores (explanatory
variables)werethenanalysedusingmultilevel,mixed-effectslinearregressionmodels.The
modelsincludedrobuststandarderrors,accountedforclusteringattheleveloffacilitiesand
usedsamplingweights.Ialsoincludedadummyvariableforobserverratingsandcontrolled
forrandomeffectsatthelevelofindividualfacilitiesandhealthworkers.
5.11:Researchethics
EthicalapprovalforthestudywasobtainedfromthePublicHealthcareSociety(PHS)Ethics
Review Board in India and the London School of Hygiene & TropicalMedicine in the UK
(LSHTMEthicsRef:8858)whichincludedspecificdetailsontheQoCassessmentsandthefinal
study instruments. The study protocol also received clearance from the National Health
MissioninUttarPradesh.
ThefocusofthisPhDresearchwasontheobservationsoflabourandchildbirthatmaternity
facilities. It did not involve clinical interventions or other controversial issues such as
collectionofbiologicalsamplesorconductofclinicalexaminations.Alltheinvestigators,field
researchersandstafffromthelocalresearchpartnerwereexternalanddidnothavearolein
project implementation or provision of services at maternity facilities. All the observers
employedforclinicalpracticeobservationswerefemales.Effortsweretakentoensurethat
respect,dignity,privacyandculturalsensitivityweremaintainedasmuchaspossible.
Theobserverswereprovidedafive-daytrainingincludingfourhoursspecificallydevotedto
research ethics and informed consent as a part of their training. Unless, therewere life-
threateningemergencies, theobserverswere instructednot todirectly intervene in cases
wheretheyobservedmedicalmistreatmentorininstanceswheresubstandardcarewasbeing
delivered.Inthetrainingmanuals,Ihadalsodesignedvariouscase-studiesoutliningdifferent
scenariosthatobserverscouldcomeacrossandthesuggestedprocessofdealingwithsuch
instances.Theobserverswereinstructedtoreportsuchinstancestomeattheendofevery
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dayandIdiscussedtheseissueswithfieldsupervisorsandinformedthefacilityin-charges,as
appropriate.
Informed written consent was taken prior to the start of data collection from all health
workers,allthelabouringwomenandmanagersofhealthfacilitiesthatparticipatedinthe
study.Aninformationsheetwithdetailsontheobjectivesoftheresearch,confidentialityof
datacollected,thevoluntarynatureofparticipation,thepossibilityofrefusaltoparticipate
atanytimewithoutprovidingaspecificreason,andmycontactdetailswereprovidedtoall
theparticipantspriortothestartofdatacollection.Allparticipantsinthestudyprovideda
written informed consent. The copies of the ethical approval letters and samples of the
consentandinformationformareprovidedinappendix3and4.
5.12:Datamanagement
Dataconfidentialitywasmaintainedthroughsecurestorageofpaper-basedquestionnaires,
anonymizationofdataonceenteredandsecurestoragewithpasswordprotection.Allefforts
weremadetoensurethattheriskofconfidentialitybreacheswasminimum.Datacollected
fromQoCassessmentandmanagementsurveywereonly linkedatthetimeofanalysisby
me. Data were not shared with anyone apart from my supervisors. All completed
questionnaireshavebeenstoredinalockedcupboardandwillbedestroyedaftermyPhdis
completed.
Chapter6:Qualityofessentialcareatthetimeofbirth:Findingsfromclinicalobservationsofspontaneouslabourandchildbirthat26publicandprivatesectorfacilitiesinUttarPradesh,India.PrefaceThischapterpresentsthefirstofthreeresearchpapers,whichformtheresultssectioninmy
PhDthesis.TheobjectiveofthispaperwastodescribevariationsinQoCatthetimeofbirth
inpublicandprivate sectormaternity facilitiesandexaminewhetherquality isassociated
withcharacteristicsofwomen,healthworkersorfacilities.Thispaperutilisedprimarydata
collectedfromclinicalobservationsof275mother-babypairsat26hospitalswhichwerethen
weighted to obtain population-based estimates for the study districts. I also developed
innovativeframeworksforthemeasurementofQoCatthetimeofbirth,bydevelopingthe
overallessentialQoCindex,anindexforqualityofobstetriccareandanindexforqualityof
neonatal care. I conducted a descriptive analysis using the Svy command to incorporate
weightsandaccountforclusteringatthefacilitylevelandusedamulti-levelmixedeffects
linearregressiontechniqueusingthemixedcommandinStatatoinvestigatetheassociation
ofQoCwithcharacteristicsofwomen,healthworkersandhealth facilities. Mixedeffects
regressionsarearobustmethodthatoffersapracticalwaytoanalyseclustereddatasuchas
data from different hospitals and these techniques account for random effects and fixed
effectsinthelinearregressionmodel.
Thisisthepre-copyedited,finalauthorapprovedversionofthearticlesubmittedafterpeer
reviewtothepublishers.Sincethepublishedversionofthearticlewascopy-editedfurther
for language and style and could not accommodate many of the interesting figures and
importantdiscussionpoints,inchapter6,Ihavesubmittedthefinalauthor-approvedversion.
Ashortercopy-editedversionofthispaperwaspublishedbytheBulletinoftheWorldHealth
Organizationinaspecialthemeissueonmeasuringqualityofcare(publishedJune2017).It
is available online at http://www.who.int/bulletin/volumes/95/6/16-179291.pdf. The
publishedversionofthefinalmanuscriptisalsoavailablefromappendix5.
RESEARCH PAPER COVER SHEET PLEASE NOTE THAT A COVER SHEET MUST BE COMPLETED FOR EACH RESEARCH PAPER
INCLUDED IN A THESIS.
SECTION A – Student Details
Student Gaurav Sharma
Principal Supervisor Véronique Filippi
Thesis Title An investigation into quality of care at the time of birth at public and private sector maternity facilities in Uttar Pradesh, India
If the Research Paper has previously been published please complete Section B, if not please move
to Section C
SECTION B – Paper already published
Where was the work published? Bulletin of the WHO
When was the work published? June 2017
If the work was published prior to registration for your research degree, give a brief rationale for its inclusion
No
Have you retained the copyright for the work?* Yes Was the work subject to
academic peer review? Yes
*If yes, please attach evidence of retention. If no, or if the work is being included in its published format, please attach evidence of permission from the copyright holder (publisher or other author) to include this work. SECTION C – Prepared for publication, but not yet published
Where is the work intended to be published? The Bulletin of the World Health Organization
Please list the paper’s authors in the intended authorship order:
Gaurav Sharma, Timothy Powell-Jackson, Kaveri Haldar, John Bradley, Véronique Filippi
Stage of publication In press SECTION D – Multi-authored work
Page90of248
6.1:IntroductionThequalityofcare(QoC)offeredatmaternityfacilitiesaffectspregnantwomen,physically
and emotionally, but also impacts the survival and long-term health of mothers and
newborns.16,21 An increased focus on care during childbirth has multiple returns on
investmentthroughthereductionofmaternalandneonataldeaths,preventionofstillbirths
andfuturedisability.16,18
Manycountrieshaveadoptedpoliciestoencouragebirthsinhealthfacilitiesandglobally72%
ofalldeliveries,including69%ofdeliveriesinSouthAsiaarenowatinstitutions.345Failuresin
processes of care result in badobstetric andneonatal outcomes346,347 andpoor quality is
associatedwithlowdemandformaternalhealthservices.348,349Inaddition,aschildbirthisa
normalphysiologicalprocess,somecareprovidedcanbeineffectiveorevenharmful.114
Despite substantial efforts to promote evidence-based obstetrics, the uptake of
recommended interventions into clinical practice has been limited worldwide.119,120,337
Clinical practices are influenced bymultiple factors such as health-worker characteristics,
patientcharacteristics,task-complexity,theinstitutionalenvironment,andthesocio-cultural
environment,350,351makingpracticesdifficulttochange.
Indiaisthesecondhighestcontributortomaternaldeathsglobally(45000deathsin2015)352
andachievingthe“Survive”targetsformothersandnewbornsasapartoftheglobalstrategy
for women’s, children’s and adolescents’ health (2016-2030)6 is dependent upon future
progressinIndia.MaternityservicesinIndiaareavailableinbothpublicandprivatesectors,
fromanenormousrangeofhealthproviders.Maternitycareinthepublicsectorisprovided
throughanetworkoflevel1,2and3facilities,whichinprincipleprovideroutinecare,Basic
EmergencyObstetricCareandComprehensiveEmergencyObstetricCarerespectively.353The
privatesectorisheterogeneousandrangesfromsmallmaternityhomestolarge(100ormore
beds)multispecialtytertiaryhospitalsandmedicalcolleges.
Increasingly,theprivate-sectorhasemergedasanimportantproviderofmaternityservices.
ArecentanalysisofDemographicandHealthSurveysfor57countries(2000–2013)foundthat
theprivate-sectorshareamongappropriatedeliverieswas9–56%acrossworldregionsandit
Page91of248
is often less equitable than the public sector.33 India has a mixed health system with a
dominantprivatesectorandextremeheterogeneityoffacilities.Anestimated75%ofprivate
health facilities are micro-enterprises and the rest are medium to large medical
establishments.324Recentestimatesindicatethatupto22%ofalldeliveriesinIndiaoccurin
theprivatesector.40Womenwithpreviouslynegativepregnancyoutcomestendtochoose
privatesector.40Highersocio-economicstatusandaccessibilityareassociatedwithincreased
privatesectoruse.40Scheduledcasteandtribestatusarenegativelyassociatedwithuseof
privatefacilities.248Theprivatesectorismoreexpensivethanthepublicsectorandthereisa
perceptionthattheyprovidebetteramenitiesandahigherstandardofcare.248
Although,there isconsiderable literatureonthequalityofemergencyobstetriccare,354,355
thereislimiteddescriptiveinformationonQoCforuncomplicatedspontaneousvaginalbirths
inIndia,particularly,fromprivatesectorfacilities.Mostoftheavailableevidenceisfromthe
publicsectorandfromqualitativestudies.ThesestudieshavefoundpoorQoCwithhighrates
of labour augmentation, routine episiotomies, no choice of position, non-adherence to
protocols,limitedmonitoring,earlydischargefromthehospitalandpoorneonatalcare.71,77,78
It iswell-established that theprivate sector is adriverof caesarean section rates inmost
world-regions.36,39,356,357Inaddition,a2011studyusingmultivariateanalysisofover11000
deliveryrecordsinThailandfoundthatwomenwhodeliveredintheprivatesectorwere9.4
timesmore likely tohavehadacaesarean than thosewhodelivered inapublic sector.358
Usingprimarydataobtainedfromclinicalobservations,wesoughttodescribeQoCforlabour
andchildbirthinpublicandprivatefacilitiesandexaminewhetherqualityisassociatedwith
characteristicsofthewomen,healthworkersandfacilitiesinUttarPradesh,India.
6.2:Methods
6.2.1:Studysetting
ThisstudywasnestedwithinalargerresearchprojectinthreedistrictsofUttarPradesh(UP):
Kannauj,KanpurNagar,andKanpurDehat.359AmongstIndianstates,UPisthemost-populous
anditsmaternalmortality(258per100,000livebirths)wasthesecondhighestandneonatal
mortality (49per1,000 livebirths)wasthethirdhighest in2012-13.253Neonatalmortality
ratesinthethreestudydistrictswerehigh(Kannauj-55,KanpurDehat-41andKanpurNagar
-24per1000livebirths),aswasthematernalmortalityratio(240per100000livebirths).253
Upto39%ofdeliveriesinUPoccuratpublicsectorfacilities(43%inKannauj,46%inKanpur
Page92of248
Dehatand34%inKanpurNagar).253Theprivatesectordeliveryshareisestimatedtobe18%
inUP(15%inKannauj,34%inKanpurNagar,and10%inKanpurDehat).253Therearealso
widespread inequities across the continuum of care for all reproductive, maternal and
newbornhealthindicatorsinthethreestudydistricts.253Primarydataonestimatedcaseloads
atourstudysitesshowthatthemedianannualnumberofdeliverieswas2,216(range:1,433-
5,126)andthecaesareansectionratewas6%(range:0%-34%)inoursampleofpublicsector
facilities.Forprivatesectorfacilities,themedianannualnumberofdeliverieswas697(range:
234-2,392)andthecaesareansectionratewas32%(range:2%-59%).
6.2.2:Sampling
We used a multistage stratified sampling methodology. The sampling frame included 29
public sector facilities (obtained from the Department of Health) and 30 private facilities
(identifiedbykeyinformants).Thepublicsectorfacilitieswereeligibleiftheyhad200ormore
deliveriesmonthlybasedonHMISdata342andwereround-theclockBEmOCsites.Therewas
nosamplingframeavailablefortheprivatesectorandacensusofallprivatesectorfacilities
wasnotfeasible.Wereliedonlocalknowledgeofourcollaboratingorganisation(whichhas
workedinhealthresearchinthestudydistrictsforyears)todrawupalistofprivatesector
facilities providing 24/7maternity care in the study districts and selected all facilities for
inclusion in the study. In the second stage, 18 public facilities were randomly selected
stratifiedby typeof facilityandallagreedtoparticipate.Amongst the30private facilities
invitedtoparticipate,13facilitiesrefused.Therewerenocasesatanadditionalnineprivate
facilities during the oneweek that researcherswere stationed there. Figure 6 shows the
overallstudyflowchart.Powercalculationsweredonetoestimatetherequirednumberof
observations at each facility (discussed in chapter 5, section 5.6).We expected up to 10
observationsintwodaysperpublicsectorfacilityand10observationsperweekinprivate
sectorfacilitiesandultimately,couldobserveanaverageof12and8observationsinpublic
andprivatesectorfacilities,respectively.
6.2.3:Studyparticipants
Study participants included pregnant women with spontaneous, uncomplicated labour
operationallydefinedaswomenwithlow-risk,gestationalagebetween37and42(+0)weeks
withsingletonpregnancywithvertexpresentationadmittedtofacilitieswhoconsentedto
participateinthestudyandtheirnewborns.
Page93of248
Figure6:StudyflowdiagramfortheassessmentofQoCduringlabourandchildbirth
• 59maternityfacilitiesinUttarPradeshassessedforeligibility:
• 29fromthepublicsector• 30fromtheprivatesector
•
13privatefacilities–declinedtoparticipate
• 218deliveriesobserved
Uncomplicatedvaginaldeliveriesobservedinall18publicfacilities
• 18publicfacilitiesenrolled:• 12communityhealthcenters• 4districthospitals• 2medicalcollegeteachinghospitals
Uncomplicatedvaginaldeliveriesobservedinonly8oftheprivatefacilities
17privatefacilitiesenrolled:• 8maternityhomes• 7multispecialtyhospitals• 2medicalcolleges
• 64deliveriesobserved(noreferralsordeaths)
Randomsampleof18publicfacilitiesandall30privatefacilitiesinvitedtoparticipate
• Analysisofobservationaldataon211deliveriesinpublicfacilities
• Analysisofobservationaldataon64deliveriesinprivatefacilities
• 7deliveriesexcludedfromanalysis:
• 5neonataldeaths• 1referredforspecialist
careelsewhere• 1referredforcaesarean
section
Page94of248
6.2.4:Datacollection
WedevelopedaQoCassessment toolbasedona critical assessmentofpreviously tested
instruments337,360andWHOguidelinesforcareduringpregnancyandchildbirth.361Questions
capturing educational, demographic and socio-economic status were adapted from the
NationalFamilyHealthSurveyquestionnaire.338TheQoCassessmenttool isavailablefrom
Appendix 1. At maternity facilities, 14 trained enumerators with maternal and newborn
healthbackgroundsvisitedtheadmissions,emergency,labourroomandpostnatalwardsto
identify pregnant womenwhowere likely to undergo uncomplicated vaginal births. Two
enumeratorswere stationedat each facility andobserved round-the-clock careprovision.
Datawerecollectedafterobtainingwomen’sinformedwrittenconsentbetween26thofMay
to8thofJuly2015.EthicalapprovalwasobtainedfromthePublicHealthcareSocietyEthics
ReviewBoardandtheIndianCouncilforMedicalResearchinIndia,andtheLondonSchoolof
Hygiene&TropicalMedicineintheUK.
6.2.5:Measures:
Learning from previous quality measurement efforts,151,153 we operationalized QoC as
encompassingclinicalcareprovisionandclients‘experiencesofcare.Clinicalcareprovision
meansapplicationofevidence-basedprocesses includingprinciplesofdoingnoharmand
experiencesof care relate towoman-centred respectful carepracticesduring thebirthing
process.141Wecollecteddataon42itemsforeveryobservation.Eachitemwascodedas1if
completed,and0otherwise.Wethenaggregateditemsintoclinicalpractices–nineobstetric
carepractices,eightnewborncarepracticesand17practicesoverallforessentialcareatbirth
(Table7).Somepracticeswerebasedonasingleitem(e.g.earlyinitiationofbreastfeeding
wascoded1 if themotherwasobservedto initiatebreastfeedingwithinonehour).Other
practiceswerebasedonmultipleitems(e.g.ActiveManagementofThirdStageofLabourwas
codedas1 ifuterotonicwithin1min,cordclampingandcontrolledcordtractionwereall
done). Finally, summary scores for obstetric care (nine practices), newborn care (eight
practices)andanoverallessentialcareatbirth index(17practices)werecalculatedasthe
percentageofpracticescompletedperwoman(i.e.thenumberofpracticesdonedividedby
thenumberofpracticesmeasuredwithinthequalityofcaredomain).
The exposure variable was public or private sector and the explanatory variables were
women’s characteristics (parity, age, referral status, caste, wealth, time and day of
Page95of248
admission),healthworkercharacteristics (deliverybyqualifiedpersonnel,dutyhours)and
facility characteristics (volume). Principal component analysis was applied to data on
ownershipofacommonsetofassets,andquintilesofwealthstatusweregenerated.343
Table7:IndicesforQualityofCare
Timing Obstetric Foetal/Neonatal
Onadmissionandfirststageoflabour
Regularmonitoringoflabourusingapartograph(1item:labourmonitoredregularlywithpartograph)
Checksfundalheightandfoetalpresentation(2items:fundalheightchecked;foetalpresentationchecked)
Maternalinfectionpreventionmeasuresduringadmission(2items:hand-washingpriortoexam;sterilegloveswornpriortovaginalexam)
Foetalheartratemonitoredatregularintervals(1item:foetalheartratemonitoredatregularintervals)
Preeclampsia/eclampsiascreening(2items:BPmonitoredandurinetestedforproteins)
Duringsecondstageoflabourtocompletionofchildbirth
MaternalInfectionpreventionmeasures(2items:healthworkerwearssterilegloves,cleansthevulvaandperineumwithanantiseptic)
Healthworkerspreparedforresuscitationifrequired(2items:ventilationbagavailable;newbornmaskavailableandlaidout)
Activemanagementofthethirdstageoflabour(3items:uterotonicwithin1min;cordclamping;andcontrolledcordtraction)
Neonatalsterilecordcare(1item:sterilecordcutting)
Maternalbloodlossassessment(3items:completenessoftheplacentaandmembranes;assessingforvaginaltears;andlacerationsandmonitoringbleeding.)
Appropriatenewbornthermalcare(3items:babydried;skintoskincontact;babycoveredwithadrytowel)
Womencentredrespectfulcarepractices(5items:processoflabourexplainedtothemotherorsupportpersonatleastonce;companionallowedtobewiththemotherduringlabour;womeninformedpriortovaginalexamination;visualprivacyensured;motheraskedaboutchoiceofposition)
Apgarscore1minand5minutes(2items:Apgarscoreassessedat1minafterbirth;Apgarscoreassessedat5minafterbirth)
Initiatesearlybreastfeedingwithin1hour(1item:motherinitiatesbreastfeedingwithin1hourofbirth)
Noharmfulorunnecessaryinterventionsdoneformotherduringthelabourandchildbirthperiod(6items:noenema;nopubicshaving;noapplyfundalpressuretohastendeliveryofbabyorplacenta;nouterinelavageafterdelivery;nomanualexplorationoftheuterusafterdelivery;nouseofepisiotomywithoutindication)
Noharmfulorunnecessarypracticesforthenewbornduringtheearlyneonatalperiod(3items:noroutineaspirationofthenose;noslapthenewborn;noholdingthenewbornupsidedown)
Page96of248
Noharmfulorunnecessarybehavioursdonetothemotherduringthelabourandchildbirthperiod(3items:norestrictfoodandfluidduringlabour;noshout,insultorthreatenthewomanduringlabourandchildbirth;noslap,hitorpinchthewomanduringlabourandchildbirth)
6.3:Analysis
DescriptiveanalyseswerecarriedoutatthelevelofindividualwomenusingtheSvycommand
inSTATA14(http://www.stata.com/)toincorporateweightsandaccountforclusteringatthe
facilitylevel.Post-samplingweightswereappliedtoobtainpopulation-basedestimatesusing
dataonfacilitycaseloadofnormaldeliveries,theideabeingtogivegreaterweighttotheQoC
providedbyfacilitieswithmorepatients.Prevalence,proportions,frequencies,andmeans
werecalculatedforcovariatesdisaggregatedbysector.Atwo-levellinearmixedeffectsmodel
wasusedwitharandomeffectatthefacilityleveltoaccountforclustering.344Theregression
includedtheexplanatoryvariablespreviouslydescribedaswellasadummyvariableforeach
enumerator to mitigate biases across observers. Estimation was by restricted maximum
likelihood.WeusedaWaldtesttogenerateanoverallp-valueforeachcategoricalvariable
(e.g. agegroup) toassesswhether therewasanassociationbetweenagivenexplanatory
variableandthequalityofcareoutcome.
6.4:Results6.4.1:SamplecharacteristicsMostobservationswereconductedinthepublicsector(n=211,77%)andmostwomencame
directlytofacilities(92%)(Table8).Mostwomenwerebetween20-35yearsofage(90%),
multi-parous(56%)andbelongedtotheotherbackwardcastecategory(51%).Womenofthis
castewere inhigherproportionatprivatematernities than thepublic sector (p=0.002).A
higherproportionofprivatesectorclientswerefromthehighestquintileandthirdquintile
thanpublicsectorpatients(p=0.07).Agreaterproportionofdeliveriesintheprivatesector
(73%) compared to public sector (27%) were performed by qualified personnel (doctors,
nurses,andmidwives)(p=0.01).Agreaterproportionofcaseswereadmittedtotheprivate
sector (99.5%) during daytime work-hours compared to public (93%) maternity facilities
(p=0.003).
Page97of248
Table8:Samplecharacteristics
Unweighted Weighted
Total
(n=275)
Public
(n=211)
Private
(n=64)
Total
(n=52047)
Public
n=41512
Private
(n=10535)
Pvalue
Women’sage 0.85a. <20years 16/275(6%) 12/211(5.6%) 4/64(6.2%) 5.5% 6% 4.4%b. 20-35years 247/275(90%) 191/211(90.5%) 56/64(87.5%) 90.4% 90% 90.5%c. 35yearsormore 12/275(4%) 8/211(4%) 4/64(6.2%) 4.1% 4% 5.1%Parity 0.7a. Primipara 119(43% 90/211(43%) 29/64(45.3%) 44% 41.6% 53.4% b. Multipara 156(57%) 121/211(57%) 35/64(54.7%) 56% 58.4% 46.6%Referralstatus a. Patientdirectlytothisfacility 243/275(88.4%) 197/211(93.4%) 46/64(72%) 91.5% 96% 74% 0.003b. Patientreferredfromanotherfacility 32/275(11.6%) 14/211(6.6%) 18/64(28%) 8.5% 4% 26%Castea. “Scheduledcaste” 59/275(21.4%) 53/211(25.1%) 6/64(9.4%) 24.2% 29% 6.4% 0.002b. “Scheduledtribe” 2/275(0.7%) 0/211(0%) 2/64(3.1%) 0.3% 0% 1.4%c. “Otherbackwardcaste” 153/275(55.6%) 111/211(52.6%) 42/64(65.6%) 51.4% 49% 61.1%d. “Generalcaste” 61/275(22.2%) 47/211(22.3%) 14/64(22%) 24.1% 22.3% 31%Socio-economicstatusa. 1stquintile(lowest) 56/275(20.4%) 49/211(23.2%) 7/64(11%) 22.5% 24.2% 16% 0.07b. 2ndquintile 54/275(19.6%) 46/211(22%) 8/64(12.5%) 18% 19.5% 11%c. 3rdquintile 55/275(20%) 36/211(17%) 19/64(30%) 18% 18% 18%d. 4thquintile 55/275(20%) 46/211(22%) 9/64(14%) 19.5% 22% 10%e. 5thquintile(highest) 55/275(20%) 34/211(16.1%) 21/64(33%) 22.5% 17% 45.2%Typeofbirthattendanta. Qualifiedbirthattendant 113/275(41%) 75/211(35.5%) 38/64(59.4%) 36% 27% 73% 0.01b. UnqualifiedSBA 162/275(59%) 136/211(64.5%) 26/64(40.6%) 64% 73% 27%Admissionduringworkhours?a. Withinworkhours(9:00AM-17:00PM) 254/275(92.3%) 191/211(90.5%) 63/64(98.4%) 94.4% 93% 99.5% 0.003b. Outofhours(17:01PMto8:59am) 21/275(7.6%) 20/211(9.5%) 1/64(1.5%) 5.5% 7% 0.5%Admissionduringweekends?a. Admissionduringweekdays 211/275(77%) 158/211(75%) 53/64(83%) 77% 76% 82% 0.58b. Admissionduringweekends. 64/275(23%) 53/211(25%) 11/64(17%) 23% 24% 18%
Page98of248
6.4.2:VariationsinessentialcareatbirthacrosspublicandprivatesectorsfacilitiesTable 9 below shows the QoC by sector for each of the clinical practicesmeasured. For
obstetric care provision, monitoring of labour using partograph (2%), screening for pre-
eclampsia/eclampsia(2%),woman-centredcare(4%),noharmful/unnecessaryinterventions
(4%) and AMTSL (24%) were particularly low in both sectors. Facilities in both sectors
performed relatively better formaternal infection preventionmeasures during admission
(76%)andnoharmfulhealthworkerbehaviours(74%).However,partographuse(p=<0.001),
maternalinfectionpreventionmeasuresduringchildbirth(p=0.05)andmaternalbloodloss
assessment(p=0.01)weresignificantlybetter intheprivatesectorcomparedtothepublic
sector.Wedidnotfindanysignificantdifferencesbetweensectorsinuseofnoharmfulor
unnecessary maternal care interventions (p=0.2) or in harmful health worker behaviours
towardsmothers(p=0.45).
Forfoetal/neonatalcare,foetalheartratemonitoringatregularintervals(20%),assessment
of foetalpresentationand fundalheight (1%),andassessmentofApgar scoresat1and5
minutes(1%)wereespeciallypooracrossbothsectors.Facilitiesinbothsectorsperformed
relativelybetterforresuscitationpreparedness(68%),sterilecordcare(95%)andsupportfor
earlyinitiationofbreastfeeding(70%).However,significantdifferenceswereseenbetween
publicsector(7%)andprivatesector(73%)forfoetalheartratemonitoring(p=<0.001).Figure
7showsdatadisaggregatedfurtherbyeachofthe42itemsobserved.
Qualityofessentialcareduringlabourandchildbirthwasfoundtobedeficient(36%)across
theentiresampleofmaternityfacilities(Table9).Onaverage,45%ofclinicalpracticeswere
completed amongstwomen giving birth in the private sector compared to 33% in public
sector facilities (p=0.01). For obstetric care, private sector clients received 40% of the
recommended obstetric care practices compared to 28% in the public sector (p=0.01).
Neonatalcarewasalsobetterintheprivatesector(p=0.02)whereclientsreceived51%of
recommendedpracticescomparedto39%inthepublicsector.
Page99of248
Figure7:Qualityofcareitemsforobstetricandnewborncarebysectorusingweighteddata.
TheresultsfromthemultivariateanalysisrevealthatoverallQoCwas6percentagepoints
higher (p=0.03) inprivate sector facilities thanpublic sector facilities, after controlling for
confounders(Table10).Wefoundnoassociationbetweenuseofqualifiedpersonnel,facility
caseloadorclientcharacteristicsandoverallQoCatthetimeofbirth.Specifically,therewere
no statistically significant differences in quality of carewith respect to thewoman’s age,
parity, referral status, caste, or socio-economic status. However, admission during the
weekendswasassociatedwitha3-percentagepointpoorerstandardofcare(p=0.03).
We examined adjusted variances between healthworkers and health facilities and found
greater variation within health workers than between health workers for QoC (SD
within=0.004,SDbetween=0.002,intraclasscorrelationof0.33).Similarly,therewasgreater
variationwithinhealthfacilitiesthanbetweenhealthfacilities(SDwithin=0.005,SDbetween
=0.002,intraclasscorrelationof0.27).WefoundthatQoCdidnotchangesignificantlybythe
orderofobservation,suggestingthathealthworkerswerenotexertingmoreeffortsimply
becausetheywerebeingobserved.GraphshowinglimitedHawthorneeffectispresentedin
Figure8.
Page100of248
Table9:VariationsinessentialcareatbirthacrosspublicandprivatesectorsinUttarPradesh,India
Measures Unweightedestimates(n,%) Weightedestimates(%)
Total
(n = 275)
Public
(n = 211)
Public
sector
95%CI
Private
(n=64)
Private
sector95%CI
pvalue
Total
(n = 52 047)
Public
(n = 41 5
12)
Public
sector95%
CI
Private
(n = 10 53
5)
Private
sector95%
CI
pvalue
Clinicalpracticesforobstetriccare
Regularmonitoringoflabourusingpartograph 3(1.1) 1(0.5) 0.1to3.3 2(3.1) 0.7to12 0.07 1.6 0.2 0.1to1.9 7.2 1.7to26 <0.001
MaternalInfectionpreventionmeasuresduringadmission
212(77) 159(75.4) 69to81 53(83) 71.4to90 0.21 76.4 73.4 65to80 88.2 77to94 0.1
ScreeningforPreeclampsia/Eclampsia 3(1.1) 2(0.9) 0.2to3.7 1(1.5) 0.2to10.5 0.67 2.3 2.22 0.5to9.3 2.5 0.3to16 0.9
MaternalInfectionpreventionmeasuresduringchildbirth
115(42) 76(36) 30to43 39(61) 48.4to72.2 <0.001 45.5 38.3 31to46% 74.1 59to85 0.05
Activemanagementofthethirdstageoflabour 73(26.5) 58(27.4) 22to34 15(23.4) 14.6to35.5 0.52 24.5 25.4 19.3to32.5 21 11to36 0.7
Maternalbloodlossassessment 124(45.1) 81(38.4) 32to45 43(67.2) 54.7to77.6 <0.001 43 34.5 27.4to42.4 75.7 61to86 0.01
Womencentredrespectfulcarepractices 12(4.4) 9(4.3) 2.2to8 3(4.7) 1.5to14 0.88 3.4 3 1to6 5.6 1.1to24 0.5
Noharmfulinterventionsdonetothemother 15(5.4) 14(6.6) 4to11 1(1.5) 0.2to10.5 0.12 4.3 5 3to9 1.5 0.2to10 0.2
Noharmfulhealthworkerbehaviourstowardsthemother
215(78.2) 162(77) 70.5to82 53(83) 71.4to90.3 0.306 74 72.4 64to79 81 57to93 0.45
Clinicalpracticesfornewborncare
Checksfundalheightandfoetalpresentation 4(1.4) 1(0.5) 0.1to3 3(4.7) 1.5to13 0.014 1.1 0.5 0.1to3.6 3.4 0.7to14 0.08
Foetalheartratemonitoredatregularintervals 61(22.2) 20(9.5) 6.2to14 41(64) 51to75 <0.001 20 6.6 45to10.5 73.3 58to84 <0.001
Healthworkerspreparedforresuscitation,ifrequired 179(65.1) 132(62.6) 56to69 47(73.4) 61.2to83 0.11 68 67.2 60to74 71.5 51to86 0.8
Neonatalsterilecordcare 265(96.4) 202(96) 92to98 63(98.4) 89.5to99.8 0.3 95.2 94.6 89to97.5 97.5 84to99 0.5
Appropriatenewbornthermalcare 84(30.5) 62(29.4) 23to36 22(34.4) 23.7to47 0.4 38 36.5 29to45 42.4 26to62 0.7
Apgarscore1minand5min 1(0.36) 0(0) 0to0 1(1.5) 0.2to10.5 0.07 0.9 0 0to0 4.7 0.6to27 0.08
Initiateearlybreastfeeding 191(69.4) 148(70) 64to76 43(67.2) 55to77 0.6 70 71 62to78 65.6 49to79 0.6
Noharmfulorunnecessarypracticesforthenewborn 95(34.5) 70(33.2) 27to40 25(39) 28to52 0.3 38 35.3 28to43.5 49 31to67 0.3
Aggregateindicesofqualityofcareattimeofbirth
ObstetriccareIndex 31.2 29.6 28to31 36.5 33to39.5 0.03 30.5 28.2 26to30.5 40 35to44 0.01
Neonatalcareindex 40 37.6 36to39 48 44to51.6 0.02 41.3 38.9 37.2to41 51 45to57 0.02
Essentialcareatbirthindex 35.3 33.4 32to35 42 38to45 0.01 35.6 33.3 31.6to35 45 40to49 0.01
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Table10:Resultsfromthemultilevelmixedeffectslinearregression
Outcome:Essentialcareatthetimeofbirthindex Coef. pvalue 95%Conf.intervalExplanatoryvariablesBysector• Publicsector Base • Privatesector 0.06 0.03 0.01-0.11Wastheadmissiononaweekend? • Weekdayadmission Base • Weekendadmission -0.03 0.03 -0.06-0.003Numberofdeliveriesatmaternityfacilitylastyear • lowvolume<2000deliveries/year Base • averagevolume(2000-2999deliveries/year) 0.01 0.77 -0.05-0.06• Highvolume(>3000deliveries/year) -0.02 -0.08-0.05Woman'sage • Lessthan20years Base • 20-34years 0.01 0.91 -0.04-0.05• 35andgreater 0.01 -0.05-0.08Parity • Primipara Base • Multipara 0.01 0.22 -0.01-0.03Referraltothehospital? • Patientdirectlytothisfacility Base • Patientreferredfromanotherfacility 0.00 0.84 -0.04-0.03Caste • Scheduledcasteandscheduledtribe Base • Otherbackwardcaste 0.02 0.15 -0.01-0.04• Generalcaste 0.03 0.00-0.06Socio-economicstatus • 1stquintile(lowest) Base • 2ndquintile(lower) 0.00
0.08
-0.03-0.03• 3rdquintile(average) 0.00 -0.03-0.03• 4thquintile(higher) 0.00 -0.03-0.03• 5thquintile(highest) 0.04 0.0- 0.07Admissionduringworkhours? • Withinworkhours(9:00AM-17:00PM) Base • Outofhours(17:01PMto8:59am) -0.01 0.62 -0.05-0.03Whoconductedthedelivery? • Non-qualifiedbirthattendant Base • Qualifiedbirthattendant 0.01 0.61 -0.02-0.04
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Figure8:EstimatedHawthorneeffectacrosssampledobservationsin26hospitalsofUttarPradesh
6.5:DiscussionUsingdatafromclinicalobservations inUttarPradesh,wefoundthatessentialcareatthe
timeofbirthprovidedtowomenandtheirnewbornswaspoorquality.Thereweresignificant
differencesamongstsectors,withprivatefacilitiesoutperformingpublicsectorfacilitiesfor
overallcareatbirth,obstetricandneonatalcare.Theprivatesectoralsoperformedbetterfor
specificproceduressuchasmaternalbloodlossassessment,monitoringofprogressoflabour
andmonitoringoffoetalheartrate.Preventivemeasuresagainstmajorcausesofmaternal
mortalitysuchashaemorrhage,sepsisandhypertensivedisorderswerefrequentlynotdone
atfacilitiesinbothsectors.
Our study advances the descriptive evidence base on QoC at the time of birth in India,
particularlyfortheprivatesectorwhichhasanincreasingmarketshareformaternitycare.33
We used direct observations of clinical practices that offer many advantages over other
qualityassessmentmethods.Wefoundnoevidencethatobservinghealthworkersgenerated
aHawthorneeffect.Inaddition,weprovidedacomprehensivemeasureofQoCthatincludes
adherencetoevidence-basedguidelines,useofharmfulandunnecessaryinterventionsand
behaviours, and respectful care practices. The essential care at birth, obstetric care and
neonatalcareindicescouldbeusedformonitoringQoCinothersettings.
The findings from themultivariate analysis confirmed that the private sector provided a
higher standard of care compared to the public sector andQoCwas not associatedwith
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characteristics of thepatient, facility, ormidwiferypersonnel.However, admissionduring
weekendswasassociatedwithpoorerqualityofcare.Ourfindingsaresimilartootherstudies
thathavefoundaweekend-effectwithpoorerobstetricandneonatalcareoutcomesduring
weekends.362,363
Althoughcarewaslesslikelytobeprovidedbyqualifiedstaffinthepublicsector,qualified
personnelattendingbirthswasnotassociatedwithbetterqualityofcare.Previousstudies
haveshownthatevenwhenaqualifiedbirthattendantispresenttheymaynotbeadequately
skilled.78,364AstudyusingstandardizedpatientsinIndiaalsofoundminordifferencesbetween
trainedanduntrainedprovidersandQoC,although,thisstudydidnotfocusonmaternaland
newborncare.178
WedidnotfindanyrelationshipbetweenfacilitysizeandQoCatbirth.Thiscouldperhapsbe
explainedbythefactthatourobservationswerelimitedtouncomplicatedvaginalbirthsand
QoC in this settingwasdeficientacrossall sampled facilities.Previous studieshave found
betterQoCathigher level facilities,potentiallyexplainingwhypatientsbypass lower level
facilities.348 Although, we do not have robust evidence on factors influencing quality of
obstetricandneonatal careat facilities in India, there isevidence fromother low income
countrieswhichshowsthatprovidereffortmaybeakeydeterminantforQoC365andthatthe
private sector provides better QoC because it has superior operational andmanagement
systemsincludingbetterincentiveschemestoattractbetterqualifiedandmotivatedstaff.178
Weintendtoexploresomeoftheseissuesinsubsequentanalyses.
Our findingsaresimilar tootherstudies from India thathave foundpartographuse tobe
especially weak and that monitoring often consists of repeated unhygienic vaginal
examinationswithinadequateattentiontoeitherfoetalormaternalwell-being.71Wefound
slightlyhigherratesofAMTSLcomparedtoarecentstudyinneighbouringdistrictsofUP.77
Respectfulcarewaspoorinbothsector:only4%womanreceivedrights-basedcare.141Verbal
(13%) and physical abuse (8%)was endured by somewomen. Our informal observations
during data collection were consistent with other studies, in Madhya Pradesh66 and
Rajasthan78,thatfoundlabourroomenvironmentswerechaoticandhealthworkerscanbe
dominant,abusiveand threateningonoccasions.66Someresearchershavesuggested that
inadequateknowledgeandskills,staffingshortages,poorqualityin-servicetrainings,lackof
enablingenvironmentsandlimitedsupportivesupervisioncouldbeunderlyingcausesofpoor
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quality care in India.66,71 We note that the Government of India and its partners are
implementing a range of schemes to improve the quality of intrapartum and immediate
postpartumcare.366Givenimmenseshortagesofskilledhumanresourcesformaternitycare,
focusedeffortstoestablishaprofessionalcadreofmidwivescouldbebeneficial.Wefound
greater variance in QoCwithin individual health workers than between them. This could
indicatethathealthworkersdonotfollowstandardprotocolsorprovidepreferentialcare.
Wenoteseverallimitationsofthestudy.First,theremayhavebeenobserverbiasduetothe
generalperceptioninthecommunitythattheprivatesectorissuperiorbecauseithasbetter
infrastructureandbettertrainedpersonnel,leadingtoanover-estimationofqualityinprivate
facilities. Second, there were challenges to sampling the private sector. Not only did 13
privatefacilitiesrefusetoparticipate,wehadnoofficialsamplingframefromwhichtoselect
thefacilities.ItispossiblethattheQoCoftheparticipatingprivatefacilitieswasdifferentfrom
thosethatwereeithernotsampledorrefusedtoparticipate.Third,aggregatingnumerous
indicators masks variations between individual indicators but was essential to report
comprehensivelyonQoC.Indevelopingaggregatemeasuresofquality,wegaveequalweight
toeachindicatorastherewasnoscientificbasisforapplyingintervention-specificweights.
Thevalidationoftheindexwasbeyondthescopeofthepresentstudy.Ontheotherhand,
therewerenorefusalsbywomentorecruitmentandastrictcase-definitionwasfollowed
whichminimisesselectionbiasatthelevelofparticipants.Researcherswerewell-trainedand
astructuredinstrumentwasusedwhichlimitssubjectivity.
Although,thegovernmenthashadsuccessinencouragingwomentodeliverinfacilities,we
foundlimitedevidence-basedcarepracticedatpublicandprivatesectormaternityfacilities
inUP.Ourfindingssuggestthreekey implications. First,there isaneedforauthoritiesto
introduceasystematicefforttomeasureandidentifyexistingqualitygapsduringlabourand
childbirth especially in high-burden states. These efforts should include private-sector
facilitiesastheyprovideasubstantialproportionofmaternitycareinIndia.Second,reasons
for high rates of untrained personnel providing maternity care and widespread non-
adherencetorecommendedprotocolsshouldbeinvestigatedfurther.Thepracticeofrelying
heavilyonpersonnel,notformally-trained,toprovidematernitycareisaworryingmodelof
service provision in the 21st century, which makes improving QoC particularly difficult
because such personnel are invisible within the health system. Third, tailored quality
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improvementinitiatives88mustbedesignedforfacilitiesinbothsectorswithregularauditing
ofactualcare-processeslinkedtofunctionalaccountabilitymechanisms.
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Chapter7:AninvestigationintomistreatmentofwomenduringlabourandchildbirthinmaternitycarefacilitiesinUttarPradesh,India:amixedmethodsstudy
Preface:
Chapter6presentedresultsonoverallqualityofcareatthetimeofbirthinpublicandprivate
sector facilities. Since there is limited research evidence on mistreatment of women in
maternityfacilitiesinUttarPradesh,Idecidedtoinvestigatemistreatmentindetail.
In this chapter, I report on amixed-methods study employing structured clinical practice
observations and analysis of open-ended observer comments to describe the nature and
contextofmistreatmentofwomenatpublic andprivate sector facilities inUttarPradesh
India.Forthequantitativedata,Iusedabivariatedescriptiveanalysistechniqueandforthe
qualitativedata,Iusedathematicapproachtoanalyseopen-endedobservercommentsand
describepatternsofmistreatmentinpublicandprivatesectormaternityfacilities.
Theresultsofthestudyshowamixedpictureofcareduringlabourandchildbirthatpublic
andprivatesectormaternityfacilitieswithahighprevalenceofcertainharmfulpractices.I
demonstratethatmistreatmentofwomenfrequentlyoccursinmaternityfacilitiesinUttar
Pradeshasaresultofcomplexfactorsrelatedtopolicy,infrastructureandresources,ethics,
cultureandpoorstandardsatmaternityfacilities.
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RESEARCH PAPER COVER SHEET PLEASE NOTE THAT A COVER SHEET MUST BE COMPLETED FOR EACH RESEARCH PAPER INCLUDED
IN A THESIS.
SECTION A – Student Details
Student Gaurav Sharma
Principal Supervisor Véronique Filippi
Thesis Title An investigation into quality of care at the time of birth at public and private sector maternity facilities in Uttar Pradesh, India
If the Research Paper has previously been published please complete Section B, if not please move to
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SECTION B – Paper already published
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*If yes, please attach evidence of retention. If no, or if the work is being included in its published format, please attach evidence of permission from the copyright holder (publisher or other author) to include this work. SECTION C – Prepared for publication, but not yet published
Where is the work intended to be published? Reproductive Health
Please list the paper’s authors in the intended authorship order:
Gaurav Sharma, Loveday Penn-Kekana, Kaveri Halder, Véronique Filippi
Stage of publication Not yet submitted SECTION D – Multi-authored work
For multi-authored work, give full details of your role in the research included in the paper and in the preparation of the paper. (Attach a further sheet if necessary)
As first author on this paper, I developed the idea for the paper, undertook the analysis, wrote the first two draft of the manuscript and incorporated co-author comments
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Page108of248
7.1:IntroductionThenumberofmaternaldeathsremainshighinIndiawith45,000estimateddeathsin2013.5
Since2006,theGovernmentof Indiahaspromotedskilledattendanceatbirthandrapidly
expandedtheJananiSurakshaYojana(JSY)programmethatnowbenefitsapproximately40%
of India’sbirth cohort.367 The JSY is a cash transferprogramme thatprovides amonetary
incentivestowomendeliveringinhealthfacilities.332
However,recentevidencefromJSYhasbeencautionaryandhighlightstheneedtoimprove
QualityofCare(QoC),concomitantlywitheffortstoincreaseinstitutionalbirths.10Ensuring
highQoCatthetimeofbirthencompassestheapplicationofevidence-basedobstetricand
neonatal care and efforts to ensure positive birth experiences for pregnant woman. 89
Respect, dignity and emotional support, although, integral to ensuring positive birth
experienceshavebeenoverlookedinresearch,policy,programmesandpractice.368,15
There is now increasing research evidenceonmistreatment ofwomenduring labour and
childbirthfrombothhigh,80,128-131and lower incomesettings132-134.Mistreatmenthasbeen
previously described as disrespect and abuse,125 obstetric violence126 and dehumanised
care.127 However, conceptualising what constitutes mistreatment, and therefore how to
measuremistreatmentarebothcomplex.Acomprehensivedefinitionofmistreatmentneeds
tocapturethehealth,humanrightsandsocio-culturaldimensionsofmistreatment,while,
measurement efforts need to capturewhat,where, howandwhymistreatmentoccurs.81
Freedmanetal.havehighlightedthatmeasurementeffortsshouldalsobeabletocapture
whether mistreatment was intentional or not, and the role of local societal norms (for
example-women’sstatus,patient-providerdynamics)thatinfluenceswomen’sperceptions
ofmistreatmentindifferentcontexts.81
Giventhesechallenges,arecentWHOsystematicreviewtriedtoestablishtheevidence-base
formistreatmentglobally.80They reviewed65 studies (53qualitativeand12quantitative)
from34countriesandfoundthatmoststudieshaveuseddifferentoperationaldefinitions
and measurement approaches.80 Amongst the quantitative studies, only three studies
reportedaprevalenceofmistreatmentatmaternityfacilities,whichvariedfrom15to98%.80
Thisreviewalsoproposedatypologyofitemsconsideredmistreatment,andidentifiedthe
following: physical, verbal or sexual abuse, stigma and discrimination, lack of informed
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consent,breachesofconfidentiality,neglectandabandonment,refusaltoprovidepainrelief,
lack of supportive care, detainment in facilities, bribery and extortion.80 The review
incorporated elements from the work by Bowser and Hill (2010), who proposed seven
categoriesofdisrespectandabuse,namely:1)physicalabuse(beating,slapping,punching),
2) non-consented care (prior to vaginal examination or caesarean operation), 3) non-
confidentialcare(lackofprivacy),4)non-dignifiedcare(shouting,scolding,anddemeaning
care),5)discrimination(basedonage,wealthstatus,castegroup),6)abandonmentduring
care(beingleftaloneafterchildbirth),and7)detentioninfacilities(ifclientscannotpayuser
fees).125
However,aphenomenonoftenoverlookedinthedisrespectandabusediscourserelatesto
theoveruseofinappropriateorunnecessaryinterventionsforcareatnormalbirth.Thereare
examples of health workers in both high and low-income settings underusing simple,
inexpensiveinterventions(forexample,birthcompanionshiporcounsellingonbreastfeeding)
and overusing ineffective interventions that are more technical, lucrative or convenient
despite potential for harm (for example: labour augmentation without indications or
caesareansections).369-371
For this study, we operationalised mistreatment as those related to the following: 1)
disrespectandabuse(noprivacy,nobirthingpositionchoice,notinformingwomenpriorto
a vaginal examination, not allowing birth companions, not explaining reasons for
augmentation of labour, restricting food and water and informal payments); 2)
Overtreatment(routineuseofenema,routineuseofperinealshaving,applicationofextreme
fundalpressure,routineuterinelavage,routinemanualexplorationoftheuterusandroutine
episiotomy);andlastly,3)Under-treatment(deficienciesininfectionpreventionbyindividual
health workers, deficiencies in hospital environmental hygiene and use of unqualified
attendants). Research and programme efforts to improveQoC at the time of birth have
largelyneglectedtoexamineandaddressmistreatment insuchacomprehensivemanner.
Further,itisalsopossibleforbothundertreatmentandovertreatmenttooccurwithinthe
samepatientandwithinthesamefacility370whichmakesinterpretingdatadifficultbutthis
shouldbeconsideredbyresearchersworkingtoimproveQoC.
Uttar Pradesh (UP) is India’s most populous and deprived state.253 In related work, we
previouslydescribedoverallpoorqualityofcareatthetimeofbirth47butdidnotspecifically
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examinemistreatmentofwomenatmaternityfacilities.Therearelimitednumberofstudies
thathavedescribedpatternsandthecontextofsuchcareatmaternityfacilitiesespeciallyin
theprivatesectorwhichhasanestimated18%ofthemarketshareformaternitycareinUP.253 This information is essential for understanding the context of care provision and in
developingeffectiveinterventions,policyandadvocacyapproachesforimprovementofQoC
at the time of birth. Available research evidence indicates that women with previously
negativepregnancyoutcomestendtochooseprivatesector.40Highersocio-economicstatus
andaccessibilityareassociatedwithincreasedprivatesectoruse.40Scheduledcasteandtribe
statusarenegativelyassociatedwithuseofprivatefacilities.248Theprivatesectoristhought
tobemoreexpensivethanthepublicsectorandthereisageneralperceptionamongstIndian
womenthattheprivatesectorprovidesbetteramenitiesandahigherstandardofcare.248
Qualitative studies in India have describedmany challenges to ensuring high QoC during
childbirth such as overcrowding of labour rooms, chaotic work environments, poor
coordinationbetweenhealthworkers, limited skills and competenceof healthworkers in
performing routine care procedures.65,66,372 They have also described situations where
labouring women have been left unsupported, were shouted at or slapped, not given
informationaboutwhatprocedureswerebeingdoneandwhytheywerereceivingit.66,239
In this paper,we report on thenature and context ofmistreatment recordedduring 275
clinicalobservationsoflabourandchildbirthin26maternityfacilitiesinUttarPradesh.This
richobservationaldatahelpsusindescribingthecontextofcare-provisioninalow-resource
settingincludingwhat,howandwhymistreatmentofwomenduringlabourandchildbirth
occursatmaternityfacilities.
7.2:Methods
7.2.1:Studysetting
ThestudywasconductedinthedistrictsofKannauj,KanpurNagarandKanpurDehatofUttar
Pradesh.In2012-2013,thematernalmortalityacrossUttarPradeshwas240per100,000live
births.253Atthistime,theneonatalmortalityratewere55per1000livebirthsinKannauj,41
inKanpurNagarand24inKanpurDehat.253Despitegovernmentschemestoimproverates
ofinstitutionalbirthsinpublicsectorfacilities,approximately39%ofdeliveriesinUP(43%in
Kannauj,46%inKanpurDehatand34%inKanpurNagar)occurredatpublicsectorfacilities
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in2012-2013.253Theprivatesectordeliverysharewasestimatedtobe18% inUP(15% in
Kannauj,34%inKanpurNagar,and10%inKanpurDehat)duringthattime.253TheNational
RuralHealthMission has also appointed community healthworkers known asAccredited
Social Health Activists (ASHAs) in every Indian village.333 Motivating pregnant women,
accompanying them to institutions for childbirth and arranging suitable transportation to
hospitalsatthestartoflabouralsofallsundertheresponsibilitiesofASHAswhoarepaida
smallmonetaryincentive(INR600-equivalent£7)forthesetasks.
7.2.2:SamplingOursamplingframeincludedallhigh-volumepublicsectorfacilities(>200monthlydeliveries
based onHMIS data342) and established private sector facilities providing round-the-clock
basic emergency obstetric care identified by Sambodhi Research and Communications
(Lucknow,UttarPradesh)thathasextensiveexperienceofworkinginhealthresearchinthe
studydistricts.Aftermappingoffacilities,weselectedsixpublicsectorfacilitiesperdistrict
byconductingarandomselectionoffourcommunityhealthcentres,onemedicalcollegeand
onedistricthospitalandweinvitedallidentifiedprivatesectorfacilitiestoparticipate.Since
Kanpur Dehat did not have amedical college,we selected an additional district hospital.
Amongst the selected facilities, all public-sector facilities agreed to participate while 17
privatefacilities(outof30)agreedtoparticipate.Atnineoftheprivatefacilitiesthatagreed
to participate, there were no deliveries while observers were present. Therefore, the
observational data that we analysed came from 18 public facilities and 8 private sector
facilities. Further details on the samplingmethods are described elsewhere.47Theoverall
studyflowdiagramwaspresentedinFigure6.
7.2.3:StudyparticipantsStudy participants included pregnant women with spontaneous, uncomplicated labour
(definedaswomenwithlow-riskpregnancy,ofgestationalagebetween37and42weeksand
singleton vertex presentation, admitted to facilities who consented to participate in the
study)andtheirnewborns.
7.2.4:DatacollectionWecollecteddataon15potentiallyharmfulinterventionsasoutlinedpreviously.Eachitem
was codedas1 if observedand0otherwise.Anaggregatemeasureofmistreatmentwas
developedwhichwasthemeanofobserveditemsofmistreatmentforeverywoman(Range:
0-15). Potential covariates included women’s age, parity, referral status, caste, socio-
Page112of248
economic status, deliverybyqualifiedpersonnel, admissionduringwork-hours, admission
duringweekendsandpublicorprivate sector. For socio-economic status,wealthquintiles
weregeneratedusingprincipalcomponentanalysisusingdataonownershipofhousehold
assets.343
Weconceptualisedmistreatmentofwomenduringlabourandchildbirthasdisrespectand
abuse,overtreatmentandundertreatmentduringthetimeofbirthasdescribedpreviously.
Specifically, our questionnaire captured information on ensuring adequate privacy,
explainingtheprocessoflabour,restrictingfoodandfluids,informingwomenpriortovaginal
examinationandpriortolabouraugmentation,performinganenema,perinealshaving,not
allowing a birth companion, not offering choice of birthing position, routine episiotomy,
physical abuse (slapping or hitting), verbal abuse (insult, threaten and shout), routine
applicationoffundalpressure,routineuterinelavageandroutinemanualexplorationofthe
uterusafterchildbirth.
Questionscapturingeducational,demographicandsocio-economicstatuswereadaptedfrom
the National Family Health Survey questionnaire.338 At the end of every case, clinical
observerswithmaternal and child health backgroundswere encouraged to record open-
endedcommentsabouttheQoCtheyobserved,particularly,anythingtheyfeltwasimportant
toexplainthecontextandthingsthatwereparticularlystrikingtothem.Observershadbeen
orientedtotheprinciplesofrespectfulmaternitycareduringfield-leveltrainings.141Ateam
of14clinicalobserversworkinginpairsateachfacilityobservedcareroundtheclock.They
visited theadmissions,emergency, labour roomandpostnatalwards to identifypregnant
womenwhowerelikelytoundergouncomplicatedvaginalbirthsandobservedcareprovided
from admission to one hour postpartum. Data were collected after obtaining women’s
informedwrittenconsentbetween26thofMayto8thofJuly2015.
7.2.5:EthicsEthicalapprovalwasobtainedfromthePublicHealthcareSociety(PHS)EthicsReviewBoard
in India and the London School of Hygiene and Tropical Medicine in the UK
(LSHTMEthicsRef:8858).ThestudyalsoreceivedgovernmentclearancefromtheNational
HealthMissioninUttarPradesh.
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7.3:Analysis7.3.1:MeasurementWecollecteddataon15potentiallyharmfulinterventionsasoutlinedpreviously.Eachitem
was codedas1 if observedand0otherwise.Anaggregatemeasureofmistreatmentwas
developedwhichwasthemeanofobserveditemsofmistreatmentforeverywoman(Range:
0-15). Potential covariates included women’s age, parity, referral status, caste, socio-
economic status, deliverybyqualifiedpersonnel, admissionduringwork-hours, admission
duringweekendsandpublicorprivate sector. For socio-economic status,wealthquintiles
weregeneratedusingprincipalcomponentanalysisusingdataonownershipofhousehold
assets.343
7.3.2:QuantitativeanalysisDescriptiveanalyseswerecarriedoutatthelevelofindividualwomenusingSTATA14(Stata
Corp.LP,CollegeStation,UnitedStatesofAmerica).Sincepreliminaryanalysisshowedthat
allwomenencounteredatleastoneitemofmistreatment(Appendix6),wecategorisedthe
sampleintotwogroupsbasedonthemediannumberofitemsofmistreatmentobserved,as
shown in Table 11. We then conducted a bivariate analysis to examine the relationship
between indicators of mistreatment and socio-demographic characteristics. Means,
proportionsandatotalmistreatmentscorewerecalculatedforallcovariates.Chisquaretests
wereusedtoassesswhethertherewasasignificantdifferenceamongsttheuseofpractices
consideredmistreatmentandtherelevantco-variates.
7.3.3:QualitativeanalysisTheopen-endedcommentsweretranscribedinHindiandtranslatedtoEnglishandanalysed
usingNvivo11software(QSRInternational).Athematicanalysisapproachwasutilised.Two
researchers(GS,LPK)independentlyreviewedcommentsline-by-lineandthenagreedona
setofcodesbroadlycategorisedintocodesrelatedtothequantitativechecklistandcodesfor
otheremergingissues.Bothresearchersthenjointlycodedalltheopen-endedcomments.In
caseswheredisagreementsarosebetweenresearchers, furtherdiscussiontookplaceuntil
consensuswasachieved.Throughouttheanalysisprocess,researchersreflectedonhowtheir
background,trainingandworldviewmightinfluencetheirinterpretationofresultsandefforts
were taken to minimise them. We triangulated the quantitative data with qualitative
comments.Commentsthatsummarisecommonfindingsacrossobservationsarereported.
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7.4:ResultsWe first report onwomen’s socio-demographic characteristics categorised by two overall
mistreatment levels. Next, we present bivariate analysis of the prevalence of specific
indicators of mistreatment for which quantitative data are available and examine their
relationship with socio-demographic characteristics of the sample. Finally, we report our
qualitative findings, which provide additional information, and triangulate these to the
quantitativeresults,wherepossible,tofurtherexplainthenatureandthecontextinwhich
mistreatmentoccurs.
1. DemographiccharacteristicsThemajorityofobservationswere conducted in thepublic sector (n=211,77%)andmost
women came directly to facilities (88%) (Table 11). Amongst our sample, themajority of
participantswerebetween20-35yearsofage(90%),multi-parous(53%),belongedtotheso-
called“otherbackwardclass”category(55%)andwerefromthelowestwealthquintile(20%).
Mostdeliverieswereperformedbyunqualifiedpersonnel(59%)duringregularwork-hours
(92%)onweekdays(77%).Theonlyvariablesignificantlydifferentwastimingofadmission
andagreaterproportionofmistreatmentwasobservedincasesadmittedduringworkhours
comparedtoobservationsdonebeyondregularworkinghours(p=0.02).
Table11:Socio-demographiccharacteristicsofthesamplebytwooveralllevelsofmistreatment
Total(n=275)N,(%)
LessthanorequaltomediannumberofmistreatmentitemsN,(%)
Greaterthanmediannumberofmistreatmentitems
N,(%)
Pavalue
1. Women’sage
a. <20years 16(5.8) 14(7.5) 2(2.3)0.23b. 20-35years 247(89.8) 165(88.2) 82(93.2)
c. 35yearsormore 12(4.4) 8(4.3) 4(4.6)2. Parity
a. Primipara 119(43.3) 76(40.6) 43(48.9)0.32b. Multipara 145(52.7) 102(54.6) 43(48.9)
c. Grandmultipara 11(4.0) 9(4.8) 2(2.3)3. Referralstatus
a. Patientcomesdirectlytothisfacility 243(88.4) 164(87.7) 79(89.8) 0.62b. Patientreferredfromanotherfacility 32(11.6) 23(12.3) 9(10.2)
4. Castegroupb
a. “Scheduledcasteandtribe” 61(22.2) 38(20.3) 23(26.1)0.40b. “Otherbackwardcaste” 153(55.6) 109(58.3) 44(50.0)
c. “Generalcaste” 61(22.2) 40(21.4) 21(23.9)5. Socio-economicstatus
Page115of248
a. 1stquintile(poorest) 56(20.4) 41(21.9) 15(17.1)
0.56
b. 2ndquintile 54(19.6) 35(18.7) 19(21.6)c. 3rdquintile 55(20.0) 39(20.9) 16(18.2)d. 4thquintile 55(20.0) 39(20.9) 16(18.2)e. 5thquintile(wealthiest) 55(20.0) 33(17.7) 22(25.0)
6. Deliverybyqualifiedattendants
a. Qualifiedattendantsc 113(41.1) 78(41.7) 35(39.8)0.76
b. Unqualifiedattendantsd 162(58.9) 109(58.3) 53(60.2)7. Timingofadmission
a. Withinworkhours(9:00AM-17:00PM) 254(92.4) 168(89.8) 86(97.7)0.02
b. Outofhours(17:01PMto8:59am) 21(7.6) 19(10.2) 2(2.3)8. Admissionday
a. Admissionduringweekdays 211(76.7) 141(75.4) 70(79.6) 0.45b. Admissionduringweekends 64(23.3) 46(24.6) 18(20.5)
9. Sector
a. Public 211(76.7%) 138(73.8) 73(82.9) 0.09b. Private 64(23.2%) 49(26.2) 15(17.1)
aForthecomparisonoftheproportionsforlessthanorequaltomediannumberofitemsofmistreatmentobservedandgreaterthanmediannumberofitemsofmistreatmentthatwereobserved.bThecastesysteminIndiaisasystemofsocialstratificationthatplacespeopleinoccupationalgroups.Membersofscheduledcastesarethelowestcastesinsocietyandprotectedbythegovernmentthroughspecialconcessions.373Forcaste,wehaveusedtheexactlanguageofthevariousethniccategoriesgiveninIndiannationalfamilyhealthsurveyquestionnaires.cDoctors,nursesornurse-midwives–withatleast5,4and2yearsofpre-servicetraining,respectively–whoarelicensed,regulatedandendorsedbythegovernmenttoprovidematernitycareathealthfacilities.dAccreditedsocialhealthactivists,cleaners,hospitalporters,othercommunityhealthworkers,traditionalbirthattendantsandotherswhoarenotlegallyallowedbythegovernmenttoprovidematernitycareathealthfacilities.
2. Patternsofmistreatmentbysocio-demographiccharacteristicsFigure 9 below shows that amongst mistreatment practices, birthing position choice not
offeredtothelabouringwoman(92%),manualexplorationoftheuterusafterdelivery(80%)
andreasonforaugmentationnotexplained(46%)wereparticularlyhighatfacilitiesinboth
sectors.
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Figure9:Quantitativeresultsshowingtheprevalenceofindicatorsofmistreatmentinpublicandprivatesectormaternityfacilities
Tabletwelvebelowillustratesthatamongstallsocio-demographiccharacteristics,thehighest
mistreatmentscores(mean)forwomen,werefoundinwomenabove35yearsofage(5.1);
primiparous women (5.2); those that were referred from another facility (5.0); amongst
womenbelonging to“scheduledcasteand tribes” (5.0); those in the fifth (richest)wealth
quintile(5.1),andamongstcasesadmittedduringwork-hours(5.0)onweekdays(5.0)inthe
public sector (4.9). However, the timing of admission (during weekdays or weekends)
influencedagreaternumberof indicatorsofmistreatmentcompared toadmissionduring
regularwork-hours,despitetotalmistreatmentscoresbeingsimilaracrossbothco-variates.
More women admitted during weekdays underwent episiotomies (p=0.04) and enemas
(p=0.01) whereas, more women admitted during weekends were not informed prior to
vaginal examination (p=0.03) and did not have the process of labour explained to them
(p=0.04).Wefoundthatmorewomenadmittedduringregularwork-hoursdeliveredwithout
adequate privacy (p=0.01), underwent enemas (p=0.03) and extreme fundal pressure
(p=0.01)morefrequently.
0 10 20 30 40 50 60 70 80 90 100
UterinelavageafterdeliveryperformedRestrictfoodandwaterintakeduringlabour
PhysicalabusebyhealthworkerCompanionnotallowed
PublicshavingdoneVerbalabusebyhealthworker
EpisiotomyperformedWomannotinformedpriortovaginalexam
ApplicationforfundalpressureVisualprivacynotensured
EnemagivenpriortochildbirthProcessoflabournotexplained
HWdoesnotexplainreasonforaugmentationManualexplorationoftheuterusperformed
Positionchoicenotoffered
Indicatorsofm
istreatmen
tduringlabo
urand
childbirth
Total Public Private
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Tabletwelveshowsthatthepublicsectorperformedworsethantheprivatesectorfornot
ensuringprivacyofthelabouringwomen(p=<0.001),notinformingwomenpriortoavaginal
examination (p=0.01)andforphysicalviolence (shout,hitorpinch) towardsthe labouring
woman (p=0.04).On theotherhand, theprivate sectorperformedworse than thepublic
sectorfornotallowingbirthcompanionstoaccompanythelabouringwoman(p=0.02)and
forperinealshaving(p=<0.001).
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Table12:Bivariateanalysisofthesignificancebysocio-demographicfactorsandtheprevalenceofobservedindicatorsofmistreatment
Noprivacy
%
NoPositionchoice%
Womannotinformedpriorto
vaginalexam%
Companion
notallowed
%
Processoflabour
notexplained
%
Reasonforaugmentationnotexplained
%
Restrictfoodandwater%
Enema%
Publcshaving
%
Fundalpressure
%
Uterinelavage%
Manualuterus
exploration%
Episiotomy%
Physicalabuse%
Verbalabuse%
Totalscore(mean)
TotalNreportingmistreatment(N=275) 82 252 74 23 99 40 21 84 27 79 10 221 65 21 37 Range
1-15Women’sage<20years 18.8% 81.3% 25.0% 0.0% 18.8% 12.5% 0.0% 62.5% 6.3% 18.8% 0.0% 68.8% 43.8% 0.0% 0.0% 4.4
20-35years 30.4% 92.3% 27.1% 8.9% 36.0% 15.0% 8.5% 28.7% 10.5% 28.7% 4.0% 81.4% 23.1% 7.3%14.2%
4.9
35yearsormore 33.3% 91.7% 25.0% 8.3% 58.3% 8.3% 0.0% 25.0% 0.0% 41.7% 0.0% 75.0% 8.3% 25.0%16.7%
5.1
Chisquare 0.59 0.30 0.97 0.46 0.10 0.79 0.28 0.02 0.43 0.42 0.56 0.42 0.08 0.04 0.26 ParityPrimipara
26.1% 91.6% 24.4% 9.2% 31.9% 20.2% 6.7% 36.1% 16.% 34.5% 5.0% 80.7% 45.4% 7.6%16.0% 5.2
Multipara33.1% 91.0% 30.3% 8.3% 41.4% 10.3% 7.6% 24.1% 4.8% 25.5% 2.8% 78.6% 7.6% 8.3%
11.7% 4.7
Grandmultipara27.3%
100.0% 9.1% 0.0% 9.1% 9.1% 18.% 54.5% 0.0% 9.1% 0.0% 100.0% 0.0% 0.0% 9.1% 4.3
Chisquare 0.45 0.59 0.22 0.57 0.05 0.07 0.39 0.02 0.003 0.10 0.50 0.23 <0.001 0.61 0.55 Referralstatus
Patientcomesdirectlytothisfacility 29.6% 91.8% 27.2% 7.4% 36.6% 13.2% 7.4% 30.0% 9.9% 30.0% 2.9% 79.8% 21.8% 7.4%
12.3% 4.9
Patientreferredfromanotherfacility 31.3% 90.6% 25.0% 15.6% 31.3% 25.0% 9.4% 34.4% 9.4% 18.8% 9.4% 84.4% 37.5% 9.4%
21.9% 5.0
Chisquare 0.85 0.83 0.80 0.11 0.55 0.07 0.69 0.62 0.93 0.19 0.07 0.54 0.05 0.69 0.14 Caste“Scheduledcasteandtribe” 32.8% 93.4% 36.1% 8.2% 39.3% 13.1% 9.8% 27.9% 6.6% 34.4% 1.6% 78.7% 19.7% 11.5%
13.1% 5.0
“Otherbackwardcaste”28.1% 92.2% 24.2% 6.5% 35.3% 13.1% 8.5% 30.1% 10.5% 24.2% 3.9% 82.4% 20.3% 6.5%
15.0% 4.8
“Generalcaste” 31.1% 88.5% 24.6% 13.1% 34.4% 19.7% 3.3% 34.4% 11.5% 34.4% 4.9% 77.0% 36.1% 6.6% 9.8% 4.9Chisquare 0.77 0.58 0.19 0.11 0.82 0.44 0.33 0.72 0.61 0.18 0.60 0.63 0.04 0.44 0.60 Socio-economicstatus1stquintile(lowest) 41.1% 89.3% 42.9% 7.1% 46.4% 17.9% 5.4% 25.0% 8.9% 30.4% 0.0% 83.9% 10.7% 3.6%
12.5%
4.9
2ndquintile 27.8% 90.7% 37.0% 3.7% 33.3% 11.1% 7.4% 29.6% 3.7% 27.8% 5.6% 74.1% 16.7% 14.8%20.4%
4.8
3rdquintile 23.6% 96.4% 18.2% 5.5% 43.6% 12.7% 12.7% 38.2% 5.5% 20.0% 9.1% 74.5% 25.5% 3.6% 7.3% 4.7
4thquintile 32.7% 92.7% 21.8% 5.5% 32.7% 12.7% 7.3% 20.0% 5.5% 30.9% 3.6% 83.6% 21.8% 10.9%16.4%
4.8
5thquintile(highest) 23.6% 89.1% 14.5% 20.0% 23.6% 18.2% 5.5% 40.0% 25.5% 34.5% 0.0% 85.5% 43.6% 5.5%10.9%
5.1
Chisquare 0.22 0.62 0.002 0.01 0.09 0.76 0.59 0.11 0.001 0.53 0.05 0.37 0.001 0.10 0.31 Deliverybyqualifiedattendants*
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Unqualifiedattendants 30.2% 93.2% 32.7% 4.9% 36.4% 15.4% 9.3% 28.4% 6.2% 29.0% 1.9% 78.4% 17.3% 9.9%16.0%
4.8
Qualifiedattendants 29.2% 89.4% 18.6% 13.3% 35.4% 13.3% 5.3% 33.6% 15.0% 28.3% 6.2% 83.2% 32.7% 4.4% 9.7% 4.9Chisquare 0.85 0.26 0.01 0.01 0.86 0.62 0.23 0.35 0.02 0.90 0.06 0.33 0.003 0.09 0.13 Admissionduringworkhours#Withinworkhours 31.9% 90.9% 28.0% 9.1% 36.2% 15.0% 7.1% 32.3% 10.6% 30.7% 3.9% 80.7% 24.8% 7.9%
13.8%
5.0
Outofhours 4.8%100.0%
14.3% 0.0% 33.3% 9.5% 14.3% 9.5% 0.0% 4.8% 0.0% 76.2% 9.5% 4.8% 9.5% 3.7
Chisquare 0.01 0.15 0.18 0.15 0.79 0.50 0.23 0.03 0.12 0.01 0.35 0.62 0.11 0.61 0.58 Admissionduringweekends?Admissionduringweekdays
30.8% 90.0% 23.7% 10.0% 32.7% 14.2% 7.1% 34.6% 11.% 29.4% 4.7% 82.0% 26.5% 8.5%14.7%
5.0
Admissionduringweekends.
26.6% 96.9% 37.5% 3.1% 46.9% 15.6% 9.4% 17.2% 4.7% 26.6% 0.0% 75.0% 14.1% 4.7% 9.4% 4.6
Chisquare 0.52 0.08 0.03 0.08 0.04 0.78 0.55 0.01 0.12 0.66 0.08 0.22 0.04 0.31 0.28 SectorPublicsector 35.5% 91.0% 30.8% 6.2% 38.9% 14.7% 7.1% 28.9% 6.2% 31.3% 2.8% 78.2% 21.8% 9.5%
15.2%
4.9
Privatesector 10.9% 93.8% 14.1% 15.6% 26.6% 14.1% 9.4% 35.9% 21.% 20.3% 6.3% 87.5% 29.7% 1.6% 7.8% 4.7Chisquare <0.01 0.49 0.01 0.02 0.07 0.90 0.55 0.29 <0.01 0.09 0.20 0.10 0.19 0.04 0.13
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3. Specificpatternsofmistreatmentthatoccuratmaternityfacilities
Thesectionbelowsummarisesqualitativeinformationobtainedfromobservers’open-ended
comments on mistreatment. It provides contextual insights into the quantitative data
presented earlier, as well as additional information on categories and themes of
mistreatmentsuchasdeficienciesininfectionprevention,lackofanalgesiaforepisiotomy,
informalpaymentsandpoorhealthfacilityenvironmentalhygienewhichwerenotcaptured
bythequantitativechecklist(Table13).
Table13:Themesandtheircomposition-clinicalobservationsoflabourandchildbirthatmaternityfacilities
Categories Themes Composition1. Over-
treatmenta) Extremefundal
pressureOccursfrequentlyandhelpoftensoughtfromotherspresent
b) Routineepisiotomy
Occursfrequentlyandoftenconductedwithoutanyanalgesia.
2. Under-treatment
c) DeficienciesinInfectionpreventionbyindividualhealthworkers
Usingdirtyclothestocleantheperinealandvaginalareas,unhygieniccareprocedures,conductingunnecessarymanualexplorationofuterusoruterinelavageandusingunsterileglovesandequipment.
d) Unqualifiedbirthattendants
Chronicstaffshortagesmeanthatunqualifiedhealthworkersareofteninvolvedprovidingmaternitycareservices.
e) Healthfacilityenvironmentalhygiene
Limitedadherencetoinfectionmanagementprotocols,nofacilitiesforhandwashing,nouseofantiseptics,non-availabilityofprotectivegear,inadequatesterilisationofequipments,apronsorfacemasks,nowastedisposalsystemsandstrayanimalssuchasdogsandcowsinpremises.
3. Disrespectandabuse
f) Physicalviolenceandverbalabuse
Healthworkersareoftenanxiousandsometimesusephysicalviolenceandverbalabuse.Physicalabuserangedfromslappingthepregnantwoman,tohittingandpinchingherthighsorrestrainingforcefully.Verbalabuserangedfromtalkingdowntothepregnantwoman,usingfoullanguageandthreateningwomenwithcaesareansections,iftheydidnotstopshoutingorcrying.
g) Informalpayments
Frequentinbothpublicandprivatesectormaternityfacilities.TheserangefromRupees200–2000,equivalent£2.4to£24
1. Overtreatmentbyhealthworkersa) FundalPressure:Ourquantitative results (Figure9) show that theprevalenceof fundal pressurewas29%;
similar across both sectors (p=0.09) but donemore frequently during regularwork-hours
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(p=0.01) compared to outside regular work hours. The descriptions of fundal pressure
recordedbyobserversinopen-endedcommentsrangedfromapplicationoflightpressureto
extremepressureontheupperabdomendirecteddownwardstothebirthcanal. Ina few
instances,observersnotedthatmaternitycarepersonnelclimbedontopofthebedanduse
bothhandstopushdownforcefullyontheabdomen.Oftenphysicalviolencewasalsoused
whileperformingfundalpressure.Although,fundalpressurewasmostlydonebypersonnel
attendingtothedelivery,helpwasalsosoughtfromotherspresentinthelabourroomsuch
asmother-in lawsandayahs. Thecircumstances leadingtothedecisiontoapplyextreme
fundal pressure included to expedite the delivery process, when the woman could not
tolerate labourpainsorcouldnotbeardownorpushproperly.Thequotebelowillustrate
someexamplesofhowfundalpressurewasdescribedinthefieldnotes.
‘Thelabourroomofthedistricthospitalconductsdeliveriesinamiserablestate.Theygive
fundalpressureontheabdomenthewaypeopleusepumpsforfillingair incycletyres.
Theywerepressingtheirabdomenwiththeirelbowsduringdeliveryandalsoslappedthe
ladybadly’.(Clinicalobservationof35-year-old,primiparousatdistricthospital.)
b) Episiotomy:
Quantitative results indicate that episiotomy was done in 24% of cases and that the
prevalence was similar across both sectors (p=0.19). However, amongst cases where
episiotomywasgiven,noanalgesiawasgiven in25%ofcases, similaracrossbothsectors
(p=0.09).Commentsrecordedbyobserverscorroboratethatanalgesicswereoftennotgiven
duringepisiotomiesdespitewomencryingandshoutinginpain.Anecdotalevidencecollected
duringfieldworksuggeststhathealthworkersseemtobelievethatwomendonotrequire
analgesia during episiotomy as they are already in so much pain and will not feel any
additionalpain.Thequotesbelow illustrate twoexamplesofepisiotomy recorded in field
notes.
“Episiotomy was conducted without analgesia because of which the patient was
constantly shouting. The nurse consoled her saying it was only a few stitches, but no
analgesiawasgivenandinsteadthenursescoldedherbeforegivingherstitches”(Clinical
observationatadistricthospitalina34-yearmultigravidawoman.)
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“Familymemberswerenotallowedtoenter inthelabourroomwhenpatientcamefor
delivery.Thiswasherfirstlabourandshelookedscared.Shewasstoppingthenursefrom
doingPVexamination.“Thepregnantwomensaidthatshehasbeeninpainfora long
timebutnooneispayingattention.Insidelabourroom,whenwomenaskedforwater,
nursesaidnottogivewaterassheisjustdoingdrama.Veryhighpressurewasappliedon
abdomenandepisiotomywasdoneduringlabour.Stitchesweregiven2-3hourslater.The
womanwascryingandsaidthatshewon’tevercomeagaintopublichospitalasnurse
insultedherbadly.”(Clinicalobservationatadistricthospitalina22-year-oldprimiparous
woman.)
2. Undertreatment:
c) Deficienciesininfectionprevention:
Deficienciesininfectionpreventionbyindividualhealthworkerswasalsoanimportanttheme
in theobservers’comments. Thesedeficienciesby individualhealthworkers rangedfrom
using dirty clothes to clean the perineal and vaginal areas, pouring oil over the vagina/
perineum,conductingunnecessarymanualexplorationofuterus,andusingunsterilegloves
andequipment.Althoughquantitativedataisnotavailableforallofthesepractices,available
quantitativeresultscorroborateahighprevalence(80%)ofmanualexplorationoftheuterus
whichwassimilarinbothsectors(p=0.10).Enemaswerealsoobservedin30%ofcases,risking
possiblefaecalcontamination.Itisencouragingtonotethatmosthealthworkersusedsterile
gloves;useofunsterileglovestoconductvaginalexaminationswaslowandhappenedinjust
2.2%ofallcases,allinthepublicsector(3%).Uterinelavageafterdeliverywasalsoinfrequent
inbothpublic(3%)andprivatesectors(6.3%)cases.Observer’scommentsalsoindicatethat
insomefacilities,instrumentsweresterilisedonceadayandoftenjustdippedinwarmwater
andchlorhexidinesolutionandreusedmultipletimes.Vaginalexaminationswereobserved
tobeconductedmultipletimesbydifferenthealthworkers. Inafewinstances,observers’
commentsmentionthatusedsyringeswereleftdiscardedonthefloor,whichisapotential
hazardforneedle-stickinjuries.
The quote below illustrates some examples of deficiencies in infection prevention by
individualhealthworkers:
“Whilesuturingtheepisiotomy,ayahacceptedaphonecall,alsotouchedthebedwith
herglovedhandsand thencontinuedwith the suturing.Manualexplorationof the
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placenta was also done to check whether anything was left inside” (Clinical
observationinacommunityhealthcentreofa28-year-oldmultiparouswoman)
“Here,glovesaretakenoutfromthepowder.Idon’tknowiftheyuseautoclaves.They
did not inform me. They just wash instruments with water only. Mostly they dip
instruments inwarmwater,butthebloodstainsarestill there.Cheatle forcepsare
availablebuttheydonotkeepitproperly.”(Clinicalobservationatadistricthospital
ina30-year-oldgrandmultiparouswoman).
d) Healthfacilityenvironmentalhygiene:
Thewiderfacilityenvironmentandhospitalinfectionpreventionandcontrolmeasureswere
alsonotedasaseriousconcerninmanyoftheobservers’comments.Thisthemecaptures
issuesbeyondthecontroloftheindividualhealthworkers,suchasthoseattheinstitutional
level,andhasbeenconceptualisedasunder-treatment,whichconstitutesmistreatmentof
women since it is unethical to allow women to deliver in such unhygienic conditions.
Observer’s comments frequently describe limited adherence to infection management
protocolsatfacilities,nofacilitiesforhandwashing,nouseofantiseptics,non-availabilityof
protectivegear, inadequate sterilisationofequipments, apronsor facemasks. Systems for
segregationofwastes (used injectionvials, sharp instrumentsorwastes suchasplacenta,
otherfluids)suchascolour-codedbinswerenon-functional.Afrequentfindingwasthatstray
animals suchasdogsandcows roamed throughout the facility compoundandoften took
shelter in thewards or labour rooms. Clean towels and sterile padswere frequently not
availableathospitals;instead,women’soldclothessuchasoldsariswereusedtowipethe
womanandnewbornafterchildbirth. Suctionmachinesandradiantwarmers,evenwhen
available,wereoftenfoundtobeunusedanddirty.Bedssheetswerenotchangedregularly
andmultiplewomenwereobservedgivingbirthinthesamebed.Thequotesbelowillustrate
someexamplesofcommentsrecordedunderthistheme.
“Instrumentshereareneitherwashedproperlynorplacedintheautoclave.Theyclean
itwithwaterandusethemagain.Doctor,nurse,ayah-noneof themtakecareof
anything.There isnowateravailable inthebathroom.Noonecleansthebedafter
deliveryfornextpatient.Anotherwomanwasaskedtolayoverthesamebedwhere
therewasblood fromthepreviousdelivery.” (ClinicalobservationataCommunity
healthcentreofa25-year-oldmultiparouswoman).
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“Thehospitalisprivatebutitdoesn’tlooklikeone.Repeateddeliveriesareconducted
withoutevencleaningthebedproperly.Inthelabourroom,thestaffchewandspit
tobaccoandtherearestainseverywhere. There isa large focus light in the labour
roomwhichiscoveredwithdust.Therearemiceinthelabourroom.Theyneveruse
the autoclave machine although it is available.” (Clinical observation at a private
hospitalof27-year-oldmultiparouswoman.)
e) Unqualifiedbirthattendants:
Quantitativedata indicate that 59%of all birthswere attendedbyunqualifiedpersonnel,
more frequently in the public (64%) than the private (41%) sector (p=0.001). We
conceptualisedtheuseofunqualifiedpersonnelasunder-treatment.Moreover,itisunethical
forwomentoreceivedcarefromunqualifiedpersonnelatinstitutions.Ourfindingsindicate
thatgiventhechronicstaffshortages,theroleofunqualifiedpersonnelseemsimportantand
established in theprovisionof careduring labourandchildbirth. The sweeper, traditional
birthattendant (dai) and theayah (helper) tend tobe involved in supportingwork in the
labourroomsuchasbringinginstrumentsordeliverytrayswhenthedelivery is imminent.
Theyareoftenalsoinvolvedinconductingthedeliveriessincethedoctorsandnursesarenot
available or do not attend all the normal deliveries. The quotes below highlight some
examplesfromfieldnotes.
“Afterexaminingthepregnantwoman,thenurseaskedifanydaihadcheckedheras
well.Daisareroutinelyinvolvedinprovidingcareatthisfacility.Ididnotobserveany
doctorsduringmyshift”(Clinicalobservationatacommunityhealthcentreofa25-
year-oldmultiparouswoman).
“Nurses of this private hospital are not trained. They are studying now and are
workingbasedonsomeexperience.”(Clinicalobservationinaprivatehospitalofa26-
year-oldprimiparouswoman).
3. Disrespectandabuse
f) Physicalviolenceandverbalabuse
Physicalviolenceandverbalabusewereacommonthemeinobserver’scomments.Fromthe
quantitativedata,theprevalenceofphysicalabusewas7.6%;andmorefrequentinthepublic
sectorthantheprivatesector(p=0.04)andgreateramongstwomenabove35yearsofage
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(p=0.04).Although,verbalabusewasalsomoreprevalentinthepublicsector(15%)thanin
the private sector (8%), this was not statistically significant (p=0.13). The descriptions of
physicalviolenceintheopen-endedcommentsrangedfromslappingthepregnantwomanto
hittingandpinchingherthighswhileshewasbearingdown.Slappingoftenoccurredwhile
fundalpressurewasbeingapplied.Verbalabuserangedfromtalkingdowntothepregnant
woman,usingfoullanguageandthreateningwomenwithcaesareansections,iftheydidnot
stopshoutingorcrying.Inmostinstances,field-researchersnotedthatstaffappearedanxious
atthetimeofthebirthandoftenusedphysicalviolence(suchasslapping,forcingwomanto
beardownorrestrainingthewoman)duringthebirthingprocess.Therewerenoinstances
recorded in the field notes where pregnant woman or their companions stood up to
mistreatment or abuse by health workers. The quotes below illustrate physical violence,
verbalabuseandmistreatmentofpregnantwomanencounteredduringclinicalobservations.
“The nurse said, when you are with your husbands, you don’t shout but you are
shoutingnow.Youwillcomeagainwithanotherbabysoon!”(Clinicalobservationata
districthospitalofa27-year-oldmultiparouswoman.)
“Thenursewasbadlyscoldingthepregnantwoman.Thewomenappearedrestless
and was screaming and shouting. The nurse threatened her and said that if she
continues to scream, shewouldoperateonher.” (Clinicalobservationat adistrict
hospitalina25-year-oldprimiparouswoman)
g) Informalpayments:
Thepracticeofmaternitycarepersonnelaskingforinformalpaymentswasthemostcommon
theme identified from the observers’ comments and is a form of disrespect and abuse.
However, quantitative data about this phenomenon were not captured during clinical
observations. Observers’ comments indicate that, in most instances, maternity care
personnel demandedmoney from families for doing activities that are a part of their job
descriptionsuchasdryingandwrappingthenewborn,weighingthenewborn,cleaningblood
spills on the delivery bed or labour room floor and cleaning up. Often in public sector
hospitals,maternitycarepersonneldemandedmoneyfromclientsandtheirfamiliestocover
their costs, as they were contractual staff, allegedly, without a regular monthly income
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source.Insomeinstances,informalpaymentswerealsogiventohealthworkersasgratuity
paymentstoexpresshappinessatthebirthofnewborn.
Fieldnotesalsoindicatethatthereisanunderstandingbetweenthematernitycarepersonnel
andcommunityhealthworkersuchasASHA’swhooftenactastheintermediarybetweenthe
clientsandhealthworkers,facilitatingtheexchangeofsuchpayments.Inaddition,inmost
observations,familieswereaskedtopurchasedrugsandcommoditiessuchasgloves,baby
towels,medicines,deliverykits fromoutside,although, inprinciple these itemsshouldbe
providedfreeofcostathealthfacilitiesundertheJSYscheme.Therewerealsoafewcases
where observers documented that newbornswerewithheld from families until providers
receivedpaymentsfromfamilies.Iftheprovidersdidnotreceivemoney,womenweremore
likelytobemistreatedduringtheirhospitalstay.Theamountof informalpaymentsvaried
betweenIndianRupees200–2000,equivalentUKPoundsSterling£2.4-24.Thequotesbelow
illustratesomeexamplesofthepracticesofinformalpaymentsatmaternityfacilities.
Thejuniornursesaskformoneyinthishospital.Theysay,“GivemeRs.2000.Wehave
performedthedeliverysowell.Ifwehadnotdonethatthechildwouldhavediedinside
you.Iwilltakehalfofthemoneyandwillgivetheresttomadam.”(Clinicalobservation
atadistricthospitalofa22-year-oldmultiparouswoman).
“Nursewas fighting formoney. She conducteddeliveryonlyafter receivingmoney.
Familymembersareaskedtobringclothesforcleaningmotherandchild.Moneyfor
gloves is also taken from familymembers.” (Clinical observation at a community
healthcentreofa23-year-oldprimiparouswoman.)
7.5:DiscussionThisstudyexploredthenatureandcontextofmistreatmentamongstwomenattendingpublic
andprivatesectormaternityfacilitiesinUttarPradesh.Allwomeninthestudyencountered
atleastoneindicatorofmistreatment.Ourestimatesaresimilartoanothercross-sectional
studyfromateachinghospitalinsouth-easternNigeriawhere98%ofwomenreportedsome
kindofmistreatmentduringchildbirth.374Theprevalenceofmistreatmentreportedacross
studiesvariesdependingonhowmistreatmentisconceptualisedandmeasured.80Arecent
cross-sectional study fromUttarPradesh, India reported that 57%ofurban slum-resident
women reported some form of perceivedmistreatment during childbirth.375 In Tanzania,
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researchers found 19%perceivedmistreatment amongst a sample ofwomenwhile using
hospital-exitinterviewsandupto28%mistreatmentamongstthesamewomenfollowed-up
athomewhichtheyattributetocourtesybiasintheexitinterviews.376However,unlikeinour
study, both of these studies measured perceived mistreatment rather than direct
observationsoflabourandchildbirth.
Wefoundthattotalmistreatmentscoreswerehigheramongstwomenabovethan35years
ofage(5.1),primiparous(5.2),thosethatwerereferredfromanotherfacility(5.0),amongst
womenbelongingtothe“scheduledcasteandtribe”(5.0),thoseinthefifth(richest)wealth
quintile(5.1),andamongstcasesadmittedduringwork-hours(5.0)onweekdays(5.0)inthe
publicsector(4.9).Thecross-sectionalstudyfromurbanslumsinUttarPradesh,mentioned
earlier also found thatwealthierwomen,migrantwomen andwomen from lower castes
reported higher levels of disrespect and abuse.375 The importance of caste is well
documented in Indiawithmany studies reporting inferior care anddiscrimination against
womenbelongingtotheseso-calledscheduledcastes.377,378Researchershavesuggestedthat
sincethesewomenarelessempowered,healthworkersaremorelikelytothinkthattheycan
getawaywithmistreatmentofthesewomen.375
Wefoundthatnotofferingwomanachoiceofbirthingposition(92%),manualexplorationof
theuterusafterdelivery(80%)andnotexplainingthereasonforaugmentation(46%)were
particularly high at facilities in both sectors. There is evidence from a systematic review
supportingthebenefitsofdeliveringinalternativepositionscomparedtosupinepositionsfor
normalbirthssuchasshorterlabourduration,fewerepisiotomiesandfewersecond-degree
tears.379Manualexplorationoftheuterusisanimportantriskfactorforpuerperalsepsisand
shock114andshouldbeavoidedunlessindicatedandconstitutesovertreatmentwhichisform
ofmistreatment.Further,itisessentialtoprovideallwomenwithadequateinformationand
obtain an informed consent prior to any invasive clinical procedures such a vaginal
examination.114
Wefoundthatthepublicsectorperformedworsethantheprivatesectorfornotensuring
privacy of the labouring women (p=<0.001), not informing women prior to a vaginal
examination (p=0.01)andforphysicalviolence (shout,hitorpinch) towardsthe labouring
woman(p=0.04). Therecouldbemanyreasonsforpoorperformanceofthepublicsector
such as inadequate infrastructure, high-workloads, poor communication skills and
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normalisationof disrespect andabuse in actual practice.During fieldwork,wenoted that
publicsectorfacilitieswerecrowdedandthatmaternitycarepersonnelworkedinchallenging
environmentsoftenwithoutbasicamenities,limitedincentivesandtheseenvironmentswere
notconducivetopracticeevidencebasedmaternitycare.
Ontheotherhand,theprivatesectorwasfoundtoperformworsethanthepublicsectorfor
notallowingbirthcompanionstoaccompanythelabouringwoman(p=0.02)andforperineal
shaving (p=<0.001). This could perhaps be due to existing institutional polices in private
hospitallabourroomswhichdonotallowbirthcompanions.ArecentCochranereviewfound
thatthatcontinuoussupportfromachosenfamilymemberorafriendincreasedwomen’s
satisfactionwiththeirchildbearingexperience.380 Although,perinealshavingisperformed
with the belief that it reduces the risk of infection, a systematic review has found no
associatedclinicalbenefitsofshaving.381PerinealshavingisalsodiscouragedintheIndian
skilledbirth attendance trainingmaterials382,which suggests that, perhaps, private sector
healthworkersmaynothavereceivedthesetrainingsorthatqualityofsuchtrainingsispoor.
We also found some interesting associations between women’s socio-demographic
characteristics and the prevalence of specific indicators ofmistreatment. Castewas only
associatedwithepisiotomyandwomenintheso-called“generalcaste”werefoundtohave
greaterproportionsofroutineepisiotomies(p=0.04)perhapsbecausetheyusedpublicsector
facilitiesmoreoften.Womeninthefirstquintile(poorest)wereleastlikelytobeinformed
prior to a vaginal exam (p=0.002) which suggests discriminatory care based on wealth
status.378 However,women in thehighestwealthquintile (richest)weremore frequently
unaccompanied by a birth companions (p=0.01), had higher rates of perineal shaving
(p=0.001)andepisiotomy(p=0.001)whichcouldperhapsreflectgreateruseoftheprivate
sectorandconsequentovertreatmentofwomenthatattendprivatesectorfacilities.
Womenwhodeliveredwithanunqualifiedattendantweremore frequentlynot informed
priortoavaginalexamination(p=0.01)andtheseexaminationswereoftenconductedwith
unsterilegloves(p=0.04).However,deliverywithaqualifiedattendantwasassociatedwith
lower rates of birth companionship (p=0.01), and routine episiotomy (p=0.003) which
suggestseitherunfavourableinstitutionalpoliciesoroutdatedknowledgeofhealthworkers
resulting inovertreatment. Interestingly,we found that totalmistreatment scores (mean)
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werehigherfordeliveriesconductedbyqualifiedattendants(4.9)ascomparedtounqualified
attendants(4.8)whichsupportsthenotionofovertreatmentbyqualifiedpersonnel.
Mistreatmentwasseentocoexistwithlimitedadherencetoevidence-basedpracticesinthis
setting.47 Saini et al. (2017) suggest that the primary drivers for poor care arise out of
inequalitiesofinformation,wealth,andpower.370Inthiscontext,wesuggestthatthedrivers
for mistreatment include resource constraints, shortages of health workers, limited
incentives,weakmentorshipandsupervision,restrictiveinstitutionalpolicies,lackofup-to-
date knowledge and unequal power dynamics between health workers and pregnant
women.376,383,384Someresearchershavealsoarticulatedthatlong-standingpatternsofpoor
workconditions,resourcescarcity,lowskillsoroverburdenedhealthworkersatfacilitiesand
limitedchoiceforclientsleadstopoorQoC.125Inaddition,healthworkersmayoftennotbe
awareofrights-basedapproachesorunabletoprovidehighqualitycaredespitetheirbest
intentionsduetoinherentorganizationalandwork-environmentrelatedconstraints,which
areparticularlyrelevantinthissetting.
Anotherimportantfindingofthisstudycapturedthroughobservers’commentswasinformal
payments. Upon reflection, our QoC assessment tool should have specifically captured
detailed information on informal payments. Informal payments can range from gratuity
payments from appreciative patients, payments to jump the queue, receive better or
additional care, to obtain drugs and commodities, or simply to receive any care at all.385
Informalpaymentsareconsideredtobeinequitableandconstituteinstitutionalisedbribery,
whichmay hamper the entire health system.385,386 Further, they tend to be prevalent in
settingswherehealthsystemsareunder-funded,supervisorymechanismsareweak;where
womenarenotempoweredornotawareoftheirrights,andwhereprovidersareunlikelyto
facedisciplinaryactionfortheirbehaviours.385
Insummary,theliteraturesuggeststhatmistreatmentduringlabourandchildbirthmaybe
the result of many factors such as unfavourable institutional policies, resource and
infrastructural constraints, socio-cultural factors, limited knowledge and skills of health
workers.Weargue thatnon-adherence toclinicalprotocols, includingunder treatmentor
overtreatmentalsoconstitutemistreatmentofwomenatmaternityfacilities.Animportant
questionthatemergesfromourstudyiswhetheritisethicaltoallowandencouragewomen
todeliverinconditionswherebasicstandardsofevidence-basedcare,cleanliness,hygiene,
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dignity and equity cannot bemet.We demonstrated thatmistreatment ofwomen often
occursbecauseofover-treatmentandunder-treatmentwhichconstituteafailuretoadhere
to professional standards of care80. Over-treatment and under-treatment should be
considered intheglobaldiscourseondisrespectandabuse,astheyarealsoaviolationof
humanrightsandconstitutepoorqualityofcareatmaternity facilities. It ispossible that
somepracticessuchasthoserelatedtoindividualhealthworkers’deficienciesinknowledge
orskillsareperhapseasiertochangecomparedtolong-standingsocio-culturalfactorsthat
may give rise tomistreatment.Ultimately,mistreatment occurs, at least in part, because
governmentshavenotcommittedtoorinvestedinparticipatoryaccountabilitymechanisms
likesocialaudits,communityscorecardsandothers,whichensurethatwomen’sexperiences
and perceptions of care are addressed and that respectful maternity care standards are
followed.81Thisisoneofthekeyrecommendationsemergingfromthiswork.
7.6:LimitationsThisstudyuseddatafromanobservationalstudydesignedtocapturedescriptiveinformation
onelementsofQoCfornormallabourandchildbirth.Thestudywasnotspecificallypowered
to measure and explain mistreatment as a separate category of poor quality of care.
Fieldworkers used open-ended comments to capture information that was contextually
importantorevents thatwereparticularly striking to them.Therefore, it is likely that the
commentsperhapscapturedthemoreextremeeventsratherthanroutinecareprocesses.
Theremayalsohavebeenanobserverbias,forexample:commentsrecordedbyobservers
perhaps reflects theirownprofessional experiences, trainingandknowledgeof respectful
carepractices.Duringfieldwork,wealsonotedthatyoungerobserversweremorelikelyto
takedowndetailednotescomparedtotheolderobservers,whoweremoreexperienced,and
perhaps,moreinclinedtoacceptmistreatmentasanormaloccurrence.Oursampleofprivate
sectorfacilitieswasalso limitedbythefactthatwehadnoofficialsamplingframeforthe
privatesectorfacilitiesinthestudydistrictsandthat13privatefacilitiesrefusedtoparticipate
inthestudy.ItispossiblethattheQoCofparticipatingprivatesectorfacilitieswasdifferent
fromotherprivatefacilitiesthatwereeithernotsampledorthosethatrefusedtoparticipate.
WehavepreviouslyshownthatanyHawthorneeffectwasnegligibleinthisstudysincethe
aggregatequalityscoresforindividualobserversdidnotchangedependingontheorderof
observations.47 The mixed methods approach taken to triangulate our findings, data
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collection round-the-clock on all seven days of theweek, and the use of clinical practice
observationsarekeystrengthsofthisstudy.
7.7:ConclusionsMistreatmentiscommoninbothprivateandpublicsectors,albeitofdifferenttypes.Efforts
toexpandinstitutionalbirthsinUttarPradeshandotherhighmaternalandperinatalmortality
settingswouldbenefit fromstrengtheningthequalityofmaternitycare inbothsectorsso
thatevidence-basedmaternitycareisprovided,andpositivebirthsexperiencesareensured.
Thereareatleastfourspecificrecommendationsemergingfromthiswork.First,thereneeds
tobeasystematicandcontext-specificefforttomeasuremistreatmentinhighburdenstates
inIndiainbothpublicandprivatesectors.Second,atraininginitiativetoorientallmaternity
carepersonneltotheprinciplesofrespectfulmaternitycarewouldbeuseful.Third,systems
topromoteaccountabilityfortheapplicationofrespectful,woman-centred,maternitycare
pathways are needed. Lastly, we note that there needs to be a long-term, sustained
investment in health systems so that supportive and enabling work-environments are
availabletofront-linehealthworkers.
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CHAPTER8:Managementisnotassociatedwithqualityofcareduringlabourandchildbirth:evidencefromacross-sectionalstudyofmaternityfacilitiesinUttarPradesh,India.
Preface:Inchapter6,Idescribedtheresultsfromacomprehensiveassessmentofqualityofcareat
the time of birth in Uttar Pradesh. Chapter 7 described the nature and context of
mistreatmentofwomeninmaternityfacilities,whichoccursduetohealthworkeractions,
restrictiveinstitutionalandlabourroompolicies,andlackofup-todateknowledgeandskills
amonghealthworkers.
Inthischapter, Iassessanddescribemanagementpracticesatmaternityfacilities inUttar
Pradeshandexaminewhethermanagementpracticesareassociatedwithqualityofcare.I
collectedprimarydataonmanagementpracticesfrominterviewswithhospitalmanagersin
the study sites. I merged two datasets on QoC andmanagement, performed descriptive
analyses and then used multi-level mixed effects regression techniques to investigate
whethertherewasarelationshipbetweenmanagementpracticesandQoCduringlabourand
childbirth. Multi-level mixed effects regression techniques are a robust and practical
statisticalmethodtoanalyseclustereddatasuchasdatafromdifferenthospitalsandthese
techniquesaccountforrandomeffectsandfixedeffectsinthelinearregressionmodel.
MyresultsindicatethatQoCandmanagementpracticeswerebothpoorinmaternityfacilities
in Uttar Pradesh, India. In this setting, my results indicate management practices at the
institutionalleveldonotinfluenceQoCduringlabourandchildbirth.Theonlymanagement
domainthatstronglyinfluencedQoCwasperformancemanagement,whichwasassociated
withuptoaseven-percentagepointhigherqualityscore.Theseresultssupporttheroleof
performancemonitoring activities focussed on quality improvement such as auditswhich
have been found to encourage the use of evidence-based-practices, improve supportive
supervision of health workers, encourage regular monitoring, and reporting on key
performanceindicators.
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RESEARCH PAPER COVER SHEET PLEASE NOTE THAT A COVER SHEET MUST BE COMPLETED FOR EACH RESEARCH PAPER INCLUDED
IN A THESIS.
SECTION A – Student Details
Student Gaurav Sharma
Principal Supervisor Véronique Filippi
Thesis Title An investigation into quality of care at the time of birth at public and private sector maternity facilities in Uttar Pradesh, India
If the Research Paper has previously been published please complete Section B, if not please move to
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8.1:IntroductionManagersofmaternityfacilitiesareresponsibleforimplementingappropriatesystemsand
procedurestoensurehigh-qualitycareforlabouringwomenfromthetimeofadmissionto
theirdischargefromfacilitiesafterchildbirth.300Managerialpracticesaredefinedas“theset
of formal and informal rules and procedures for selecting, deploying, and supervising
resourcesinthemostefficientwaypossibletoachieveinstitutionalobjectives.”387
Althoughwegenerallyassumethatmanagementinfluencesqualityofcare(QoC)athospitals,
empiricalevidenceexaminingthisrelationshipislimited.300
Sincemanagementpracticesarebroadinnature,traditionallyresearchershavefoundithard
tomeasuremanagementpracticescomprehensivelythroughquantitativemethods.However
recentmethodologicaladvancesfromstudiesinhigh-incomecountriesofferaninteresting
frameworkformeasuringmanagementpracticesathospitals.42,46,300
The only systematic reviewwhich examined the role of hospitalmanagers in quality and
patientsafetyfoundlimitedandinconsistentevidencetosupporttheseclaims.300Themodest
evidence that exists does suggest that managers’ time spent, engagement and work
specifically onquality assurance influences indicators of clinical quality andpatient-safety
positively. 300 Managerial activities thought to improve quality include activities such as
establishinggoalsandstrategies to improveQoC, setting thequalityagenda,promotinga
qualityimprovementcultureandprocurementofinstitutionalresourcestoensurequalityof
care.300
Inlow-resourcesettings,although,inadequatemanagementcapacityhasbeenrecognisedas
an important bottleneck for improving maternal and newborn health, research evidence
examining this relationship is limited.388 In addition, the likely relationship between
managerial practices and QoC may also be of a lesser magnitude as more fundamental
barriers to quality such as unavailability of essential drugs, commodities, poor referral
linkages,weakinformationsystems,deficienciesinknowledge,skillsandmotivationofhealth
workersexist16thatareoftenbeyondthecontrolofhospitalmanagers.
Manyresearchersarguethattherearearangeofmanagementpracticesoriginallyappliedin
themanufacturingandserviceindustriesthatarerelevanttohealthcare.269,389-391However,
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transferringandapplyingthesemanagementpracticestohospitalsmustconsidercomplex
healthcareissuessuchasquality,safetyandmedicalerrors.266
In the recent decade, there have been important advances in measuring management
practices fromstudies in the fieldofhealtheconomics. Forexample, inacross-sectional
study at cardiac units in USA, management practices were significantly associated with
mortalityaswellasprocessofcaremeasures.312Inanotherstudyatsubstanceabuseclinics
intheUSA,researchershavefoundastrongassociationbetweenmanagementpracticesand
clientdaystotreatmentandincreasedrevenuegeneratedattheseclinics.313Similarly,inUK
hospitals, management practices had a strong association with both health outcomes
(improvedsurvivalratesafteracutemyocardialinfarction)andfinancialindicators.310
OtherstudiesthatconductedsecondaryanalysisofdataconductedasapartoftheWorld
ManagementSurveyefforts(http://worldmanagementsurvey.org/),whichcollectsdatafrom
over 2,000 hospitals in nine countries have found that hospitals with more effective
management practices provide higher-quality care.46,42,311 One of these studies which
restrictedanalysistodatafromhospitalsintheUSAandEnglandfoundthatwhenhospital-
boardspaidmoreattentiontoclinicalquality,managersweremorelikelytopayattention
to clinical quality and that hospital boards which used clinical quality measures more
effectivelyhadhigherscoresontargetmanagementandoperationsmanagement.46
However,itisimportanttonotethatmostresearchstudiesonthistopicarefromhigh-income
countries,fromtheprivatesector,andnoneofthemhasspecificallyfocusedonexamining
the relationshipbetweenmanagementpracticesandqualityofmaternitycare.Therefore,
examining whether there is a relationship between management practices and QoC in
maternityfacilitiesisakeyevidencegap.
India has one of the highest burden of maternal and neonatal deaths352 and, available
evidencefromhigh-burdenstateslikeUttarPradeshindicatessignificantdeficienciesinQoC
atmaternityfacilitiesparticularlyaroundthetimeofchildbirth.47Giventheincreasingrates
ofinstitutionalbirths,exploringwhethermanagementcandrivegainsinqualityisimportant
toinvestigate.Wecollectedprimarydataonmanagementpracticesat33maternityfacilities
afteradaptationofapreviously testedsurvey instrument toour studysetting. Ourstudy
objectives were: 1) to assess and describe existing management practices at public and
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privatesectormaternityfacilitatesinthreedistrictsofUttarPradesh,India;and2)toexamine
whethermanagementpracticesinfluencequalityofcareofferedduringlabourandchildbirth.
8.2:Methods8.2.1:ConceptualizationofmanagementThepastdecadehasseena rise in the innovativemeasurementefforts thathave tried to
quantify therelationshipbetweenmanagementandQoCoutcomes.Mostof this research
stems from the field of health economics and are primarily from studies in high income
countries.42,46,300Notableamongstthese,isthepioneeringworkbyBloometal.(2010)who
initiallystudiedmanagementpracticesacrossmanufacturingfirmsinnumerouscountries.307
ThisworkhassincebeenreplicatedinthehealthsectorandthetoolsdevelopedbyBloomet
al.(2010)havenowbeenusedformeasuringmanagementpracticesindiversehealthsystem
contexts suchas inhigh-income (Australia,Canada, France,Germany, Sweden,UK,USA),
upper-middleincome(Brazil)andlower-middleincomecountries(India).43,282,308,309
These research efforts have employed a telephone- based interview methodology and
assessedmanagementpracticesunderfourkeydimensions:measuresofhospitaloperations,
measures of hospital performance, measures of targets management at hospitals and
measuresofpeoplemanagementathospitals.44,310,311
Briefly,operationsmanagementandperformancemonitoringsectionsofthetoolassessed
howwellmodernmanagementtechniqueswereintroducedatmaternityfacilities;whether
systemsforcontinuousimprovementexisted;andwhetherfacilityperformancewasregularly
trackedwithuseful indicators. Targetmanagementsectionassessedwhetherappropriate
targetshadbeenset,whethertheypushedfacilitiestoimproveperformanceandhowwell
they had been communicated across the hospital. People management section assessed
whetheremphasishadbeenplacedongoodhumanresourcepractices,whethermechanism
toincentivisehighperformingstafforreprimandpoorperformingstaffexist.42
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8.2.2:StudydesignGiventhepaucityofempiricalevidenceontherelationshipbetweenmanagementpractices
and quality of care, we conducted a cross-sectional survey to collect primary data on
management practices and conducted clinical observations of labour and childbirth at
maternityfacilitiesinUttarPradesh,India.
8.2.3:SettingsThisstudywasconductedinthreedistrictsofUttarPradesh(UP)inIndia:Kannauj,Kanpur
NagarandKanpurDehat. 359KanpurNagar ispredominanturban,withhigher literacyand
lowermortality than the stateaverage.By contrast, Kannauj andKanpurDehat aremore
typicalofthestate.Thematernalmortalityratio(240per100000livebirths)andneonatal
mortalityrates(Kannauj-55,KanpurDehat-41andKanpurNagar-24per1000livebirths)
werebothhighinthestudydistricts.253Acrossthecontinuumofcare,largediscrepanciesin
maternalandchildhealth indicatorsexistacross the studydistricts. Forexample,43%of
deliveriesinKannauj,46%inKanpurDehatand34%inKanpurNagaroccuratpublicsector
facilities.Theprivatesectordeliveryshareisestimatedtobe15%inKannauj,34%inKanpur
Nagar,and10%inKanpurDehat.253
8.2.4:DatacollectionWe conducted clinical observations of labour and childbirth care at maternity facilities
between26Mayand8July2015.Subsequently,weconductedface-to-face,interview-based
data collection onmanagement practices from 9 August to 12 of September 2015. We
establishedtelephonecontactwith facilitymanagersearlyonandsetupappointmentsto
ensureahighresponserate.Theinterviewswerepresentedasfollow-upactivitiestotheQoC
assessments and were confidential conversations about management experiences and
challenges.Wedidnotcoversensitiveissues,forexample,financialearningsofthehospital.
The participants were not aware that they were being rated for their responses to the
managementquestionnaire.All interviewsweredouble-scored;whileone researcher (GS)
conducted all the interviews, another researcher also scored them independently. The
researchershadbeenorientedonmanagementconcepts,thesurveytool,andthescoring
techniqueoverathree-daytrainingsession.
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8.2.5:SamplingTheoverallstudyflowdiagramforthisstudyisillustratedinFigure10below.Samplingfor
the QoC assessments was described in Chapter 6 and the QoC study flow diagram was
presentedinFigure6ofchapter6.Altogether,fortheQoCassessments,wecouldobserve
careprovided to 275mother-babypairs at 18public sector facilities and8 private sector
facilities(n=26).Forthemanagementsurvey,weemployedthesamesamplingstrategyas
theQoC assessments.However,we received a better response rate for themanagement
survey (n=33) compared to the clinical observations which could only be obtained in 26
facilities.Allthesurveyedfacilitieshadcomplexorganizationalstructures-definedasfacilities
withseparateadministrative,information,therapeutic,diagnosticandsupportservicesand
greaterthanfivebedsallottedformaternitycare.
8.2.6:SurveyinstrumentWeadaptedandusedamanagementsurveytoolthathaspreviouslybeenusedformeasuring
managementpracticesindiversehospitalsettingsinhigh-income(Australia,Canada,France,
Germany, Sweden, UK, USA), upper-middle income (Brazil) and lower-middle income
countries (India)282,308,309 and tailored it to be applicable to the context ofmaternity care
provisioninruralUttarPradesh.Specifically,afterpre-testing,weremovedquestionsona
category known as target interconnection, which was not applicable in this context and
simplifiedthelanguagesothatquestionsretainedtheirmeaninginHindi.
Essentially, this interview-based tool assessesmanagement practices at hospitals through
fourkeydomains:operationsmanagement,performancemanagement,targetmanagement
and peoplemanagement as described previously. The interviewer (GS) asked a series of
structured but open-ended questions (up to four questions for every domain) so that
sufficientinsightstoscoreeachmanagementpracticewereobtained.Ascoringgrid(between
1to5)wasusedbyassessorstogivescoresforresponsestoallquestionsdependingonhow
closely answers matched descriptors for each question. The survey tool is available in
appendix2.
8.2.7:StudyparticipantsStudyparticipantsforthemanagementsurveyincludedadministratorsorclinicalleadersat
33maternityfacilities(10privateand23publicsector).ParticipantsfortheQoCassessments
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included pregnant women and their newborns that consented to the clinical practice
observations.
Figure10:Overallstudyflowdiagram-investigatingtherelationshipbetweenmanagementpracticesandqualityofcareduringlabourandchildbirth.
Page140of248
8.2.8:EthicsEthicalapprovalwasobtainedfromthePublicHealthcareSociety(PHS)EthicsReviewBoard
in India and the London School of Hygiene & Tropical Medicine in the UK
(LSHTMEthicsRef:8610).Thestudydesignhasalsoreceivedgovernmentclearancefromthe
NationalHealthMissioninUttarPradesh.
8.2.9:Measurement8.2.9.1:MeasuresofQualityofcareTheoverallessentialcareatbirthindexwhichmeasuresQoCduringlabourandchildbirthis
theoutcomevariableinouranalysis.Detailsonthedevelopmentofthisindicatorhavebeen
providedinChapter6.
8.2.9.2:MeasuresofmanagementMeasures of management included scores for overall management and individual
managementdimensions:operations,performance,targets,andpeoplemanagement.Two
independent assessors gave individual ratings for questions asked to managers at 33
maternityfacilities.Correlationofscoresgivenbythetwoindependentassessorswashigh
(seeTable14below)soameanscorewascalculatedforeachvariable.Asisstandardpractice,
thesescores(between1to5)werethenconvertedtoZscores;whichexpresshowfaravalue
isfromthepopulationmeanandexpressesthisdifferenceintermsofstandarddeviationsby
which it differs. Z scores were calculated primarily for the purposes of the regression
analysis.277
8.2.9.3:ExplanatoryvariablesOther explanatory variables included hospital characteristics such as number of beds,
ownership,when thehospitalwasestablishedand teaching status.Adummyvariable for
individualobserver’squalityratingwasalsousedtomitigateconcernsrelatingtoobserver
bias.
8.2.10:AnalysisAnalysiswas carriedoutusingSTATA14 (StataCorp. LP,CollegeStation,UnitedStatesof
America).Total scores foroverallmanagementand individualmanagementdomainswere
calculated for every facility. Descriptive analyses were performed to examine the
determinantsofmanagementpracticesatthe33sampledmaternityfacilities.Determinants
ofmanagementincludedthenumberofbeds,ownership,teachingstatus,managers’tenure
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in post,when thehospitalwas established andwhether therewas external development
partnersupporttothefacility.
TherelationshipbetweenmanagementpracticesandQoCwasinvestigatedaftermergingthe
managementdataset(facilityn=33)withtheQoCdataset(facilityn=26).Therefore,thedata
thatweanalysedwereatthelevelofindividualwomen(n=275)at26facilities.
Fourmultilevel,mixed-effectslinearregressionmodelswithoverallqualityindex(outcome
variable)andZscoresfortotalmanagementandZscoresforsub-categoriesofmanagement
(explanatoryvariables)weredeveloped.Thefirstmodelwastheunadjustedmodelandthe
secondmodeladjustedforfacilitycharacteristics.
All four models included robust standard errors, accounted for clustering at the level of
facilities, used sampling weights, included a dummy variable for observer ratings and
controlledforrandomeffectsatthelevelofindividualfacilitiesandhealthworkers.Sampling
weightswereappliedsothateachfacilityreceivedequalweight intheanalysis.Maximum
likelihood estimation was used. The coefficients of the multivariate regression were
interpretedtoshowtheassociationofonestandarddeviationofmanagementZscoreonthe
outcome(QoC).
8.3:Results8.3.1:MaternityfacilitysamplecharacteristicsTheaveragehospitalinoursamplewas10yearsoldandhad12bedsallocatedformaternity
services.Most sampled facilitieswerenon-teaching (88%) and in thepublic sector (70%).
Mostmanagersat surveyed facilitieshada clinicalbackground (91%);48%of themhada
postgraduateclinicalspecialisationand6%reportedtohaveaMBAdegree.
Theaveragemanagementscoreformaternityfacilitiesinoursamplewas1.6(SD+0.7)(See
figure11below). Figure12showsmanagementscoresdisaggregatedbypublicorprivate
sector.Publicsectorfacilitiesreceivedameanscoreof1.5(SD+0.4)comparedtotheprivate
sector facilities that received a mean score of 2.0 (SD+ 0.9). Private sector facilities
outperformed the public sector for allmanagement dimensions: operationsmanagement
(private:2andpublic:1.7),performancemanagement(private:1.9andpublic:1.5),targets
management(private:1.6andpublic:1.2)andpeoplemanagement(private:2.4andpublic:
1.2).
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Table14:Correlationresultsbetweenindependentassessorsratingsformanagementdimensions
Managementscores Correlationbetweenindividualassessors
Totalmanagementscore 0.9• Operationsmanagement 0.7• Performancemanagement 0.9• Targetsmanagement 0.7• Peoplemanagement 0.9
Figure11:Histogramshowingtotalmanagementscoresacrosssampledfacilities(n=33)
Figure12:Graphshowingscoresfortotalandindividualmanagementdomainsatpublicandprivatesectorfacilities
Table15showsthedescriptiveanalysisoftherelationshipbetweenmanagementscoresat
maternity facilities and their characteristics. We did not find significant differences in
characteristicsamongstsampledfacilities.
0.5
11.
5D
ensi
ty
1 1.5 2 2.5 3 3.5 4 4.5 5Total score for management practices.
0
1
2
3
4
5
Operationsmanagementscore(mean)
Performancemanagementscore(mean)
Targetmanagementscore(mean)
Peoplemanagementscore(mean)
Totalmanagementscore(mean)
Privatesector(n=10) Publicsector(n=23)
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Table15:Maternityfacilitysamplecharacteristicscategorisedbytheirmanagementscores
Characteristicsofmaternityfacilities
Lessthanorequaltomedianmanagementscore(facilityn=17)
Abovethemedianmanagementscore(facility
n=16)
p-value
n % n %
1. Bedcapacity
a)Lessthan15beds 10 59% 7 44%
0.38b)Morethan15beds 7 41% 9 56%
2. Ownership
a)Privatefacility 4 23.5% 6 37.5%
0.38b)Publicfacility 13 76.5% 10 62.5%
3. Teachingstatus
a)Non-teachinghospital 16 94% 13 81%
0.25b)Teachinghospital 1 6% 3 19%
4. Managerstenureinpost
a)Yearsinpost(<5years) 9 53% 9 56%
0.85b)Yearsinpost(>5years) 8 47% 7 44%
5. Hospitalestablished
a)Lessthan10years’old 11 65% 7 44%
0.23b)Morethan10years’old 6 35% 9 56%
6. DevelopmentPartnersupport
a)No 6 35% 3 19% 0.28
b)Yes 11 65% 13 81%
8.3.2:RelationshipbetweenmanagementZscoreandfacilitycharacteristicsTable 16 shows results froma linear regressionexamining the relationshipbetween total
managementZscoreandfacilitycharacteristics.Olderfacilities(established>10years)were
associatedwithhighermanagementzscores(p=0.04)andthenumberofbedswasfoundto
beborderlinesignificant(p=0.07).Othercharacteristicssuchasownership,teachingstatus,
manager’stenureinpostandsupportbydevelopmentpartnersdidnothaveastatistically
significantrelationshipwithtotalmanagementZscore.
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Table16:Relationshipbetweenfacilitysamplecharacteristicsandmanagementscores
Totalmanagementzscore Coef. pvalue [95%Conf.Interval]
1. Numberofbeds a)Lessthan15beds Base b)Morethan15beds 0.60 0.07 -0.06 1.252. Ownership a)Privatefacility Base b)Publicfacility -0.63 0.20 -1.59 0.343. Teachingstatus a)Non-teachinghospital Base b)Teachinghospital 0.87 0.21 -0.52 2.274. Managerstenure a)Yearsinpost(<5years) Base b)Yearsinpost(>5years) -0.28 0.41 -0.95 0.405. Hospitalestablished a)Lessthan10years’old Base b)Morethan10years’old 0.67 0.04 0.04 1.296. DevelopmentPartnersupport
a) No Base b) Yes 0.30 0.41 -0.43 1.02
8.3.3:RelationshipbetweenqualityofcareduringlabourandchildbirthandmanagementpracticesFigure 13 shows variations in QoC at facilities dichotomised based on theirmanagement
scores.Facilitieswithbelowmedianmanagementscoresprovided39%ofallrecommended
interventionscomparedto34%byfacilitieswithabovemedianmanagementscoresbutthis
difference was not statistically significant (p=0.28). For maternal care, better-managed
facilities provided 30% of the recommended interventions compared to 34% for poorly
managedfacilitiesbutthisdifferenceisnotstatisticallysignificant(p=0.4).Fornewborncare,
better managed facilities provided 39% of the recommended interventions compared to
poorlymanagedfacilitiesthatprovided44%oftherecommendedneonatalcareinterventions
butthisdifferencewasalsonotstatisticallysignificant(p=0.13).
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Figure13:Weightedestimatesofqualityofcareatmaternityfacilitiescategorisedbytheirmanagementscores
8.3.4:ResultsfromthemixedeffectslinearregressionmodelInmultivariateanalysis(seeTable17below),therewasnostatisticallysignificantrelationship
(p=0.85)betweentotalmanagementZscoreandqualityofcare intheunadjustedmodel
(model 1). This relationship remains statistically insignificant after adjusting for all
explanatoryvariables(Model2,p=0.55).
Table18showsresultsfromthemultivariateanalysisinvestigatingtheassociationbetween
the four domains of management and QoC, and we find that, amongst individual
management dimensions, performance monitoring (p= 0.02) is the only dimension
statisticallyassociatedwithQoC(outcome).One-unitincreaseinperformancemanagement
wasassociatedwithaseven-percentagepointincreaseinqualityofcare.Further,resultsfrom
bothmultivariatemodels(Table17&18)showthatdeliveringinprivatematernityfacilities
wasassociatedwith7-10%pointhigherstandardofcareforwomen.However,wefoundno
association between bed capacity, teaching status or duration since establishment of
maternityfacilitiesandqualityofcare.
34% 44.5% 39%
30% 39% 34%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
Maternalhealthindex
Newbornhealthindex
Overallessentialcareatbirth
index
Qualityofcaredu
ringlabo
urand
childbirth
Poorlymanagedfacilities Bettermanagedfacilities
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Table17:MixedeffectslinearregressionexaminingtherelationshipbetweenoverallQoCatbirthandZscoreindexfortotalmanagementscoreat26maternityfacilities
Outcome:Essentialcareatbirth Model1 Model2Variables Coef. pvalue [95%Conf.Interval] Coef. pvalue [95%Conf.Interval]Managementscorezindex 0.00 0.85 -0.02 0.02 -0.01 0.55 -0.03 0.02Bedcapacity
• Lessthan15beds X X X X Base • Greaterthan15beds X X X X -0.01 0.76 -0.06 0.05
Ownership • Public X X X X Base • Private X X X X 0.10 0.003 0.03 0.16
Hospitalestablished • Lessthan10years X X X X Base • Morethan10years X X X X 0.00 0.92 -0.04 0.04
Teachingstatus • Non-teachinghospital X X X X Base • Teachinghospital X X X X -0.03 0.27 -0.09 0.03
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Table18:Mixedeffectslinearregressionexaminingtherelationshipbetweenqualityofcareandzscoresindexesformanagementsub-categoriesfor26maternityfacilities
Outcome:Essentialcareatbirth Model1 Model2Variables Coef. pvalue [95%Conf.Interval] Coef. pvalue [95%Conf.Interval]Operationsscorezindex -0.04 0.03 -0.07 0 -0.03 0.12 -0.06 0.01Performancescorezindex 0.08 0.01 0.02 0.15 0.07 0.02 0.01 0.12Targetscorezindex -0.01 0.7 -0.07 0.05 -0.02 0.33 -0.06 0.02Peoplescorezindex -0.04 0.02 -0.08 -0.01 -0.03 0.09 -0.07 0.01Bedcapacity • Lessthan15beds X X X X Base • Greaterthan15beds X X X X -0.03 0.25 -0.07 0.02Ownership • Public X X X X Base • Private X X X X 0.07 0.01 0.02 0.13Hospitalestablished • Lessthan10years X X X X Base • Morethan10years X X X X 0.00 0.87 -0.04 0.04Teachingstatus • Non-teachinghospital X X X X Base • Teachinghospital X X X X -0.03 0.29 -0.08 0.03
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8.4:DiscussionThispaperprovidesempiricalevidenceonmanagementpracticesandtheirassociationwith
quality of care at maternity facilities in Uttar Pradesh, India. Overall, we found that
managementpracticeswerepooracrossthesurveyedmaternityfacilitiesinUttarPradesh.
WedidnotfindastatisticallysignificantrelationshipbetweentotalmanagementZscoresand
QoC.However,amongstmanagementdomains,performancemonitoringwasfoundtohave
asignificantrelationshipwithQoC(adjustedpvalue=0.02).One-unitincreaseinperformance
monitoringwasassociatedwitha7-percentagepointhigherqualityscore.
Onascaleof1to5,theaveragemanagementscoreforfacilitiesinoursamplewas1.6with
facilities intheprivatesector (2.0)receivingbettermanagementscoresthanpublicsector
facilities (1.5). These findings are in line with previous studies that have found higher
managementscoresintheprivatesector.42Ourresultsarealsocompatiblewiththefindings
reportedbyalargerIndiansurveyin3,892privatesectorhospitalsthatusedthesurveytool
thatweadaptedbutwasdonethroughtelephoneinterviews.44ThisstudybyLemosetal.
(2012)reportedatotalmanagementscoreof1.9,whichiscomparabletoourprivatesector
scoreof2.0.Similarly,scoresforallmanagementdimensionsobtainedbytheprivatesector
samples inourstudywere in linewiththosereportedbythepreviouslymentionedstudy,
suchas:operationsscore(2.0to2.1),performancescore(1.9to2.0),targetmanagement
score(1.6to1.6)andpeoplemanagement(2.4to1.9).44
PreviousstudiesutilizingthesametoolhavefoundthatIndianhospitalswerepoorlymanaged
comparedtohospitalsinUS(3.1),UK(2.9),Sweden(2.7),Germany(2.6),Canada(2.5),Italy
(2.5)andFrance(2.4).44InIndia,researchersfoundawidespreadoftotalmanagementscores
acrossstates, ranging from2.2 (highest) inHaryana,1.9 inDelhi (median) to1.7 inKerala
(lowest).44HospitalsinUttarPradeshwerebelowthemedianandobtainedatotalscoreof
1.844whichis0.2pointshigherthanourtotalmanagementscore.
In our sample, most managers had a clinical background (91%) rather than a business
background(6%)and3.0%hadajointdegree(MD/MBA).InthelargerIndianstudy,30%of
managershadanMBAdegreeorsomesortofequivalentbusinesstrainingand54%hada
clinical degree.44 Thesedifferences couldperhapsbedue toour study setting,whichwas
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predominantlyruralwithanascentprivatesectorintwodistrictsorcouldalsoindicatelimited
formalmanagement training amongst administrators. Cross-sectional evidence fromhigh-
income settings indicates that hospitals employing clinically trainedmanagers often have
bettermanagementpractices.308ResearchfromtheUnitedKingdomusingthesamesurvey
tool has also found that doctors often make better managers if they have the relevant
managementskillsandunderstandingofhospitaloperations.309
Previous research in India has found that Indian hospitalmanagers are often unaware of
modern management practices.44 Our data shows that that most public-sector hospital
managershave clinical backgrounds and tend to come into their positionsbasedon their
tenurethroughanincrementalcareerprogressionscheme.Whereas,privatesectorhospitals
weremore likely tobe familyor self-owned, for-profitenterprisesandmanagersat such
privatesectorinstitutionshadformalmanagementqualifications(6%),whichmayperhaps
explainbettermanagementscores in theprivatesector.Our impressionsduring fieldwork
wasthatmanagersofpublicsectorfacilitiesareoftenconstrainedbybureaucraticprocedures
thatlimitsfinancialautonomy,authorityforrecruitmentordismissalandabilitytoincentivise
highperformers.Thesecouldperhapsalsopartlyexplainpoorperformanceofpublic-sector
facilitiescomparedtotheprivatesector.
Wealsofoundthatolderfacilities(established>10yearsago)hadhighermanagementscores
compared tonewly established facilitieswhich could indicate that older facilities perhaps
have more standardized and established care pathways compared to newer maternity
facilities.
Although we found some variation in overall QoC between better managed and poorly
managedfacilities,thisdifferencewasnotstatisticallysignificant(p=0.28).Resultsfromthe
mixed effects model confirmed that there was no statistical association between total
managementZscoreandQoCinboththeunadjusted(Model1;p=0.85)andadjustedmodels
(Model2;p=0.55).Thisfindingisnotconsistentwithpreviousresearchevidencefromhigh-
incomesettings,43,45,308however,noneofthesestudiesweredoneinlow-incomesettingsor
specificallyfocussedonqualityofmaternitycare.
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Amongstallmanagementdimensions,performancemonitoringwastheonlydimensionthat
hadasignificant relationshipwithQoC(adjustedpvalue=0.02)withone-unit increase in
performancemonitoring associated with a 7-percentage point higher quality score. Our
findings are in line with previous studies that have shown performance monitoring may
encourage the use of evidence-based-practices, improve supportive supervision of health
workers, encourage regular monitoring, and reporting on performance indicators.293 The
effectivenessofauditsandfeedbackwasevaluatedinaCochranereview,whichfoundthat
audits and feedback interventionshave thepotential for amodest improvement (median
+4.3%)inhealthworkercompliancewithdesiredpractice.195 Inaddition,thereviewfound
thataudits and feedbackareparticularlyeffectivewhenbaselineperformance is low, the
sourceisasupervisororacolleague,itisdonemultipletimes,deliveredinbothverbaland
writtenformatsandincludesexplicittargetsandanactionplan.195Sincehospitalsareoften
themostexpensivecomponentofhealthsystems,performancemonitoringhaspotentialto
beusefulinallsettings.392
Wealso foundthatdelivery inaprivate-sector facilitywasassociatedwitha7-10%point
higherstandardofcarecomparedtodeliveringinapublic-sectorfacility.Thisisinlinewith
ourresultsfromtheQoCassessmentswhichfoundbetterQoCintheprivatesector.47These
resultsindicatethatmanagementpracticesdonotfullyexplainthedifferencesinqualityof
carebetweenpublicandprivatesectors.Itispossiblethattheprivatesectorattractsmore
competent,better-motivatedhealthworkerswithhigherremunerationwhointurnprovide
betterqualityofcare.Furtherresearchusingrobustmethodswouldbeusefultounderstand
whethermanagementinfluencesqualityofcareduringnormallabourandchildbirthacross
sectors.
8.5:LimitationsWenotethefollowinglimitationsofthestudy.First,oursampleofprivatesectorfacilitiesfor
theQoCassessmentswerelimitedbythefactthatwehadnoofficialsamplingframeforthe
privatesectorandundertakingacomprehensivecensusofprivatesectorfacilitieswasnot
feasible.Inaddition,13privatefacilitiesrefusedtoparticipateintheQoCstudy.Management
practicesandQoCatfacilitiesthatwerenotsampledorrefusedtoparticipatemayhavebeen
differentfromparticipatingprivatefacilities.Hence,ourfindingsontherelationshipbetween
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managementpracticesandQoCarenotgeneralizabletoallfacilitiesprovidingmaternitycare
servicesinUttarPradesh.
Second,weinterviewedmanager’sface-tofaceunlikepreviousstudiesthathaveemployed
telephoneinterviews.Therefore,itispossiblethatassessorsmaybebiasedbytheappearance
ortheoperationsofaparticularfacility.Third,althoughweadaptedatoolthathaspreviously
beenusedinmultiplecountriesincludingIndia,thecontentandconstructvalidityofthetool
was not specifically tested which may have implications for findings. Since, correlation
betweenassessorswashighandourscoreswerecomparablewiththelargerIndianstudy,
reliabilityislessofaconcern.However,anadditionalvalidationstudyinasmallselectionof
participantswouldhavebeenusefultovalidatethestudyinstruments.Fourth,oursampleof
275observationsat26hospitalsisalsosmalltogeneratepreciseestimatesontherelationship
betweenmanagementandqualityofcare.Fifth,ourstudyinstrumentdidnotcaptureany
informationoncontextualdeterminants(political,social,economic,socio-cultural)thatmay
influencemanagersandfacilityperformanceinthissetting.Furtherresearchwouldbeuseful
toexaminetheseissuesindetail.
8.6:ConclusionsThis study is of interest to the maternal and newborn health academic and research
community,policymakers,programmemanagersandhospitaladministrators in resource-
constrained settings that are interested to improve quality of care during labour and
childbirth.Ourfindingssuggestthatmanagementbestpracticesarenotwidelyutilisedand
that considerablegaps in knowledgeand implementationexist atbothpublic andprivate
sectormaternityfacilities.Wefoundthattherelationshipbetweenmanagementpractices
andQoCfornormal labourandchildbirth iscomplexandmaynotbeapparent insettings
where both QoC and management are weak. However, we found a strong association
betweenperformancemanagementactivitiesandqualityofcare.Ourfindingsstrengthenthe
evidence-baseontheroleofactivitiessuchasauditsinlow-resourcesettingsthathavean
importantroleinimprovingqualityofcare.
ItislikelythatQoCduringlabourandchildbirthisdependentonindividualhealthworker’s
actions, competence and their motivations and health workers who are motivated will
providedhighqualitycaredespiteexistingconstraintsthattheyface.Furtherresearchinto
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determinantsofmanagementpracticesathospitalsandvalidationofapproachestomeasure
managementpracticescomprehensivelyinresource-constrainedsettingswouldbeuseful.
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Chapter9:Discussionoftheresultsoftheoveralldoctoralresearch
AddressingQoCatthetimeofbirthisanimportantpriorityforseveralglobalandnational
effortsthataimtoendavoidablematernaldeaths,neonataldeathsandstillbirths.4,103The
resultsofthreestudiespresentedinmyPhDprovideausefulcontributiontotheliterature
onQoCandmanagementpracticesatmaternity facilities inUttarPradesh, India.MyPhD
resultswillalsobeusefultoinformfuturematernalnewbornhealthprogrammesandsupport
thedesignofqualityimprovementeffortsinthestudydistricts.Atthegloballevel,myPhD
findingswillbeofinteresttotheglobalresearchcommunityworkingtodefinemetricsfor
qualityinmaternalnewbornhealth26andtodefineelementsofskilledattendanceatbirth
(SAB)393.
9.1:Summaryofkeyfindings
Theoverallpictureofmaternitycareprovisionthatemergesfromthestudydistrictsisofa
dysfunctionalcarepathwaywithlimitedadherencetoevidence-basedpracticesandahigh
prevalenceofcertainpracticesconsideredtobemistreatment.TheQoCatmaternityfacilities
in the three studied districts of Uttar Pradesh in 2015 was found to be generally poor.
Amongstalltheinvestigatedcharacteristicsofthewoman,thehealthfacilityandthetypeof
birthattendant,overallqualityofcarewasfoundtobebetterinprivatesectorfacilitiesand
forwomenthatwereadmittedduringtheworkweek(Monday-Friday).
Although I found that themajority of deliveries inmaternity facilitieswere conductedby
unqualified personnel in 2015, there were no statistical differences in care provided by
unqualifiedorqualifiedbirthattendants.Mistreatmentofwomen(definedaspresenceof
indicatorsofdisrespectandabuse,over-treatmentandunder-treatment)frequentlyoccurred
atmaternity facilities. Frommy investigation into the relationship betweenmanagement
practices and QoC, I found that there was no statistical association between total
managementscoresandQoC.Theonlymanagementdimensionthathadasignificantpositive
associationwithQoCwasperformancemanagement.
ThekeyfindingsoftheresultschaptersofmyPhDareelaboratedbelow.
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9.1.1:Qualityofcarewasgenerallypooracrossthesampledpublicandprivatesector
maternityfacilitiesinUttarPradeshin2015
Theresultsofchapter6showedthatqualityofessentialcareduringlabourandchildbirthwas
poor inUttarPradesh, India.Onaverage,women received just36%of the recommended
seventeenpractices forcareat thetimeofbirthacrossthesampledmaternity facilities in
UttarPradesh.TheclinicalpracticesthatImeasuredwerethemostessentialandbasiccare
practicesrecommendedduringlabourandchildbirthsoinrelativetermsQoCwasfoundto
beverypoor.
TheoverallQoCwasfoundtobebetteramongstwomenattendingprivatesectorfacilities
where they received 45% of recommended practices compared to 33% amongst women
attendingthepublicsectorin2015.Notwithstandingthelimitationsofsamplingtheprivate
sector,Ifoundthatprivatesectorprovidedanoverallhigherstandardofcareduringlabour
andchildbirth(p=0.01)includingforbothobstetric(p=0.01)andneonatalcare(p=0.02).The
results fromthemultivariateanalysisconfirmedthatoverallQoCwas6percentagepoints
(95%CI:1-11%)higher(p=0.03)inprivatesectorfacilitiesthancorrespondingscoresinthe
publicsectoraftercontrollingforconfounders.Although,thisresultisstatisticallysignificant
thedifferenceinqualitybetweensectorsmaynotbeclinicallyrelevantastheeffectcanbe
assmallas1%.
Thereismixedresearchevidenceonwhetherprivatesectorprovidesbetterqualityhealth
services than the public sector. For example, two systematic reviews employing different
reviewmethodologieshavereporteddifferentresultsindicatingthattheunderlyingevidence
baseonthistopicisweak394.Intheirsystematicreview(2011)ofstudiesexaminingquality
of care in formal private versus public sector facilities in LMICs, Berendes et al. (2011),
concluded that “quality in both provider groups seems poor, with the private sector
performingbetterindrugavailabilityandaspectsofdeliveryofcare,includingresponsiveness
andeffort,andpossiblybeingmoreclientoriented”.365However,anothersystematicreview
publishedayearlaterbyBasuetal.(2012)concludedthat“studiesevaluatedinthisreview
donot support the claim that theprivate sector is usuallymore efficient, accountable or
medicallyeffectivethanthepublicsector”395.
Qualitativestudiesthathavesoughttoexplainthereasonsbehindpoorqualityinthepublic
sectorhavehighlightedreasonssuchasresourceconstraints, lowsalaries,highworkloads,
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poorincentivesandconditionsofservices396,stafffavouringcertainpatients397,clientslacking
sufficientknowledgeabouttheappropriateuseofdrugsandtheirrightstochallengepoor
services.398-400
SpecifictoIndia,researchershavesuggestedthatpoorqualityofcareinIndiacanbepartly
explainedby thepoorqualityofmedical trainingsand theabsenceofnational continuing
medical educationand recertificationprogrammes.178 Other researchershave found that
providereffortisakeydeterminantforqualityandhealthworkersintheprivatesectorexert
moreeffort than thepublic sector.365 This isalso relevant in thecontextof LMICswhere
privatesectorpersonneloftenwanttodemonstratethattheyareprovidingbettervaluefor
moneyandexertgreatereffort.Researchevidencealsoindicatesthatprovidereffortcanbe
improvedbyprovidinghigherpayments,betterincentiveschemes,strengtheningmonitoring
andprovidingbettersupporttohealthworkersthroughpeer-networks.365
Quality of obstetric care, asmeasured by an index based on nine of themost important
practices,wasfoundtobelow(30.5%)acrosstheentiresample.Theobstetriccareindexwas
foundtobeloweramongstpublicsectorcases(28%)comparedtotheprivatesectorcases
(40%). Amongst obstetric care practices, regularmonitoring of labour using a partograph
(1.6%)wasrareandpartographswereusedinjust0.2%ofpublicsectorcasescomparedto
7.2%ofprivatesectorcases. Myfindingsaresimilartootherstudies in Indiawhichhave
foundpoorratesofpartographusewithinadequateattentiontoeitherfoetalormaternal
well-beingduringlabourandchildbirth.70,71Infactastudyexaminingtheimplementationof
partographsintheJSYprograminMadhyaPradeshfoundlowratesofpartographuse(6%)
andpoorcomptenceofhealthworkersinusingpartographscorrectly.67Inthisstudy,health
workersreceivedameanscoreof1.08(outof10)onclinicalvignettes,indicatingsubstantial
deficiencesinknowledgeofhealthworkers.67
Although,theuseofpartographisactivelypromotedbytheIndiangovernmentandnational
guidelinesalsorecommendthattrainingsonpartographsandessentialsuppliesshouldbe
providedatallbirthingfacilities,332,382myfindingsdemonstratethatpartographsarenotused
routinely. Other research evidence from LMICs has suggested that challenges for routine
partograph use include limited knowledge of health workers, limited availability of pre-
printed partographs, length of time needed to fully complete a partograph and high
workloadsofhealthworkers.16,67Asdiscussedabove,researchevidencealsoindicatesthat
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deficiencies in intra-partum care such as inadequate monitoring of labour through
partographsoftenleadtopreventableintra-partumstillbirthsinIndia.401
Screeningmeasures for preeclampsia/ eclampsiawere found to be low (2.3%) across the
entiresamplewith2.2%ofpublicsectorcasesreceivingthesescreeningmeasurescompared
to2.5%ofprivatesectorcases.Theseresultssuggestthatsimplescreeningmeasuressuch
as detection of elevated blood pressure and presence of proteinurea are not routinely
assessedatbothpublicandprivatematernityfacilities.
Activemanagementofthirdstageoflabour(AMTSL)wasdoneinlessthanaquarterofall
cases, amongst a greater proportion (25.4%) of public sector cases compared to 21% of
private sector cases. These rates of AMTSL were higher than reported by another
observationalstudyinaneighbouringdistrictofUPwhichusedthesameWHOdefinitionI
used.77TheWHO(2014)definesAMTSLasthreecomponents:1.provisionofauterotonic
drug–Oxytocin(10IU,IV/IM)isrecommended;2.delayedcordclampingand3.controlled
cordtractioninsettingswhereSBAareavailable.402Uterinemassageisnotrecommendedin
WHOguidelines.402InfactarecentlargeclinicaltrialledbyWHO(2012)showedthatthe
most important component of AMTSL was the administration of the uterotonic drug.403
Encouragingly,Ifoundthatadministrationofuterotonicwashigh(above90%)andsimilarin
bothsectors.
Theneonatalcareindex,whichisasummaryindexforeightofthemostimportantneonatal
carepractices,wasfoundtobe41%acrosstheentiresample.Theneonatalcareindexwas
loweramongstcasesinthepublicsector(38.9%)thancomparableratesintheprivatesector
(51%). Assessmentof foetalviabilityafteradmissionbyassessing foetalpresentationand
fundalheightwasfoundtobedonein1.1%ofallobservedcases.Moreprivatesectorcases
(3.4%)receivedthisassessmentcomparedtopublicsectorcases(0.5%).Monitoringofthe
fetalheart rateat regular intervalswas foundtobedone in20%ofallcases, inagreater
proportion(73.3%)ofprivatesectorcasescomparedto6.6%ofpublicsectorcases.
ThemonitoringofApgarscoreat1and5minuteswasdoneinjust0.9%ofallobservedcases,
4.7% amongst private sector compared to none in the public sector. The Apgar score
assessment comprises of five components: colour, heart rate, reflexes, muscle tone and
respiration,eachofwhichisgivenascoreof0,1or2.Thescoreisreportedat1minuteand
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5minutesafterbirthforallneonatesandat5-minuteintervalsthereafteruntil20minutesfor
infants with a score less than 7.404 Essentially, Apgar score is a convenient method for
reporting the status of the newborn infant immediately after birth and the response to
resuscitation if needed. Although, Apgar score measurement is recommended in WHO
guidelinesforcareatbirth114andtheIndianguidelines382asmyresultsdemonstratethese
arenotroutinelyassessed.However,someresearchershavealsoquestionedthevalidityof
theApgar score indicator sinceassessment comprisesofmany subjectiveelements. 405 In
addition, a range of factors including maternal sedation or anaesthesia, congenital
malformations,gestationalage,trauma,andinter-observervariabilitycanaffectthescore405
sotheseApgarscoresneedtobeinterpretedcautiously.
Myresultsonpoorqualityofcareforroutinenormallabourandchildbirthareinlinewith
other studies from India 70,71,78,406and fromotherLMICsettings inAfrica (Côted'Ivoire407,
BurkinaFaso,Ghana,Tanzania408)and fromArabcountries.118 In India,other researchers
have suggested that inadequate knowledge and skills, staffing shortages, poor quality in-
servicetrainings,lackofenablingenvironmentsandlimitedsupportivesupervisioncouldbe
underlyingcausesofpoorqualitycareatfacilities.66,71
Research evidence from countries such as Thailand, Malaysia and Sri-Lanka that have
achievedgoodprogress in improvingmaternalmortality indicates thatprogrammeefforts
needtogobeyond increasingcoverageof interventionsandaspecific focuson improving
qualityisrequiredwhichresearchershavereferredtoaseffectivecoverage.409,410
In the studydistricts, theQoCprovided– ineither thepublicorprivate sector–wasnot
significantlyrelatedtotheinvestigatedcharacteristicsofthebirthattendant,facilityorthe
woman’s age, caste, parity, referral status or socioeconomic status. The only covariate
associatedwithQoCwasadmissionataweekend,whichwasassociatedwith3-percentage
pointpoorerstandardofcare(p=0.03).Iwilldiscusssomeofthesefindingsingreaterdetail
below.
9.1.1.1:Poorerqualityofcareduringweekends
Manyresearchstudieshavereportedona“weekendeffect”inobstetricswithpoorQoCat
thetimeofbirthleadingtoadversematernalandperinataloutcomes.362,363,411Forexample:
a largeobservationalstudy fromtheUnitedKingomfoundhigher ratesofstillbirths,early
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neonatal deaths, puerperal infections, injuries to the neonate, and increased three-day
neonatal admissions to the emergency room during weekends.362 Another study from
Scotlandreportedahigheradjustedoddsratioforweekendneonataldeathsof1.3(1.0to
1.6) compared with weekday within regular working hours.363 Specific to LMICs, a large
retrospectiverecordreviewstudy (2015) fromtheGambia foundthatnewbornsadmitted
during weekends were more likely to die than those admitted during the weekdays
(38%vs35%,P = 0.03).412Similarly,theriskofneonataldeathwasgreaterforthoseadmitted
out of hours than those admitted during during regular working hours
(38%vs33%,P = 0.004).412OtherresearchstudiesfromLMICshavealsoreportedfluctuations
inthenumbersofstaffsuchaslessnumbersofdoctorsornurseson-siteduringweekends
and at nights, that limits EmOC capability at hospitals. 413 In addition, laboratory, blood
transfusion, emergency referral and diagnostic services may also be limited during
weekends.412,414Reseachershavesuggestedthatdeficienciesinstructuralelementsofcare,
limitedresourcesandpoormanagementofmaternityservicesduringtheweekendsarethe
reasonsbehindpoorerobstetricandneonataloutcomesduringweekends.362,363
9.1.1.2:SimilarQoCcareprovidedbyunqualifiedandqualifiedmaternitycarepersonnel
My results indicate that the majority of deliveries (59%) were attended by unqualified
personnel in maternity facilities in UP. Research evidence from observational studies in
Rajasthan,whichisanotherstatewitharelativelysimilarhealthindicators,hasalsofound
thatunqualifiedpersonnelwereinvolvedinprovidingcareduringlabourandchildbirth,inup
tohalfofallobservedcases,andthatthereweresignificantdeficienciesinquality.70,71
However,inthemultivariateanalysis,IdidnotfindasignificantdifferenceinQoCprovided
by qualified and unqualified attendants. There could be many reasons that explain this
finding. First, my observations were limited to normal vaginal births which are a normal
physiological event and had I measured QoC for complications of pregnancy, perhaps,
maternity personnel’s qualificationsmayhaveemergedas a strongerpredictor for better
quality.
Second,thequalityoftrainingsreceivedbyqualifiedpersonnelmaybepoorandtheymay
notbeawareofup-to-datetechnicalguidelinesandthereforeunabletoprovidehighquality
care.ThequalityofmedicaleducationinbothpublicandprivatemedicalcollegesinIndiais
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knowntobevariableandpreviousresearcheffortshavefoundthatthetechnicalcomptence
ofhealthworkerscanvarydependingonwheretheyreceivedtheirtrainings.178,415
Third, although, qualifiedpersonnelmayhave receivedhighquality trainings andpossess
goodknowledgeandskills,theymaynotbeabletoapplytheseintoregularclinicalpractice
as a resultofmanydifferent factors suchas resource-constraints, highwork-load, limited
incentivesandothersashighlightedpreviously.
Fourth,giventhattherearenoexistingmechanimsfortrainingunqualifiedmaternitycare
personnel(TBAs,ASHAs,BHWs,BSWs,cleaners)asapartofongoinggovernmentinitiatives,
perhaps, unqualified personnel learn informally on-the-job. My observations during field
workanddialoguewithIndiancolleaguesonthisissueconfirmsthisfinding.Since,maternity
carereliesheavilyonteamwork, theseunqualifiedpersonnelpickupessential skills from
qualifiedpersonnelasapartoftheirroutinework.Itmayalsobepossiblethatthroughthese
informalon-the-jobtrainingmechanims,unqualifiedpersonnelareabletogainequivalent
practicalskills,similartowhattheywouldobtainedthroughformaltraining.
Evidencefromameta-analysisofaudit-basedstudiesaimingtoidentifyavoidablefactorsfor
maternalandperinataldeathsinlow-resourcesettingshasidentifieddeficienciesincareby
healthworkersasthemostimportantfactorforavoidablematernalandperinataldeaths.416
SeveralstudiesfromLMICssuchasAfganistan417,Nigeria418,Pakistan75havereportedgapsin
knowledge and skills of SBAs, similar to those reported by Harvey et.al (2007) from
assessmentsinBenin,Ecuador,JamicaandRwanda364.Astudyusingstandadizedpatientsin
India also found limited differences in QoC provided by unqualified and qualified health
workers, although this study was not specifically focussed on maternity services. 178
Furthermore,itcanbeassumedthatqualificationsonpaperdonotguaranteethathealth
workers have adequate skills, up-to-date knowledge and clinical competence for proving
maternity services. Similarly, just because a doctor, nurse or a midwife meets theWHO
definedcriteriaforSBAsdoesnotmeanthattheyareadequatelyskilled.364Recevingaskilled
birthattendanttrainingcourse,feelingcompetentabouttheirexpertiseandapplyingthese
knowledgeandskillstodailyclinicalpracticeareseparateissues.
AsdemonstratedbytheLMICstudiesmentionedearlier,eventrainedSBAsoftenhavegaps
in their comptence and this may result in feeling under-qualified or uncomfortable in
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managingconditionsduringlabourandchildbirth.Although,shortagesofadequatenumbers
ofSBAsandtheabsenceofformalmidwiferycadresareimportantissuesforIndia,ensuring
competenceofexistingSBAsalsoseemstobeanimportantbarrierforimprovingQoCatthe
timeofbirthinIndia.However,itisencouragingtonotethattheGovernmentofIndiaandits
partnersare implementinga rangeof schemes to improve thequalityof intrapartumand
immediatepostpartumcare.366
9.1.1.3:NoassociationbetweenQoCandcharacteristicsofthewomenandhospital
IdidnotfindasignificantrelationshipbetweenfacilitysizeandQoCatthetimeofbirthwhich
couldbeexplainedbythefactthatmyclinicalobservationswerelimitedtouncomplicated
vaginalbirthsandQoCinthissettingwasdeficientacrossallsampledfacilities.Previouscross-
sectionalstudiesfromAfrica(Tanzania)andSouthAsia(NepalandSrilanka)havefoundbetter
QoC at higher level facilities, potentially explaining why patients bypass lower level
facilities.348,419,420 In the study fromNepal (2013), themostpopular reasons identified for
bypassing smaller birthing centres to deliver at larger urban hospitals, despite incurring
additional costs, were found to be non-availability of operating theatres and inadequate
drugsandequipmentatsmallerbirthingcentres.420
Ialsodidnotfindasignificantrelationshipbetweenwomen’sage,caste,socio-economicor
referralstatusandQoCinthemultivariateanalysis.However,Ididfindagreatervariancein
QoCwithinindividualhealthworkersthanbetweenthemwhichsuggeststhathealthworkers
may not systematically follow standard protocols or provide preferential care to some
women.
9.1.2:MistreatmentofwomenfrequentlyoccurredatmaternityfacilitiesinUttarPradeshin
2015
Chapter 7 examined the nature and context ofmistreatment amongst women attending
public and private sectormaternity facilities in Uttar Pradesh. I found that all pregnant
womenencounteredatleastonepracticedefinedasmistreatment.Myestimatesaresimilar
toanothercross-sectionalstudyfromateachinghospitalinsouth-easternNigeriawhere98%
ofwomenreportedsomekindofmistreatmentduringchildbirth.374Similarly,anothercross-
sectional study in Ethiopia also found a high prevalence ofmistreatmentwhere 100% of
womenthatwenttoateachinghospitaland89.4%thatwenttoperipheralhealthcentres
encounteredsomeformofmistreatment.421
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Asmentionedpreviously, there is now substantial researchevidencewhich indicates that
mistreatmentiswidespreadinbothhighandlowincomecountries.80,128-134Further,newer
research evidence is also emerging including from Uttar Pradesh which suggests that
mistreatmentmayalsobeassociatedwithmaternalhealthcomplicationsduringdeliveryand
thepost-partumperiod.422Hence,mistreatmentisnotjustarights-basedissuebutalsoa
medicalandpoorQoCissue.Moreover,weknowthatwomenwhoaremistreatedareless
likelytocometofacilitiesforfuturedeliveries80sothisisanimportantissuethatneedstobe
addressed.
9.1.2.1:Commonpracticesofmistreatmentinpublicandprivatesectorfacilities
Ifoundahigherprevalenceofverbalabuse(shout,threaten,talk-down)thanphysicalabuse
athealthfacilities.However,physicalabusewasparticularlyhigheramongwomenabove35
yearsofageandthoseattendingthepublicsectorfacilities.Myinformalobservationsduring
datacollectionwereconsistentwithother studies inMadhyaPradhesh66andRajasthan78,
that found labour roomenvironmentswerechaoticandhealthworkerscanbedominant,
abusiveandthreateningonoccasions.66Myimpressionsduringfieldworkalsosuggestthat
verbalabuseoccursmuchmorefrequentlythanphysicalabuse.
Ifoundthatthemostprevalentpracticesofmistreatmentwerenotofferingwomenachoice
ofbirthingposition(92%)andperformingroutinemanualexplorationoftheuterus(80.4%)
whichwere similar across facilities in both sectors. My estimates on healthworkers not
offeringwomenachoiceofbirthingpositionareinlinewithothercross-sectionalstudiesin
AfricaandAsia.421423Bohrenetal.’ssystematicreviewonbarrierstoinstitutionaldeliveries
identifiedthatwomenbeingaskedtoadoptunfamiliarpositionsandnothavingcontrolover
theirpositionduringchildbirthareimportantreasonsforwomenchoosingtodeliverathome.79InqualitativestudiesfromBangladeshandUganda,researchershavereportedthatsince
healthworkersarenottrainedtodeliverwomeninpositionsotherthanlyingontheirbacks,
theyarenotcomfortablewithofferingalternativebirthingpositions.424,425
Interpersonal communicationbetweenbirthattendantsand labouringwomenwas largely
non-existentasdemonstratedbythehighprevalenceofcaseswhereexplanationswerenot
providedtowomenpriortoinvasiveprocedures.Thesefindingsaresimilartothosereported
inotherIndianstatessuchasinRajasthanandMadhyaPradesh.66,70
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9.1.2.2:Mixedpatternsofmistreatmentinpublicandprivatesectorfacilities
Privatesectorfacilitieswerefoundtoperformworsethanthepublicsectorfornotallowing
birthcompanionsandforperineal/pubicshaving.Thiscouldbebecauseofexistinglabour
roompoliciesinprivatehospitalswhichdonotallowbirthcompanionsastheymaynotbe
awareof the latest recommendationsonbirth companionshipor perhaps they think that
limiting the number of people in the labour room is better for infection prevention and
control.Itmayalsobepossiblethathealthworkersinprivatehospitalsfeelthatsincethey
alreadyprovidepersonalisedandcomprehensivematernitycare,birthcompanionsarenot
needed.IntheIndiansetting,birthcompanionsgenerallytendtobefamilymemberssuch
asmothers,mother-in-laws,sistersorthehusband.Asmentionedpreviously,evidencefrom
a systematic review indicates that continuous support fromachosen familymemberora
friendincreaseswomen’ssatisfactionwiththeirchildbearingexperience.380
Perineal/pubicshavinghasnoassociatedclinicalbenefits381andisnotrecommendedinthe
Indian skilledbirth attendance trainingmaterials382,which suggests that, perhaps, private
sectorhealthworkersmaynothavereceivedthesetrainingsorthatqualityofsuchtrainings
ispoor.
Ontheotherhand,thepublicsectorwasfoundtoperformworsethantheprivatesectorfor
notensuringadequateprivacy,notinformingwomanpriortoavaginalexamination,andfor
physical violence towards pregnant women. There could be many reasons such as
infrastructure-related deficiences (limited number of beds or screens), larger number of
clients,poorcommunication,normalisationofdisrespectandabuse79,80inthepublicsector
inUttarPradesh.
Research evidence from LMICs has identified factors such as unfavourable institutional
policies, resource and infrastructural constraints, socio-cultural factors, poor working
conditions, limited mentorship and supervision, limited knowledge and skills of health
workers of health workers as underlying causes for mistreatment of women which are
relevantinthissettingtoo.79,80,368
9.1.2.3:Somesocio-demographiccharacteristicsareriskfactorsformistreatment
Ifoundthattotalmistreatmentscoreswerehigheramongstwomenabovethan35yearsof
age (5.1),primiparous (5.2), those thatwere referred fromanother facility (5.0), amongst
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womenbelongingtothe“scheduledcasteandtribe”(5.0),thoseinthefifth(richest)wealth
quintile(5.1),andamongstcasesadmittedduringregularwork-hours(5.0)onweekdays(5.0)
inthepublicsector(4.9).Across-sectionalstudyfromurbanslumsinUttarPradeshsimilarly
foundthatwealthierwomen,migrantwomenandwomenfromlowercastesself-reported
higher levels of disrespect and abuse, although this study was not based on actual
observations.375
The importanceofcaste iswelldocumented in Indiaandresearchershavesuggestedthat
since“scheduledcasteandtribe”womenarelessempowered,healthworkersaremorelikely
to think that they can get away withmistreatment of these women.375 However, in the
bivariate analysis, caste was only associated with episiotomy and women in the higher
“generalcaste”categorieswerefoundtohavegreaterproportionsofroutineepisiotomies
perhapsbecausetheyusedprivatesectorfacilitiesmoreoften.Womeninthefirstquintile
(poorest)were least likely tobe informedprior to a vaginal examination (p=0.002)which
suggests discriminatory care based onwealth status.378 However, women in the highest
wealth quintile (richest) were more frequently unaccompanied by a birth companions
(p=0.01), had higher rates of perineal shaving (p=0.001) and episiotomy (p=0.001) which
could perhaps reflect greater use of the private sector and consequent overtreatment of
womenthatattendprivatesectorfacilities.
9.1.2.4:Under-treatmentandover-treatmentofwomenatmaternityfacilitiesisalsomistreatment
InChapter7,Idemonstratedandarguedthatunder-treatmentsuchasthroughtheuseof
unqualifiedpersonnelwhomaynotbe capableofprovidingessential carepracticesorof
deliveries taking place in unhygienic conditions are against the rights of childbearing
women141andthereforeshouldbeconsideredmistreatment.Similarly,overtreatmentsuch
asthroughnon-adherencetoevidence-basedprotocolsorroutineuseofharmfulpractices
(uterinelavage,episiotomyorenemas)alsooccursfrequentlythatareagainsttherightsof
childbearingwomen141.Essentially,mistreatmentintersectsqualityofmaternalhealthcare
andrelatestocarethatisbothTooLittleTooLateandTooMuchTooSoon83.
TherecentWHOstatementondisrespectandabuse(2014)indicatesthatmistreatmentis
nowconsideredaserious issueattheglobal level.123TheUnitedNationshasalso issueda
resolution on preventablematernalmortality as a human rights violation426 and issued a
technicalguidanceontheapplicationofahumanrights-basedapproachtoreducematernal
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deathsin2012.427Inaddition,bodiessuchasFIGO,ICM,WHOandothershavealsoinitiated
a“MotherandBabyFriendlyBirthingFacilities”initiativewhichamongstotherthingsstates
that “Every woman and every newly born baby should be protected from unnecessary
interventions,practices,andproceduresthatarenotevidence-based,andanypracticesthat
arenotrespectfuloftheirculture,bodilyintegrity,anddignity”.428
9.1.2.5:Mistreatmentandtypeofmaternitycarepersonnel
Although I found that the majority of pregnant women were cared for by unqualified
attendants(unweightedestimate:59%)andtheyweremoreprevalentinthepublicsector,
the aggregate scores formistreatment were higher for deliveries conducted by qualified
attendants(4.9)ascomparedtounqualifiedattendants(4.8)whichsupportsthenotionof
overtreatmentbyqualifiedpersonnel.
Uponcloserexamination,unqualifiedpersonnelweremorelikelynottoinformwomenprior
to a vaginal examination (p=0.01) and use unsterile gloves (p=0.04). This indicates poor
interpersonal communication and lack of knowledge amongst unqualified personnel.
However,qualifiedpersonnelweremorelikelyconductunnecessaryproceduressuchpubic/
perineal shaving (p=0.02) and episiotomy (p=0.003) which suggests either unfavourable
institutionalpoliciesoroutdatedknowledgeofhealthworkersresultinginovertreatment.
An important issue to note at this time, relates to the problems in conceptualising and
measuringmistreatment.Forexample,thesepracticesoutlinedabovesuchaspubic/perineal
shaving or routine episiotomy or fundal pressure are not evidence based and can be
harmful.83 However, health workers are often trained to do these things and they may
genuinelybelievethatthesepracticesareforthewoman’sbenefit.Therefore,itisimportant
think further about measurement of mistreatment, and whether the act or the harmful
practicewasintentionalornot.Iwillelaborateontheseissueslaterinthesectiononfuture
recommendations for research. Moreover, the research community will need to think
carefullyabouthowtoaddressmistreatmentcomprehensivelyandtakeabalancedapproach
withoutblaminghealthworkerswhoalsoworkindifficultsituations.
9.1.2.6:Informalpaymentsasalsoformofmistreatmentofwomeninmaternityfacilities.
I foundthat informalpaymentswere routinelydemandedbyhealthworkers in thepublic
sector. These informalpaymentsoftendetermined theQoC receivedbywomen inpublic
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sectormaternityfacilitiesin2015.Informalpaymentscanrangefromgratuitypaymentsfrom
appreciative patients, payments to jump the queue, receive better or additional care, to
obtaindrugsandcommodities,orsimplytoreceiveanycareatall.385Informalpaymentsare
consideredtobeinequitableandconstituteinstitutionalisedbribery,whichmayhamperthe
entire health system.385,386 Further, they tend to be prevalent in settings where health
systems are under-funded, supervisory mechanisms are weak; where women are not
empoweredornotawareoftheirrights,andwhereprovidersareunlikelytofacedisciplinary
actionfortheirbehaviours.385
9.1.3:OverallmanagementscorewasnotassociatedwithQoCatmaternityfacilitiesinUttar
Pradeshin2015
Inchapter8,ImeasuredanddescribedmanagementpracticesatmaternityfacilitiesinUttar
Pradeshandexaminedwhethermanagementpracticeswereassociatedwithqualityoflabour
andchildbirthcare.TheresultsfromthisinvestigationfoundthattheQoCandmanagement
practiceswerebothpoor inmaternity facilities inUttarPradesh, India. In this setting,my
resultsindicatemanagementpracticesattheinstitutionalleveldonotinfluenceQoCduring
labourandchildbirth.Theonlymanagementdimensionthathadasignificantassociationwith
QoCwasperformancemanagementwhichwasfoundtobeassociatedwithuptoaseven
percentage point higher quality score. The key results from my investigation into
management practices and quality of care at the studied facilities in 2015 is summarised
below.
9.1.3.1:ManagementpracticeswerepooratthestudiedmaternityfacilitiesinUttarPradesh
IfoundthattheoverallmanagementscoresreceivedbymaternityfacilitiesinUttarPradesh
was low (1.6 on a scale of 1 to 5). Public sector facilities received a lower score of 1.5
comparedtotheprivatesectorfacilitieswhichreceivedascoreof2.0.Theprivatesectoralso
outperformed the public sector for allmanagement dimensions; operationsmanagement
(private:2andpublic:1.7),performancemanagement(private:1.9andpublic:1.5),targets
management(private:1.6andpublic:1.2)andpeoplemanagement(private:2.4andpublic:
1.2).
The lowperformanceof thepublic sector suggests that variousbottlenecksexists for the
implementationofthesemanagementbest-practicesinthepublicsector.Thesebottlenecks
couldincludeissuessuchaslimitedautonomyofmanagersinthepublicsectorwithbudgets,
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human-resourcemanagementdecisions,andlimitedabilitytoincentivisebetterperformance
inthepublicsector.Thesefindingsareinlinewithpreviousstudiesthathavefoundhigher
managementscoresintheprivatesector.42Although,mydescriptiveresultsshowedhigher
scoresforallmanagementdimensionsandqualityofcareintheprivatesector,Ididnotfind
anoverallstatisticalassociationbetweenmanagementandqualityofcareinthemultivariate
analysis.
MyresultsarealsocompatiblewiththefindingsreportedbyalargerIndiansurveyin3,892
private sectorhospitals thatused the survey tool thatweadaptedbutwasdone through
telephoneinterviews.44ThisstudybyLemosetal.(2012)reportedatotalmanagementscore
of 1.9, which is comparable to our private sector score of 2.0. Similarly, scores for all
managementdimensionsobtainedbytheprivatesectorsamples inourstudywere in line
withthosereportedbytheLemosetalstudy(2012).Forexample,operationsscore(2.0to
2.1), performance score (1.9 to 2.0), target management score (1.6 to 1.6) and people
management(2.4to1.9).44
The scores obtained by the facilities in UP in 2015 were found to be poorer than
correspondingscoresobtainedbyhospitalsinUS(3.1),UK(2.9),Sweden(2.7),Germany(2.6),
Canada(2.5), Italy (2.5)andFrance(2.4)thatweredoneusingasimilartool. 44Specificto
UttarPradesh,myscoreswere0.2pointslowerthanwhatothershavefoundinUttarPradesh
usingthesametool44,however,Isurveyedmorepublicsectorfacilitieswhichmayexplain
thedifference.
9.1.3.2:Performancemanagementwastheonlymanagementdimensionassociatedwithbetter
qualityofcareatthestudiedmaternityfacilitiesin2015
Ifoundthatfacilitieswithbelowmedianmanagementscoresprovidedanaverageof39%of
all recommended seventeen interventions to women compared to 34% by facilities with
above median management scores but this difference was not statistically significant
(P=0.28).Similarly,forobstetriccare,bettermanagedfacilitieswerefoundtoprovide30%of
therecommendedinterventionscomparedto34%ofrecommendedinterventionsinpoorly
managed facilitiesbut thisdifferencewasnot statistically significant (p=0.4).Fornewborn
care,bettermanagedfacilitiesprovided39%oftherecommendedinterventionscompared
to poorly managed facilities that provided 44% of the recommended neonatal care
interventionsbutthisdifferencewasalsonotstatisticallysignificant(p=0.13).
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Results fromthemixedeffectsmodels confirmed that therewasno statisticalassociation
betweentotalmanagementZscoreandQoCinboththeunadjusted(p=0.85)andadjusted
models (p = 0.55). This finding isnot consistentwithprevious research fromhigh-income
settings43,45,308; however, none of these studies were done in low-income settings or
specificallyfocussedonqualityofmaternitycare.
Amongstallmanagementdimensions,performancemonitoringwastheonlydimensionthat
hadasignificant relationshipwithQoC(adjustedpvalue=0.02)withone-unit increase in
performancemonitoring associated with a 7-percentage point higher quality score. Our
findings are in line with previous studies that have shown performance monitoring may
encourage the use of evidence-based-practices, improve supportive supervision of health
workers,encourageregularmonitoring,andreportingonperformanceindicators.293
TheeffectivenessofauditsandfeedbackwasevaluatedinaCochranereview,whichfound
thatauditsandfeedbackinterventionshavethepotentialforamodestimprovement(median
+4.3%)inhealthworkercompliancewithdesiredpractice.195 Inaddition,thereviewfound
thataudits and feedbackareparticularlyeffectivewhenbaselineperformance is low, the
sourceisasupervisororacolleague,itisdonemultipletimes,deliveredinbothverbaland
written formatsand includesexplicit targetsandanactionplan. 195Ashospitalsorhealth
facilitiesarethemostexpensiveandimportantcomponentsofanyhealthsystemwhetherin
LMICsorinHIC,performancemonitoringhaspotentialtobeusefulinallsettings.392
Lastly,afteraccountingforconfoundersinthemultivariateanalysis,Ialsofoundthatwomen
attendingprivatematernityfacilitiesreceiveda7-10%pointhigherstandardofcarewhichis
consistentwiththeresultsreportedinchapter6.
9.2:PlansfordisseminationUponcompletionofclinicalobservationsinindividualhealthfacilities,theresearchteamand
Iroutinelydebriefedwiththehealthfacilitymanagerand/orseniorclinicalstaff.Duringthese
debriefingmeetings,wediscussedouroverallimpressionsofQoCatthesefacilities.Wealso
discussedspecificcaseswheregrosslynegligentcare(forexamplemistreatmentofwomen)
orcaseswherelifethreateningmaternalandneonatalcomplications(suchasPPHorbirth
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asphyxia)wereobservedbytheresearchteam.Hospitalauthoritieswerealsoinformedthat
if theywere interested, I would be happy to send them preliminary results from clinical
observational data collected at their facility. These results could potentially be useful for
initiatingqualityimprovementworkatindividualfacilities.
Ialso receivedanopportunity topresentpaperoneofmyPhDatapolicyseminarat the
World Health Organization, Switzerland on June 14, 2017.My paperwas included in the
BulletinoftheWorldHealthOrganization’sspecialthemeissueonqualityofcareintheera
of the Sustainable Development Goals (SDGs). Further details on the policy seminar are
available here. https://www.wider.unu.edu/event/policy-seminar-launch-who-bulletin-
theme-issue-measuring-quality-care
Myoverallresearchfindingswerealsosharedwiththefunderandimplementingpartnersin
aworkshopinSeptember2017andotherperiodicmeetings.Thereisanationaldissemination
eventplannedinFebruary2018wheretheresultsofthestudiesreportedinmyPhDwillbe
widelydisseminatedamongstnationalandstatelevelstakeholdersinIndia.Ihopethatthis
event isable tohighlight theurgentneedto improveexistingmaternitycarestandards in
UttarPradeshandotherstatesinIndia.Asmentionedpreviously,disseminationofevidence-
basedguidelinesandtheconceptsofrespectfulmaternitycareamongstallfront-lineworkers
wouldbeusefulinimprovingqualityofmaternitycare.
Lastly, thereareon-goingdiscussionsaboutadisseminationevent inLondon,planned for
April2018,wherethelearningfromallMETprojectswillbesynthesizedanddisseminatedto
theacademicandresearchcommunity.
9.3:Reflections,strengthsandlimitations
9.3.1:Forobjective1:QoCduringlabourandchildbirthatmaternityfacilitiesinUP
9.3.1.1:Reflections
Inchapter6,Iassessedanddescribedprocessesofcareduringlabourandchildbirththatwere
investigatedusingclinicalobservationsconductedat26maternityfacilitiesinUttarPradesh.
AnimportantconsiderationwhilemeasuringQoCishowfartogowhendefiningandselecting
appropriate QoC indicators. Although, conceptually, QoC has been thought by some to
encompassmultiple levels from patients to health systems and health policies86, for the
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purposes of measuring actual services at health facilities, it is not ideal to measure
bottlenecksinhealthsystems16butratherpreferabletofocusonelementsofdirectservice
provisionandexperiencesofclients.
Hence,fortheQoCassessmentsinmyPhDstudy,IonlymeasuredprocessesofcarewhichI
definedastheapplicationofevidence-basedguidelinesandprovisionofrespectfulwoman-
centredmaternitycare.Althoughotheraspectsofqualitysuchasthoserelatedtostructure
(measured through an inventory assessment ofmedicines, infrastructure and supplies) or
outcomes(measuredthroughhospital-baseddataorspecialstudies)areimportant,theydo
not provide a comprehensive picture of quality of care during labour and childbirth that
womenreceive. Inaddition,thecontributionofmyPhDistoadvancethethinkingaround
measurement of processes of care for normal labour and childbirth which included the
developmentofthreeinnovativeindices.
TodeveloptheQoCindices,Ihadtothinkcarefullyabouthowtogroupvariousclinicalitems
intoclinicalpracticesandthendecideonhowtodevelopdifferentaggregateindices.While
developing these indices, I grouped individual items into clinical practices based on their
inherent clinical logic and their purpose rather than their relative importance in avoiding
adverseoutcomesastherewasnoscientificbasisfordoingso.Forexample,Ididnotapply
weightstointerventionssincemanyinterventionsusedforlabourandchildbirthdonothave
evidenceofefficacyastrialsonthesepracticeswouldbeunethicalforexample:monitoring
ofpost-partumbleedingorsterilecordcutting.Therefore,tokeeptheindicestransparent,I
gaveequalweighttoallindividualclinicalpractices.Iftherehadbeenevidenceforapplying
intervention-specificweights, the indiceswouldperhapshavebeenmore robust.Another
option would have been to generate a consensus on the importance of specific clinical
practicesbyundertakingamodifiedDelphi-methodapproach,asothershavedone,201but
suchmethodsarealsoknowntobesubjective429.Iwillelaborateontheseissuesfurtherin
recommendationsforfutureresearch.
9.3.1.2:Strengths
SomeofthestrengthsofthisQoCstudywerethatIdevelopedacomprehensiveassessment
toolwhichallowedforanintegratedassessmentofbothmaternalandnewborncarepractices
aroundthetimeofbirth,whichisoftenlackinginmanyoftheotheravailableassessment
tools. This tool is a direct output from this study and has also been used inUganda and
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Rajasthan.ItishopedthatitwillalsobeusefulforfutureresearcheffortstomeasureQoCin
otherhigh-burdensettings.Sinceitfocusesonnormalbirths,itsapplicabilityalsoextendsto
smallerbirthingcentresinLMICsettings.Ialsoselectedallwomenwhocametodeliverinthe
studyfacilitiesandtherewerenorefusalsbywomentorecruitmentwhichisastrengthofthe
study.OtherstrengthsoftheQoCstudywerethatIdidnotrelyonself-reportedbehaviours
orfacilityrecordsandconductedclinicalobservationsround-theclockonallsevendaysof
theweek.
To overcomemeasurement errors, QoC assessment tool was developed as a structured,
standardizedtoolandwaspre-testedandpilotedpriortofieldapplication.Timeandeffort
was invested into training of observers so that they were competent in using the study
instruments.Thislimitedsubjectivitybyobservers.Further,allobserversusedatindividual
maternityfacilitieswereexternaltothatfacilitytominimiseanyinherentbiases.Toprevent
misclassificationofpregnanciesasnormal,allobservershadbeentrainedtofollowastrict
casedefinitionofnormalvaginalbirthsandcasesthatdidnotfulfilthiscasedefinitionwere
excludedfromthestudy.Dataqualitywasassuredthroughdailyqualitychecks.
Theessentialcareatbirthindexisaninnovativeanalyticalframeworkthatcapturestheuse
ofevidence-basedinterventions,useofrespectful,woman-centredcarepracticesaswellas
patternsofharmfulcare.Alltheindices-theessentialcareatbirthindex,neonatalcareindex
andobstetriccareindexcanalsobeusedindividuallyformonitoringmaternalandnewborn
healthprogrammeefforts.Thestrengthsofcreatingsuchaggregateindicesincludetheability
tocommunicatealargeamountofinformationandconveyacomprehensivepictureofQoC
inasuccinctmanner.SinceIwantedtheseindicestobeusefulforprogrammeimprovement
efforts,Idecidedtodevelopthreeseparateindices.Dependingonthespecificareaofconcern
forquality improvement, interestedresearchersandprogrammemanagersmayusethese
indices individually, as appropriate. However, interested researchers who use the
methodologydescribedinmyPhDtoconductclinicalobservationshavetobecarefulwhile
interpretingresultsfromsuchaggregateindices.Theywillhavetothinkcarefullyaboutwhat
arethespecificpracticesthatmakeuptheaggregateindexhaveaweak(er)orhigh(er)score.
Forexample:womancentredrespectfulcarepracticesmaybe theweakestelements that
bringdowntheentireobstetriccareindexorestablishingskintoskincontactmaybeoneof
thepracticesthatbringsdowntheentireneonatalcareindex.
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Lastly,sincethesamplingforthepublic-sectorfacilitieswasdoneusingastratifiedrandom
samplingmethodology,andtheanalysisalsousedpopulationbasedweights,Iamconfident
thattheestimatesobtainedreflecttherealsituation inpublicsectorfacilities inthestudy
districts.
9.3.1.3:Limitations
Mymeasurementapproachisresourceandtime-consumingsoitmaynotbepossibletoscale
thisupbeyonddedicatedresearchprojects.However,efforts to improvemeasurementof
QoC at the time of birth are evolving rapidly despite the fact that WHO guidance on
measurementofQoCduringlabourandchildbirthdoesnotexisttilldate.
MystudywasonlyconductedinthreedistrictsofUttarPradeshwithintheframeworkofan
externalevaluationofthe“Matrika”projectsomyfindingsmaynotberepresentativeofthe
overallsituationinUttarPradesh.
Observerbias:Theremayhavebeenobserverbiasinthestudyduetothepopularperception
thattheprivatesectorissuperiorsinceithasbetterinfrastructure,bettertrainedpersonnel
whoarealsobetterpaid,leadingtoanover-estimationofqualityinprivatefacilities.
Selectionbias:Therewerechallengestosamplingtheprivatesector.Notonlydid13private
facilities refuse to participate, I had no official sampling frame fromwhich to select the
facilities. Therefore, it is possible that the QoC of the participating private facilities was
differentfromthosethatwereeithernotsampledorrefusedtoparticipate.Although,Ihad
the necessary permissions from the government and ensured confidentiality of any data
collected;asprivatelyownedfacilities,theywerenotobligedtoparticipateinmystudy.In
addition, obtaining detailed information from the private sector on their staff, their
qualifications,extrahoursofwork,numbersofcaesareansectionsandotherswasparticularly
problematicevenat facilitiesthatconsentedtotheclinicalobservations.Asreportedbya
qualitativestudythatinterviewedprivatesectorobstetriciansinthestatesofUttarPradesh
and Jharkhand in India, there is often a trust deficit between the private sector and the
government.430 My overall impressions during field work was that the private sector
authorities were very cautious with external entities given the volatile socio-political
environmentandmediastingoperationsthatfrequentlyoccurinUttarPradesh.
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Ialsohadlimitednumberofcasesintheprivatesectorcomparedtothepublicsectorasmost
privatesectorbirthsresolvedascaesareansectionsandthisisanimportantlimitation.My
research focussedon examinationof normal labour and childbirth and I did notmeasure
qualityofcareforcomplicationsofpregnancysuchaspost-partumhaemorrhageorsevere
eclampsiaorforCEmOCprocedureslikecaesareanoperations.Itispossiblethatadifferent
pictureofqualitymayhaveemergedbetweenpublicandprivatesectorshadImeasuredQoC
for these issues. Perhaps, the public sectormayhave performedbetter for being able to
manage pregnancy complications or have fewer non-indicated caesarean operations
comparedtotheprivatesector.
However, there aremany challenges associatedwithmeasuringQoC for complications of
pregnancies.Someoftheseincludelimitedavailabilityofappropriate,validassessmenttools,
problemsinrecruitingspecialistssuchasobstetriciansandgynaecologiststoworkasclinical
observersthroughoutthedurationofthestudy,alongertimeframeisrequiredtogetthe
optimalnumberofobservationsandthereispotentialforobserverbias,aswithanyclinical
observation. A recent study from Afghanistan that usedmixed-methods including clinical
observationsofcaesareandeliveriesreportedthatdirectobservationswereafeasibleand
effective method for assessing QoC of caesarean deliveries in low resource settings.431
However,inthisstudy,researchersrecommendthatalongwithclinicalobservations,others
methodssuchasrecordreviewsandinterviewswithhealthworkersshouldbeundertakenso
thatacomprehensivepictureofqualitycanbeobtained.431
UsingaggregateindicesisusefultoreportcomprehensivelyonQoCbutitmasksdifferences
betweenindividualindicators.Also,anotherlimitationisthedifficultlyinidentifyingwhya
particularindexhasalowscoreoraparticularpracticeisweak,beyondcommonindividual
orfacilitybaseddeterminants.Inordertochoosethenecessaryactionsrequiredtoimprove
QoC,researcherswillneedto identifytheexactreasonsbehindpoorscores.Forexample,
poorratesofuterotonicdrugusewithin1minutemaybeduetomanyproblemssuchasnon-
availability, incorrect formulation, incorrect timing, lack of knowledge, poor injection
technique,poorlymotivatedstaff,poorworkingconditions,norefrigeratortostoreoxytocin
andothers.
TheHawthorneeffectreferstoaphenomenonwheresubjectsunderobservationmayalter
theirbehaviourpreciselybecausetheyarebeingobserved.181Theconcerninthisstudywas
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thathealthworkersmayhaveperformedbetterwhenbeingobserved thanundernormal
conditions. To help address this problem, maternity care personnel were blinded to the
detailsoftheprimarymeasuresofthestudy.Informationsheetsprovidedtomaternitycare
personnelaspartoftheconsentproceduresemphasisedthatobservationswerenotmeant
toassess theirpersonalperformance, information collectedwill notbe liked to individual
providersandstudyfindingswillnotresultinpunitiveaction.Duringtheanalysis,Ididnot
examine individual performance of any specific maternity care personnel. However, all
observationsweretime-stampedsothatIcouldexplorethepresenceofHawthorneeffect
during analysis. It is encouraging to note that any Hawthorne effect is negligible in this
study.47
Lastly, Ididnot lookatmaternalandperinataloutcomes inmystudyas thatwouldhave
requiredlargersamplesizes,largertimeperiodfordatacollectionandadditionalfunding.As
highlightedpreviously, improvedprocessesof caredonotguaranteebettermaternal and
perinatal health outcomes. However, the global maternal health community is eagerly
awaitingtheresultsofacluster-randomizedcontrolledtrial inUttarPradeshknownasthe
betterbirthtrial.432 Inthistrial, researchersareevaluatingthe impactofa safechildbirth
checklist embedded within a quality improvement programme with a nurse “mentor”
providingsupportivesupervisionandreal-timefeedbackonQoCathealthfacilities.432Asper
their protocol, researchers are expected to report on a range of outcomes including
compositemeasures of maternal deaths, maternal severemorbidity, intrapartum-related
stillbirths,andnewborndeathoccurringwithin7daysafterbirth.432
In summary,myoverallexperiencewithclinicalobservationsof labourandchildbirthwas
promisingand,asmyresultshaveshown,withcarefuldesignandplanning,itispossibleto
conductarobustobservationalstudy.
9.3.2:Forobjective2:MistreatmentofwomenatmaternityfacilitiesinUP.
9.3.2.1:Reflections
Tomeasure and describemistreatment ofwomen atmaternity facilities, I used amixed-
methodsapproachusingquantitativedataobtainedfromclinicalobservationsandqualitative
data from unstructured observers comments. Other researchers have also measured
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mistreatmentbyaskingwomenquestionsabouttheirmaternityexperiencesduringhospital-
exitinterviewsorhouseholdsurveys.376
Upon reflection, itmayhavebeenuseful to conduct some in-depth interviewsamongsta
sample of recently delivered woman and health workers as a part of my PhD study.
Understandingwomen’sinsightsandperceptionsofmistreatmentwouldhavebeenusefulto
understandtheculturalandcontextual issuesaroundmistreatment inUP. Interviewswith
health workers would have provided me with additional information on whether health
workersunderstandwhatmistreatmentis,whattheyperceiveasmistreatmentandwhether
they understand that poor experiences of womenmight affect future utilisation of their
services.However,theinnovativeaspectofmyPhDstudyisthatdataarebasedonactual
clinicalobservationsofmistreatmentincludingintheprivatesector.
Upon reflection, from a measurement point of view, it can be hard to distinguish
mistreatmentfromreceivingcarewhichisnotevidence-based,sincetheboundariesbetween
theseoftenoverlap.Forexample: isdeliverybyanunqualifiedpersonor inanunhygeinic
settingswithoutbasicamenitiesconsideredmistreatmentofwomensinceit isagainstthe
rightsofchildbearingwomen141orisitjustanindicatoroflackofresourcesorboth?.
Lynn Freedman has suggested that a definition of mistreatment should try to capture
individualdisrespectandabuse–thatisspecificbehavioursofthehealthworkersthatare
intendedtobedisrespectfulorhumiliatingsuchasslappingorscoldingthewoman.Butalso
theroleofsystemicdeficienciesthatmaycreateadisrespectfulandabusiveenvironment,for
example, anovercrowdedandunderstaffedmaternitywardwherewomendeliveron the
floor,alone,inunhygienicconditions.81
While defining and measuring mistreatment, we also need to think about whether
mistreatmentwasintentionalornot.Forexample,somepractices,suchasfundalpressureor
routineepisiotomyarenotevidencebasedandcanbeharmful,83,114butoftenhealthworkers
havebeentrainedtodothesethingsandthinktheyareforthewoman’sbenefit.Arethese
indicatorsofmistreatmentorofpoorqualityofcare?Although,healthworkersmayhave
beentaughttousetheseinterventionsinthepast,theseharmfulinterventionsarenolonger
recommended.Hence,thisconceptofintentionalitycomplicatesmeasurementefforts.83,114
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Therefore, further conceptual clarity on the boundaries betweenmistreatment and poor
qualityofcaremaybeneeded.
Ialsohadlimitedqualitativedatafromtheobserver’scommentsanduponreflection,itmay
havebeenbettertohaveadedicatedobserverassignedspecificallyfortakingdetailedfield
notesasemployedbyotherqualitativestudies.433
Lastly,myQoCassessment tool shouldhave specifically captureddetailed informationon
informalpaymentsinthepublicsectorwhichseemtobewidespreaddespitethepresenceof
programmessuchasJSYwhichshouldintheoryensurethattherearenofinancialimplications
towomenthatchoosetodeliveratinstitutions.
9.3.2.2:Strengths
Iconductedacomprehensiveassessmentofmistreatmentofwomenatmaternityfacilities
using actual clinical observations. My PhD findings advances the understanding and
measurement of mistreatment at maternity facilities. I operationalised indicators of
mistreatmentasthoserelatedtointentionaldisrespectandabuse,overtreatmentandunder-
treatment by using a rights-based approach to conceptualise mistreatment. This
comprehensiveapproachtomeasurementisastrengthofthestudy
RatherthantakeastrictquantitativeapproachasIdidinChapter6,Ifeltthatinchapter7it
would be more insightful to explore the nature and context of care provision using the
availableinformationfromopen-endedcomments.Thisprovidesausefulcontributiontothe
literatureonmistreatmentparticularlybecausedataarebasedonactualobservationsand
weremoreobjectivecomparedtoself-reportedperceptionsofwomenasemployedbythe
vastmajorityofstudies.375,376
I also looked at public and private sector differences in the nature and patterns of
mistreatmentwhichisakeystrengthandinnovationofthisPhD.
Themixedmethodsapproachtakentotriangulatequalitativeandquantitativefindings,data
collection round-the-clock on all seven days of theweek, and the use of clinical practice
observationsweresomeofthekeystrengthsofthestudy.
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9.3.2.3:Limitations
Thisstudyuseddatafromanobservationalstudydesignedtocapturedescriptiveinformation
onelementsofQoCfornormallabourandchildbirth.Thestudywasnotspecificallypowered
tomeasureandexplainmistreatmentasaseparatecategoryofpoorqualityofcarewhichis
akeylimitationofthisstudy.
Itisalsohardtointerpretdatafromalimitedsetofunstructuredobservers’comments.While
usingunstructuredcomments,itisimportanttonotethatfindingsmaybehardtoreplicate,
sinceobserversmayonlyrecordeventsthatwereinterestingorparticularlystrikingtothem,
whichisakeylimitationofmymethodology.Theselimitationscouldhavebeenovercomeif
Ihadusedmultipleobservers433oradditionaldatacollectionmethodsasdiscussedabove.
Inafewinstances,Ialsofoundthatitwashardforobserverstofindaprivatespacetorecord
downtheirobservations.Sometimeshealthworkersatthestudiedfacilitieswouldtrytolook
atwhattheobservershadwrittendown.Insuchcases,observershadtowaituntiltheywere
aloneorwaittilltheendofthedayandrelyontheirmemorytonotedowntheirobservations
Observerbiascouldalsooccurifobserversbecometooinvolvedoraffectedbythehospital
enviorenmentordetailsofaparticularcase. Ianticipatedmanyofthese issuesand inthe
trainingsfocussedontheimportanceofbeingsilentobserversandnotinterferingorbeing
involvedwithanyaspectsofcareprovision. Inaddition,comments recordedbyobservers
perhaps reflects theirownprofessional experiences, trainingandknowledgeof respectful
carepracticeswhichisalimitation.Duringfieldwork,Ialsonotedthatyoungerobserverswere
morelikelytotakedowndetailednotescomparedtotheolderobservers,whoweremore
experienced,andperhaps,moreinclinedtoacceptmistreatmentasanormaloccurrence.
9.3.3:Forobjective3:ManagementanditsrelationshipwithQoC
9.3.3.1:Reflections
Inchapter8,IassessedanddescribedmanagementpracticesatmaternityfacilitiesinUttar
Pradeshandexaminedwhethermanagementpracticesareassociatedwithqualityofcare.
Measuringmanagementpracticesathospitalsisanemergingfieldandtherearewidespread
opinionsaboutthedefinitions,scopeandmeasurementofdifferentmanagementpractices.
Asdiscussedearlier,mystartingpointwasapre-existing tool for themanagementsurvey
whichIusedbecauseofthewideapplicationofthetoolwhichsupportscomparisonsandan
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opportunitytoundertakethisworksoonaftertheQoCassessmentsinthestudiedfacilities.
Ialsopilotedandfurtheradaptedthistoolpriortousingitfordatacollectionwhichprovided
manyusefulinsights.
Thekeyreflectionfromthemanagementstudy is that if Ihadthetimeandtheresources
available,Iwouldhaveundertakenamuchmorethoroughexplorationoftheconceptsand
determinantsofmanagementpracticesparticularlyinthepublicsector.Detailedformative
researchwouldhaveprovidedmewithbetterinsightsintothenatureanddeterminantsof
managementpracticesinUttarPradesh.Asaresultofthis,myassessmenttoolmaynothave
captured information on the contextual determinants of management for example local
politics,socio-economicfactorsandothers,whichmaydrivepublic-sectorperformancein
LMIC settings. This could mean that I may not have measured all the determinants of
managementathospitalsinUttarPradeshwhichhasimplicationsfortheresultsobtainedby
mystudy.
Ifoundthattheresearch-assistants(field-supervisorqualifications)oftenstruggledwiththe
fundamentals of hospital management, perhaps because none of us had any academic
traininginhospitalmanagementorbusinessadminstration.ThisiswhyIdecidedtoconduct
all of the interviews myself, although, it is encouraging to note that there was a high
correlationbetweenscoresgivenbymeandscoresgivenbythesecondsilentrater.While
orientingtheresearch-assistantstothemanagementtool,Ialsofoundthattheystruggledto
conceptualise hospital management as a separate entity from wider health systems
management,perhapsbecauseinmanywayshospitalsarealsohealthsystemsthemselves.
Thescoringmethodologyforindividualquestionscouldalsohavealsobeensimplified.For
example,insteadofaskingopen-endedquestionsandprovidingaratingbetween1to5,I
couldhavesimplifiedtheresponsetoayesornoresponsewhichmayhavebeeneasierto
implement.
Ifoundthatthestudyinstrumentwascomprehensiveandtriedtomeasureallthepractices
thatrepresentgoodmanagementinbothpublicandprivatesectors.However,itisimportant
tonotethatthetooloriginatesfrommanufacturingsectoranditsmainpurposehasbeento
make cross-country and cross-sector comparisions. Therefore, there is some benefit in
designinga tailored tool that ismuchmore relevent formaternity careprovision in LMIC
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settings. For example, the new assessment tool could specifically examine management
practicesassociatedwith implementingaseamlessmaternitycarepathway includingdrug
andsupplychainmanagement,organisationofclinicalteamsandothers.
Manyof thequestions in the assessment tool for example those related to the layoutof
patient flow, performance management and target management, human resource
managementand incentivesmanagementwerecomparativelypoorer inthepublicsector.
Thisraisessomedeeperquestionsonwhatitmeansforapublicsectorinstitutiontobewell
managed,particularlyinLMICssettingswherethereisnoautonomyorauthoritygiventothe
managertoimplementsomeofthesemanagementbestpractices.
I found that most hospitals in Uttar Pradesh do not have standardized maternity care
pathways.Although,protocolsfor labourandchildbirthareavailableinmostpublicsector
hospitals,theyarenotspecificallykeptinthelabourrooms,andthesetendtobeabsentin
privatehospitals. Monitoringtheuseofstandardisedprotocolswasnotroutinelydone in
bothsectorsandmanagerswereoftennotsurewhetherstaffwerefollowingtherelevant
protocols. I also found that while specialists such as doctors tend not moved across
specialities,nursesarefrequentlymovedacrossspecialitieswhichhasimplicationsforquality
ofservices.Thepublicsectorwasfoundtobeinflexibleintermsofdeploymentofstaffand
oftenstruggledwithrecruitment,selectionandretentionofstaff.
Although, the private sector was found to be relatively better for human-resource
management,managersfrequentlycomplainedthatfindingqualifiedstafftocomeandwork
intheseruralareaswaschallenging.Ididnotfindsystemsfortrackingperformanceindicators
routinely in the public sector, whereas the larger private sector hospitals often tracked
indicatorsrelatedtofinancialearningssuchasoutpatientquantitity,surgeryquantitity,bed
turnover rates and length of stay. Conversations about hospital performance were not
regularlydoneandprocessesforexposingoperationalproblemswererareinbothsectors.
Duringmyinterviewswiththemanagers,Ialsofoundthattherearenoimmidiateordirect
consequences of poor performance for staff in the public sector. For targets, the private
sectoronlyhadtargetsforrevenueandnotforqualitywhereasinthepublicsector,targets
werelimitedtotheonesprescribedbythecentralgovernment.
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9.3.3.2:Strengths
Keystrengthsofthemanagementstudyincludedobtainingdataonmanagementpractices
from facilities where actual clinical observations had taken place. To the best of my
knowledge,nostudytodatehasinvestigatedtherelationshipbetweenmanagementandQoC
insuchaLMICsetting,primarilybecauseofthedifficultiesinobtainingsuchprimarydata.
Wealsodoublescoredallresponsestotheinterviewquestionsandfoundgoodcorrelation
betweenscoresgivenbytwodifferentassessorswhichstrengthenstheinternalvalidityofmy
study.
I could also obtain better response rates for themanagement survey and interviewed all
administratorsandclinicalleadersat33maternityfacilities(10privateand23publicsector)
unlikeintheQoCstudywhereIcouldjustgetobservationsat26facilities.Managerswere
alsoappreciativeof the fact that Iwentback toengagewith themon this issueafter the
completionofQoCassessmentswhichisastrength.
I adapted a previously used survey instrument which supported comparability of results
acrossdifferentsettings.Inaddition,myresultsparticularlyfromprivatesectorsampleswere
similartothosereportedbythelargerstudyinIndiawhichisencouragingintermsofexternal
validity.ThepreviousstudybyLemosetal(2013)44inIndiawasonlyconductedintheprivate
sector.Therefore,mystudymakesausefulcontributionto the literatureonmanagement
practicesandqualityofcareinbothprivateandpublicsectors.Thisisakeycontributionof
myPhD.
9.3.3.3:Limitations
Forthemanagementsurvey,limitationsincludedpurposivesamplingofmaternityfacilitiesin
threedistrictsinUPbecauseofwhichmyfindingsarenotgeneralizabletoalldistrictsofUttar
Pradesh.
I also interviewed manager’s face-to face unlike previous studies that have employed
telephone-interviews. Therefore, it is possible that other assessors and I may have been
biasedby theappearanceor theoperationsofaparticular facility. However, face-to-face
interviews rather than telephone-based interviewsare a good researchpractice. Personal
face-tofaceinterviewswerealsoessentialtoensurethatIobtainedagoodresponserateand
managersalsoappreciatedthefollowupvisit.
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AlthoughIadaptedatoolthathaspreviouslybeenusedinmultiplecountriesincludingIndia,
the content and construct validityof the toolwasnot specifically testedwhichmayhave
implicationsforfindings.Since,correlationbetweenassessorswashighandourscoreswere
comparable with the larger Indian study, reliability is less of a concern. However, an
additional validation study in a small selection of participantswould have been useful to
validatethestudyinstruments.
Lastly, my sample of 275 observations at 26 hospitals is also small to generate precise
estimates on the relationship between management and quality of care and therefore,
follow-upstudywithalargersamplesizewouldbeuseful.
9.4:Implicationsofthedoctoralstudy
MyPhDstudyadvancestheevidence-baseonqualityofcareduringlabourandchildbirthin
in at least four ways with important implications, as I will discuss. First, I conducted a
comprehensiveassessmentofQoCfornormallabourandchildbirthincludinginprivatesector
facilitiesandthisisoneofthefirsteffortstodosoinUttarPradesh,whichisahigh-priority
statefortheIndiangovernment.MyfindingsofpoorQoCatbothpublicandprivatesector
maternity facilities shines an important light on this issue and demands a strong policy
responsetoimproveQoCduringlabourandchildbirthinUP.
Second, I demonstrated that given the high prevalence of mistreatment of women in
maternity facilities it is important to consider disrespect and abuse, over-treatment and
under-treatment innationalandglobaldebatesonpoorqualityofcare.Regardlessof the
terminologyused,mistreatmentofwomenfallsunderpoorqualityofcareandit isbotha
rights-basedandamedicalissue.
Third,thisPhDadvancesmeasurementeffortsbydevelopingthreetransparentindiceswhich
canbeusedtoevaluateandmonitoroverallQoCduringnormallabourandchildbirth,and
QoC for obstetric and neonatal care. These indices could be utilised by other quality
improvementprojectsandresearchers.
Fourth,Idemonstratethatmanagementbestpracticesarenotutilisedatmaternityfacilities
inUttarPradeshandinsuchsettings,performancemanagementactivitiessuchasauditshave
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apositiveimpactonqualityofcare.Tothebestofmyknowledge,thisisalsooneofthefirst
effortstoinvestigatetheroleofmanagementpracticesonQoCduringlabourandchildbirth
atmaternityfacilitiesinalow-resourcesetting.
Thespecificrecommendationsofmydoctoralstudyonresearch,programmesandpoliciesis
discussedinthesectionsbelow.
9.4.1:Recommendationsforthefutureresearchagenda
TheresultsfrommyPhDshowthatQoCwaspoorinbothpublicandprivatesectormaternity
facilities inUttar Pradesh. Therefore, a systematic effort tomeasure and identify existing
qualitygapsduringlabourandchildbirthisrequired,especiallyinIndia’shigh-burdenstates
andinsimilarsettingselsewhere.Theseresearcheffortsshouldalsoincludeprivate-sector
facilities,whichprovideasubstantialandincreasingproportionofthematernitycareinIndia
andinotherLMICs.
Since,Iwasnotabletoobtainasamplingframefortheprivatesectorandconductingalarge
censusofprivatesectorfacilitieswasnotfeasiblewithinthetimeframeofmyPhD,myprivate
sectorestimatemaynotbeprecise.Therefore,thereisaneedtoconductacensusofprivate
sector facilities inUP so that future research and government efforts to engagewith the
privatesectorcanbemoreeffective.ResearchersworkinginIndiawidelyacknowledgethat
obtaining participation from the private sector in research is a fundamental challenge.
Therefore, the research communitywill need to think carefully about innovative research
strategies to improve participation of the private sector in future research efforts. It is
importanttohighlightthatinvolvingtheprivatesectorinfuturelarge-scaleresearchactivities
mayonlybepossiblethroughrobustgovernmentalregulation,orasapartofgovernment
purchasing of private sector services or private-led initiatives amongst insurers or large
hospitalgroups.
TherearemanybenefitsofconductingalargerstudyusingthemethodsdescribedinmyQoC
study.A largerstudywillprovideestimatesthataremorerepresentativeforthewholeof
UttarPradeshand inparticular for theprivate sector. Future researchefforts should also
anticipate thedifficulties of sampling associatedwith theprivate sector; invest additional
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resourcesandhavealongerperiodfordatacollectionsothatagreaternumberofnormal
labourandchildbirthcasescanberecruited,especiallyintheprivatesector.
My PhD findings showed that the quality of care was generally poor during labour and
childbirthandthatbeingqualifieddidnotguaranteeprovisionofahigherstandardofcare.
Theseresultssuggestthatimprovingtheknowledge,skillsandcompetenceofqualifiedhealth
workers is important.Mixed-methods implementation research studies can be utilised to
investigate the extent to which the quality of existing trainings influence health workers
knowledge, skills and actual performance on-the job. Kirkpatrick’s model of training
programmeevaluationrecommendsacomprehensiveassessmentofreaction(ofthetrainees
tothetrainingprogram),learning(theknowledge/skillgain),behaviour(theactualchangein
practice)andresults(thefinaloutcomeduetothetraining)434.
Other innovative research questions include examining the effectiveness of innovative
trainingapproacheslikesimulation-basedtrainings/obstetricskillsanddrillsmethods435in
improving health workers knowledge, skills and confidence. Similarly, implementation
research to investigate whether training and retraining of health workers linked to re-
accreditationorcertificationwithprofessionalcouncils(medicalornursingcouncils)havethe
potentialtoimproveQoCathealthfacilitiescouldalsobeinvestigatedfurther.
Criterion-basedclinicalauditsareconsideredasausefulmethodtoauditqualityinmaternal
and newborn health. Process indicators used during these audits can help to assess the
adherence to evidence-based practices.436 Audit approaches can often use a structured
problem-solving methodology (for example: Plan, Do, Study, Act cycles) where teams of
providersareorganizedandsupportedtoidentifyandtestchangesintheprocessestheywish
to improve and tomeasure the impact of the changes against quantitative indicators of
quality.388Thesemethodshavenotbeenutilisedextensively inhospitals inUttarPradesh.
Therefore,thereisscopeforfutureresearchonexaminingtheeffectivenessofintroducing
suchapproachesinUttarPradesh.Moreover,thetrialbyDumontetal.(2013)inSenegaland
Mali offers an interesting example that researchers could replicate in India226. Additional
implementation research questions could also include issues such as feasibility, cost-
effectivenessandsustainabilityoftheseauditmechanisms.
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Since,Ifoundthattherewasahighprevalenceofunqualifiedpersonnelinmaternityfacilities
inUPin2015,itisimportanttounderstandthereasonsbehindthisphenomenon.Whatare
the contextual factors and determinants that lead to such a high reliance on unqualified
personnel in maternity facilities? Is this caused by staffing shortages, monetary issues,
sociocultural factors, deficiencies in knowledge, skills or competence of qualified health
workersorarequalifiedhealthworkersoverburdened?Understandingtheseissuesindetail,
willbeusefultoformulateappropriatepolicyresponses,thereforefurtherresearchonthis
issuewouldbeuseful.Thereisalsoanimportantglobalevidencegaparoundoptimalstaffing
levelsandSBAstaffingmodelsinhospitals.437Furtherresearchonidentifyingoptimalstaffing
levelswouldalsobeveryusefultosupportsafemotherhoodinIndia.
AsdemonstratedinmyPhDstudy,clinicalobservationsareafeasiblewaytoassessprocess
measures of quality of care for labour and childbirth. Future research efforts could also
employ clinical observations to investigate theQoC for complications of pregnancies and
caesarean sections431 in both public and private sector facilities in LMIC settings. The
differencesinQoCformanagingcomplicationsamongstqualifiedandunqualifiedpersonnel
wouldalsobeaninterestingquestionforresearch.
Thereshouldalsobefutureresearchoncharacterisingandimprovingorganizationalculture
to enhance patient safety at maternity facilities.438 These research efforts could employ
multidisciplinary approaches to investigate the effectiveness of interventions to improve
patient and provider safety such as interventions to improve hand-hygiene, improve
adherence to evidence-based practices or adherence to infection prevention and control
proceduresandothers.439,432
Furtherconceptualworkisrequiredaroundmeasurementofmistreatmentofwomenduring
labourandchildbirth in India,particularly,as I foundahighprevalenceofcertainharmful
practices which were also associated with socio-demographic characteristics of women.
Defining theboundaries formeasurementbetweenpoorqualityandmistreatment is also
requiredsincesomeindicatorsofover-treatmentandunder-treatmentareagainsttherights
ofchildbearingwomen141butalsoconsideredindicatorsofpoorQoC.Identifyingimproved
waystoincorporatetheconceptofintentionalityinmeasurementeffortsofmistreatmentas
describedearlierisalsorequired.
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Forensuringrespectfulmaternitycare,furtherresearchisrequiredtoidentify,testandscale
upeffectiveaccountabilitymechanisms.Manypromisingpilotsofaccountabilitymechanisms
suchassocialaudits,publichearings,citizen’sreportcards,verbalandsocialautopsiesand
partnership-defined-quality have been utilised but these require further implementation
researchinordertosupportscale-upinhighburdencountries.440-442Inaddition,westillneed
furtherresearchtoidentifyeffectiveinterventionsforvariouscontextsparticularlytoidentify
interventions needed to improve interpersonal care and social support for women at
maternity facilities, without blaming healthworkerswho are alsoworking under difficult
situations.
Futureresearchcouldalsoexaminetheprevalenceanddeterminantsofinformalpayments
atmaternityfacilitiesinIndia.Informalpaymentsseemwidespreaddespitenationalschemes
suchastheJSYschemeinIndia.Thisalsorelatestoalargerresearchagendaoncorruptionin
thehealthsectorinIndia.Detailedinformationonlevelandnatureofinformalpaymentscan
be collected throughobservations, household surveys, focus groupswithwomenor from
reports of other health providers385. Additional research questions could also explore
effective approaches to empower women and families so that they can refuse informal
paymentsinfacilities.
Future research efforts could examine ways to assign intervention-specific weights to
different elements of care provided during normal labour and childbirth. These research
efforts could employ methods for establishing and developing consensus such as Delphi
techniques,consensuspanels,ornominalgroupprocesses.429Theseapproachesareoften
usedincombinationandusebothquantitativeandqualitativemethods.Essentially,agroup
ofexpertsinaparticularfieldareconvenedandaskedtodecideontheimportanceofspecific
issuesofinterest.429However,somecriticshavearguedthatthereisselectionbiaswiththese
consensusmethods.429Forexample,expertsinvitedtoparticipatemaynotberepresentative
of the wider research community ormay not be front-line health workers. There is also
debateaboutthevalidityandreliabilityoftheseconsensusmethodsandnoagreementabout
whichmethodisthemostappropriate.429Thecurrentthinkingappearstobethattheresults
ofconsensusmethodsshouldbeinterpretedcautiouslyandtestedfortheirvalidityagainst
observationswhichareconsideredthegoldstandardformeasuringprocessesofcare.429To
illustrate thispoint inanexample, inorder toundertake suchanexercise for careduring
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routinelabourandchildbirth,expertswouldbeconvenedandaskedtorankitemsforvarious
dimensionsofcare.Whatdotheythinkarethemostimportantinterventionsforevidence-
based obstetric or neonatal care, for interpersonal care or for harmful care procedures?
Basedontheirratingsoftheimportanceofspecificitems,indicatorswouldthengroupedand
candidateindicesdevelopedbasedonexpert’srankings.201
The global community has now recognized the importance of QoC in achieving further
reductionsinmaternalandneonatalmortalityandstillbirths.Inordertoachievethis,weneed
validwaystoassessQoCatthetimeofbirth.ValidationoftheindicesdevelopedinthisPhD
study couldbeundertaken - face validity assessed throughexpert feedback. Content and
criterion validity assessed by using data collected from clinical observations.201 Additional
researchquestionscouldalsofocusonfeasibility,reliability,andperceptionoftheseindices
byend-userssuchasprogrammemanagersandnationalmonitoringandevaluationexperts
inhigh-burdensettings.Otherresearchersthathaveemployedasimilarmethodologyhave
foundgoodspecificityandsensitivityofindicesdevelopedonqualityofcareduringlabour
andchildbirth.201
Therearealsostatisticalmethods likeprincipal componentanalysis thatcouldbeused to
develop such indices. Principal component analysis (PCA) have generally been used to
constructmeasuresof socio-economic status fromhouseholdownershipof assets.443PCA
essentiallyemploysmathematicalalgorithmstoretainvariationsinthedataset444andare
usedtoreducealargevolumeofindicatorstoasingleindexappropriatelyconstructedfrom
thecommonvarianceofaspecificsetofindicators.443 Oneexampleofthisapproachhas
beenusedbyresearchersinvestigatinghealthservicereadinessbyusingdatafromaservice
provision assessment survey in Tanzania. 443 However, there are also limitations of this
approachsincePCAmaygivelowimportancetoindicatorsthatarecommonestinthedataset
regardless of their clinical importance. For example, uterotonic within 1 minute is an
importantclinicalindicatorbutsinceitwasrelativelycommoninmydataset,PCAwillnotgive
adequateimportancetothatindicator.
Asshownbymyresults,performancemanagementactivitieshaveapositiveeffectonquality
of care at the time of birth. Therefore, further implementation research on ways to
institutionalise and implementmechanism such as criterion-based audits,maternal death
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reviews,confidentialenquiries,near-missauditsandmaternalorperinataldeathsurveillance
and responsemechanisms, is important for all high burden settings. These activities can
provide powerful information that can guide actions to end preventable maternal and
neonataldeathsinhigh-burdensettings.
9.4.2:Recommendationforprogrammes
Currently, knowledge about best practices during normal labour and childbirth in LMIC
settingsislimited.AssessmentoftheQoCduringlabourandchildbirthneedstobeinstituted
systematicallyinallhigh-burdenstatesofIndia.Theavailabilityofassessmenttools,suchas
thosedevelopedinthisstudymaybeuseful.Programmesshouldtargettheirresourcesto
improve measurement and improve existing QoC at facilities in both public and private
sectors.Ashighlightedinthisstudy,quality improvementeffortsneedstobecentral inall
effortstoendpreventablematernal,neonataldeathsandstillbirthsinmaternityfacilities.
Disseminationofevidence-basedguidelinesandconceptsofrespectfulmaternitycareneeds
tobedoneextensivelyamongstallfront-lineworkersinIndiaandothersimilarsettings.This
isparticularlyimportantsinceIfoundthatQoCandlevelsofmistreatmentweresimilarfor
bothqualifiedandunqualifiedpersonnel.Thiscouldbeaninnovativeareaofworktodevelop
suitable training programmes for both qualified and unqualified personnel, design
appropriate skill-development activities and improve linkageswith specialists and higher-
centres.
Since, I found that QoC during weekends and outside normal working hours was poor
comparedtoweekdaysandwithinregularworkinghours.Managersatmaternity facilities
shouldensurethatoptimalstaffinglevelsandancillaryresourcesareavailableduringthese
times. Overall, given the poor quality of care inmaternity facilities inUP, improving the
knowledge and competence of all maternity care personnel is urgently needed. Use of
appropriatetrainingmethodswithadequateopportunitiesforsupervisedpracticaltraining
sessions and further on-the-job supportive supervision and refresher trainings would be
useful,asdescribedearlier.
Innovativeprojectstoimprovedeficienciesinknowledgeandskillsamongsthealthworkers,
improvementofthequalityoftrainings,mechanismtoaddresshealthworkershortagesand
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developmentofinnovativementorshipandsupervisionmechanismswouldhelpinadvance
theevidence-baseon these issuesand support furtherdeclines inmaternal andnewborn
mortality.
9.4.3:Recommendationsforpolicy
My results indicate that unqualified personnel such as TBAs, sweepers, dais, ASHAswere
frequently involved in providing care in maternity facilities in UP in 2015. This is a
troublesomefindingwithmanyimportantglobalandnationalimplications.First,itmaybe
possible that thematernal health community in India and globally, is over-estimating the
proportionofwomenthatdeliverwithSBAsparticularlyinhigh-focusstatesofIndiasuchas
Uttar Pradesh. Globalmonitoring efforts often employ advancedmathematicalmodelling
methodsthatrelyon indicatorssuchaspopulationcoverageofSBAbirths, therefore, it is
possiblethatglobalestimatesforMMRdeclinesinIndiacouldbeunder-estimatingtheactual
burdenofmaternalmortality.
TheIndianGovernmentrecommendsprovisionofmaternityservicesbyappropriatelytrained
and qualified skilled birth attendants at health facilities. However, given various context
specificchallengesdescribedearlier, theprospectofallbirthsbeingcaredforbyqualified
personnelathealthfacilitiesisanimportantchallenging,particularlyinruralareas.Therefore,
it is importantforpolicymakerstoissueclearandcomprehensiveguidanceontheroleof
unqualifiedprovidersatmaternityfacilities.
If national authorities decide against using unqualified personnel to provide institutional
services, theymust design and implement robustmonitoringmechanisms to ensure that
unqualifiedpersonnelarenot involved inservicedelivery.Up-todate jobdescriptionsare
required,sothatthere isnoconfusionaboutrolesandresponsibilities.Womenthatgoto
institutions have a right to expect care from qualified personnel irrespective of public or
privatesectoranditisthedutyofthegovernmenttoensureandprotectthatrightforwomen.
Policymakersmustinvestindesigningappropriatecareerdevelopmentpathwaysforyoung
doctors,nursesandmidwivessothattheyjointhepublicsector.Thiswillalsorequirebetter
remuneration packages to attract and retain qualified health workers particularly those
servinginruralareas.Ultimately,thereisaneedtodevelopcomprehensivenationalhuman
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resourceplanswithstrategiestoensureadequaterecruitment,rationaldeployment,ongoing
retention and capacity building of qualified health workers providing maternity care
services.16
Policymakers should consider the importance of long-term investments in strengthening
health systems and improving work conditions for front-line health workers. Given the
immenseshortagesofskilledhumanresourcesformaternitycareinIndia,focusedeffortsto
establishaprofessionalcadreofmidwivescouldbebeneficialand long-terms investments
arerequiredtoincreaseproductionofqualifiedmaternitycarepersonnel.
Policymakersalsoneedtotacklethewidespreadexistenceofinformalpaymentsbydesigning
better polices for supervision, disseminate patient charters, and institute disciplinary
mechanismsforhealthworkersinvolvedinsuchcorruptpractices.
Policymakersneedtoinvestinparticipatoryaccountabilitymechanismsashighlightedinthe
recommendationsforresearchsectionearliersothatevidence-basedandrespectfulcareis
providedtoallwomanandtheirbabiesatmaternityfacilities.
Finally,thereisnowincreasingrealisationthatgovernmentsalonemaynotbeabletodeliver
allservicestomeettheirpopulation’sneeds.Further,somewomenoftenprefertoseekcare
intheprivatesectorandthereforeitisquiteimportanttoregulateandimprovequalityinthe
private sector aswell. Comprehensive regulationon theprivate sectors’ role in providing
healthservices includingdetailedqualitystandardsexpected inprivatesector facilities for
maternity care need to be developed.Once regulations and quality standards have been
finalised,permissivepolicieswillberequiredtoimplementandtestinnovativepublic-private
partnershipmodelstoimproveefficiency,effectivenessandQoCofmaternityservices.
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Chapter10:Conclusions
The results of my PhD study indicate that in maternity facilities in Uttar Pradesh, the
personnelprovidingnormallabourandchildbirthcarewereoftenunqualified;adherenceto
evidence-basedobstetricandneonatalcareprotocolswasgenerallypoor;and,allwomen
encounteredatleastonepracticeconsideredtobemistreatment.Mistreatmentofwomen
atmaternityfacilitiesfallsunderpoorqualityofcareandneedsgreaterattentioninnational
andglobaldebates.
MyPhDresultsindicatethatasystematicandurgenteffortisneededtomeasureandimprove
QoCatthetimeofbirthinpublicandprivatesectorfacilitiesinhigh-burdenstatesinIndia.
Appropriatecontext-specificstrategiesandinterventionsneedtobedevelopedforimproving
careduringlabourandchildbirth.
Lastly,Ididnotfindanassociationbetweenoverallmanagementscoresandqualityofcare
during labour and childbirth. The only management dimension that positively influenced
qualitywasperformancemanagementandhence,performancemanagementactivitiessuch
asdifferenttypesofauditsshouldbeimplementedinallmaternityfacilitiesinhigh-burden
settings.
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433. LangeIL,KanhonouL,GoufodjiS,RonsmansC,FilippiV.Thecostsof'free':Experiencesoffacility-basedchildbirthafterBenin'scaesareansectionexemptionpolicy.SocialScience&Medicine2016;168:53-62.434. KirkpatrickDonald.GreatIdeasRevisited.TechniquesforEvaluatingTrainingPrograms.RevisitingKirkpatrick'sFour-LevelModel.TrainingandDevelopment1996;50(1):54-9.435. UtzB,KanaT,vandenBroekN.Practicalaspectsofsettingupobstetricskillslaboratories--aliteraturereviewandproposedmodel.Midwifery2015;31(4):400-8.436. GrahamWJ.Criterion-basedclinicalauditinobstetrics:bridgingthequalitygap?BestPractResClinObstetGynaecol2009;23(3):375-88.437. DasJK,KumarR,SalamRA,LassiZS,BhuttaZA.Evidencefromfacilitylevelinputstoimprovequalityofcareformaternalandnewbornhealth:interventionsandfindings.ReprodHealth2014;11Suppl2(Suppl2):S4.438. SingerSJ,FalwellA,GabaDM,etal.Identifyingorganizationalculturesthatpromotepatientsafety.HealthCareManagementReview2009;34(4):300-11.439. GonG,AliSM,TowrissC,etal.Unpackingtheenablingfactorsforhand,cordandbirth-surfacehygieneinZanzibarmaternityunits.HealthPolicyandPlanning2017.440. PuriM,LahariyaC.SocialauditinhealthsectorplanningandprogramimplementationinIndia.IndianJCommunityMed2011;36(3):174-7.441. JoshiA.Dotheywork?Assessingtheimpactoftransparencyandaccountabilityinitiativesinservicedelivery.DevelopmentPolicyReview2013;31(s1).442. WaiswaP,KalterHD,JakobR,BlackRE,SocialAutopsyWorkingG.Increaseduseofsocialautopsyisneededtoimprovematernal,neonatalandchildhealthprogrammesinlow-incomecountries.BulletinoftheWorldHealthOrganization2012;90(6):403-A.443. JacksonEF,SiddiquiA,GutierrezH,KanteAM,AustinJ,PhillipsJF.EstimationofindicesofhealthservicereadinesswithaprincipalcomponentanalysisoftheTanzaniaServiceProvisionAssessmentSurvey.BMCHealthServRes2015;15(1):536.444. JolliffeI.Principalcomponentanalysis:WileyOnlineLibrary;2002.
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12.ListofAppendicesAppendix1:QoCassessmenttoolfornormallabourandchildbirthinUttarPradeshin2015
Part 1: IDENTIFICATION
I01.NAMEANDCODEOFDISTRICT_______________________I02.NAMEANDCODEOFBLOCK_______________________I03.FACILITYTYPE 1. COMMUNITYHEALTHCENTRES(CHCs)2. DISTRICTHOSPITAL(DH)3. MEDICALCOLLEGEANDTEACHINGHOSPITAL4.PRIVATEMATERNITYCENTREI04.OWNER/MANAGERNAME_____________________________________
I05.HEALTHWORKERNAME
(Attendingnurse/doctorwhoisconductingthedelivery)
_____________________________________
[___][___]
[___][___]
[___][___]
RESEARCHER VISITS I06.DATE
I07.TIMEOBSERVATIONSTARTED
I08.TIMEOBSERVATIONFINISHED
I09.INTERVIEWER’SNAME
I10.SUPERVISOR’SNAME
Part2:SummarySheet
CIRCLEALLTHATAPPLIES
I11.UniqueIdentificationcode
FacilityNumber(FF):
ObservationNumber:
I12.Participation Agreedtoparticipate A. Refusedtoparticipate B. Didnotfulfileligibilitycriteria C. Developedacomplicationafterenrolmentandobservationended(Pleasespecifyreason)
D.
I13.Accompanyingperson Yes 1
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No 2I14.Consentreceived?
Wittenconsentbywoman A. Writtenconsentfamily B. Oralconsentbyresearcher C. ThumbPrint D.
SectionA:Screeningquestionnaire
Instructionstotheresearcher:Approachthewardnursestoidentifyallpregnantwomeninthelabourwards,admissionsdepartment,orotherplaceswherepregnantwomanmaybeadmitted.Fromtheirmedicalrecords,completeSectionAtoassesstheireligibilityforinclusioninthestudy.Evenifthewomanisdeemedeligibleshemaydevelopacomplicationduringlabourandchildbirth.Insuchacaseobservecareprovideduptothatpointintime.
Casedefinition:
Anormalvaginaldeliveryisonethatis:• Spontaneousinonset• Low-risk at the start of labour (nohistory ofmedical conditions in thepast or problems in the current
pregnancy,nohistoryofpreviousobstetricandneonatalcomplications,nofoetalcomplicationsincurrentpregnancyandnopreviousgynaecologicalhistory)
• Asingleinfantisbornspontaneouslyinavertexposition• Gestationalagebetween37and42(+0)completedweeksofpregnancy.• Thewomanshouldbebetween18-49yearsofage.UniqueID:
A1. Ageofthewoman Completeinyears___________
A2. Gestationalageofthewomen,indicateinweeksand
days
Verifywithmedicalrecords
______/Weeks_______Days
A3. Gravidity
1. Numberofbabiesbornalive
2. Numberofbabiesborndead?
3. Numberofabortions/Miscarriage
1.
2.
3.
A4. Parity(1+2)
A5. Isthelabourspontaneous Yes No DK
A6. Wasinductionoflabourconducted? Yes No DK
A7. IfyesinA6,pleaseprovidedetailsofthemethodused?(Specify
drugorproceduresused)
A8. Isthereanyhistoryofmedical/obstetriccomplicationsin
previouspregnancies?
Yes
No
DK
A9. Ifyes,Pleasespecify:
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A10. Arethereanyfoetalcomplicationsinthecurrentpregnancy? Yes No DK
A11. Isthisasingletonpregnancy? Yes No DK
A12. Isthebabyinvertexposition? Yes No DK
A13. Cervicaldilation (________cms)
A14. Wasthewoman’sBloodpressuremeasured?
Ifyes,pleasespecifythereading._______________(mm/hg)
Yes
No
DK
A15. Wasthewoman’stemperaturemeasured?
Ifyes,pleasespecifythereading./_____________(Degree
Celsius)
Yes
No
DK
A16. Wasurinetestedforpresenceofprotein? Yes No DK
A17. Didthehealthworkerperformthefollowingstepsforabdominal
examination
a. Checksfundalheightwithameasuringtape Yes No DK
b. Checksfetalpresentationbypalpationofabdomen Yes No DK
c. ChecksFoetalHeartRate Yes No DK
SectionB:Demographic,Socio-economicandEducationalStatus
Instructionstotheobserver:Ifthewomanisinactivelabour,approachcompanionsorfamilymembersofthepregnant woman to complete this section after obtaining consent. If the woman doesn’t have anyaccompanyingperson,collectinformationdirectlyfromheratasuitabletimeafterdelivery.
No. QUESTION CATEGORIES
CODE(Circle)
B1. Clienthospitalmedicalnumber B2. Addressoftheclient B3. Areyouabookedcase? Yes 1
No 2B4. Whereistheclientcomingfrom?
Directlytofacility
1
Referredfromanotherfacility
2
B5. Howmuchtimedidtheclient/familytaketotravelfromhome/elsewheretothisfacility
a. Fromhometofirstfacilityorthisfacilityifcomingdirectly.
(___/___)Timeinhh/mm
b. Fromreferralfacilitytothisfacility (___/___)Timeinhh/mm
c. Totaltimetoreachfacility (___/___)Timeinhh/mm
B6. Whatisyourreligion? Hindu 1.
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No. QUESTION CATEGORIES
CODE(Circle)
Muslim 2. Christian 3. Noreligion 4. Other 5. Don’tKnow 6.
B7. Whatisyourcaste/category?
Brahmin 1. Rajput/Thakur 2.
Kayasthi/Srivastava/Lala 3. Chamar 4. Dusadh 5.
Musahar 6. Pasi 7. Dhobi 8. Chaupal 9. Yadav 10. Vaishya/Bania 11. Kurmi/Katiyar 12.
Shah 13. Nocaste/Tribe 14.
Other; 15. Don’tKnow 16.
B8. Note:ifthecasteisascheduledcaste,scheduledtribe,otherbackwardcaste
Scheduledcaste 1. Scheduledtribe 2. Otherbackwardcaste 3. GeneralCaste 4.
Other 5.
B9. DoesthewomanorherfamilyhaveaBelowPovertyLineCard(verifyBPLcard)?
Yes 1. No 2.
Don’tKnow 3.
B10. Whatistheoccupationofthepregnantwoman?
Self-employed,Agriculture 1. Wageemployed 2. Agriculturallabourer 3. Salariedworker 4. Self/Employed,Business 5. Skilledworker 6. Retired 7. Lookingforwork 8. Notworkingandnotlookingforwork 9. Other; 10.
Don’tKnow 11.
B11. Kachha 1.
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No. QUESTION CATEGORIES
CODE(Circle)
Howhasyour(thewoman’shouse)beenconstructed?
Semi-Pucca 2.
Pucca 3. Don’tKnow 4.
B12. Whatisthemainsourceofdrinkingwaterforthemembersofwoman’shousehold?
Pipedwaterintodwelling 1. Pipedintoyard/plot 2.
Publictaps/Standpipe 3. PublicHand-pump 4. Privatehand-pump 5. Tubewellorborehole 6. Dugwell 7. Rainwater 8. Tanker/truck 9. Surfacewater(Rover,Lake,Pond,Stream,Canal,Irrigationchannel)
10.
Don’tKnow 11. B13. Whatkindoftoiletfacilitiesdoesthe
householdhave?Probeindetail
Flushorpourflushtoilet 1.
Flushtopipedsewersystem 2. Flushtoseptictank 3. Flushtopitlatrine 4. Flushtosomewhereelse 5. PitLatrine 6. Ventilatedimprovepitbiogaslatrine 7. Pitlatrinewithslab/openpit 8. Twinput/Compostingtoilet 9. DryToilet 10. Nofacilities/usedopenspaceorfield 11. Don’tKnow 12. Other(Pleasespecify)……….
B14. Whatkindoffueldoesthehouseholduseforcookingmostofthetime?
Selectonlyoneoption
Electricity 1. LPG/Naturalgas 2.
Biogas 3.
Kerosene 4.
Wood 5. Agriculturecropwaste 6. Dungcakes 7. Others(Pleasespecify) 8.
Don’tknow 9.
B15. Doesthepregnantwoman’shouseholdhave?(circleallasappropriate)
Mattress 1. Pressurecooker 2.
Chair 3.
Cot/Bed 4.
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No. QUESTION CATEGORIES
CODE(Circle)
Table 5.
Almirah/Dressingtable 6. Electricfan 7.
Radio/transistor 8.
ColourTV 9.
VCR/VCD/DVD/CDplayer 10.
Sewingmachine 11.
Mobiletelephone 12. Anyothertelephone 13.
Computer/Laptop 14.
Refrigerator 15.
Watch/clock 16.
Bicycle 17.
Motorcycle/scooter 18. Animal-drawncart 19.
Car 20. Waterpump 21.
Tractor 22. B16. Doesyourhouseholdhaveelectricity
Yes 1.
No 2.
Don’tKnow 3.
B17. Whatisthehighestlevelofeducationthewomanhasattained?
Literatewithoutformaleducation 1. LiteratewithFormalEducationBelowPrimary
2.
Primary(Upto5thstandard) 3. Middle(6thto8thStandard) 4. Secondary/MetricsClassX 5.
Hr.Secondary/Sr.Secondary/Pre-University(ClassXII)
6.
Graduate/BBA/B.TECH/Equivalent 7.
PostGraduate/MBA/EquivalentorHigher 8.
TechnicaDiploma 9. Non-technical/CertificateCourse 10. Other 96Illiterate 00
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SectionC:DirectObservationofnormalvaginaldeliveries
Instructionstotheresearcher:
Findthehealthworkerinvolvedintheprovisionofcaretothewoman.Ifthisisnotanewrespondent,proceeddirectlytopart2.Pleaseobtaininformedconsentfromboththeclientandthehealthworkerbeforebeginningtheclinicalpracticeobservations.Ensurethattheproviderknowsthatyouarenottheretoevaluatehimorherandthatyouarenotanexperttobeconsultedduringthesession.
ProvideInformationandConsentsheetstothehealthworker.
Part1:
C2.Whoisconductingthedelivery?(Circleasappropriate;severalresponsespossible)
Healthworkerqualification Categorycode
Healthworkerqualification
Categorycode
Doctor(MBBS) 1 Nursingprofessionals(post-bachelor) 7Doctor(BAMS) 2 Midwiferyprofessionals(post-bachelor) 8Obstetricianandgynaecologists 3 AuxiliaryNurseMidwife 9Paediatriciansandneonatologists 4 GeneralNurseMidwife 10Anaesthetists 5 Neonatalnurse 11Nursingprofessional(Bachelor) 6 Others(specify):…..………..………………….. 12
Instructionstotheresearcher:Providetheinformationsheetandconsentformtotheclient,nextofkinorfamilymemberpriortobeginningPart2.Didtheclient/family/accompanyingpersonprovideaninformedconsentandagreetolettheresearcherbepresentduringlabouranddelivery?
Part2:ClinicalpracticeObservationFirststageofLabour
Yes
No
DK
C4.Didahealthworkerexplaintheprocessoflabourtothewomanorcompanionatleastoncebeforethestartofactivelabour?
1 2 8
C5.Observer:Wasacompanionallowedtobewiththewomanduringlabour?
1 2 8
C6.VaginalExaminationperformedusingsterilegloves? 1 2 8C7.Womaninformedbeforevaginalexaminationperformed? 1 2 8C8.Waspartographusedtomonitorlabour?
IfNo,thenskiptoC11.1 2 8
C9.Ifactionlinereachedonpartograph,wasanydefinitiveactiontaken?
1 2 8
C10.Whatdefinitiveactionwastaken:(circleasappropriate) a. Consultwithspecialist 1 2 8b. Refertootherfacilityforspecialist 1 2 8
C1.ConsentGivenbyhealthworker:�Yes:AftercompletingthePartOneproceedtoPart2.�No:Finishtheinterview.
C3.ConsentGivenbywoman:�Yes:ContinuetoPart2.�No:Finishinterview.
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c. Prepareforassisteddelivery 1 2 8d. PrepareforC-section 1 2 8e. Other(pleasespecify__________________________)
C11.WasFoetalheartbeatmonitoredatregularintervals? 1 2 8C12.Iffoetalheartbeatindicated,writeinthebox? ……../bpmC13.Oralfluidofferedtothewomanonrequest? 1 2 8C14.VisualPrivacyofthepregnantwomanensured? 1 2 8C15.Womenencouragedtomovearoundbytheprovider 1 2 8C16.Waslabouraugmentationdone?
IfNo,thenskiptoC20.1 2 8
C17.Whywaslabouraugmentationperformed? a) Inefficientuterineactivity Ab) Cervicaldilatationoflessthan2cmin4hours Bc) Notknown Cd) Other(Pleasespecify)……..
C18.Didahealthworkerexplaintothemotherwhylabouraugmentationwasbeingdone?
1 2 8
C19.Howwaslabouraugmentationdone? a) Artificialruptureofthemembranes 1 2 8b) Useofsyntocinon/Oxytocin 1 2 8c) Others (Please Specify the name of the injection apart from
syntocinon/Oxytocin)
Questionsonexaminationandprocedures C20.Handwashingdonepriortoanyexaminationofthewoman 1 2 8C21.Healthworkerwearssterilesurgicalgloves 1 2 8C22.Cleansthevulvaandperineumwithantisepticsolution 1 2 8C23.Drapeswoman(onedrapeunderbuttocks,oneoverabdomen) 1 2 8Preparationfordelivery Checktoseeifthefollowingequipmentandsuppliesarelaidoutinpreparationfordelivery.Ifsomesuppliesareinadeliverykit,look/asktodeterminewhatitemsareincluded.
C24.Preparesuterotonic(Oxytocin)forActivemanagementofthirdstageoflabour
1 2 8
C25.Timer(clockorwatchwithsecondshand) 1 2 8C26.Self-inflatingventilationbag(250or500mL) 1 2 8C27.Newbornfacemask(size0,1) 1 2 8C28.MucusExtractor,suctiontube/Suctionbulb 1 2 8C29.Catheter 1 2 8C30RadiantWarmer 1 2 8C31.WeighingScale C32.Atleasttwocloths/blanketsfornewborn(onetodry;onetocover)
1 2 8
C33.Umblicalcordtiesorclamps 1 2 8C34.Sterilescissorsorblade 1 2 8C35.Hasthewomancompletedthefirststageoflabour? 1 2 8EnsurethatthefirststageoflabouriscompletebeforemovingdowntoSectionDbelow. SectionD:ObservationofSecond&ThirdStageofLabour PREPARATIONFORDELIVERY D1.Motherinformedofthestageoflabour 1 2 8
Page218of248
D2.Wasepisiotomyperformed 1 2 8D3.Wasalocalanestheticinjectionadministeredbeforetheepisiotomy
1 2 8
D4.Positionofthewomanduringchildbirth a) Lithotomy(onherback) Ab) Squatting Bc) Leftlateral Cd) Other(Pleasespecify)....................…………. D
D5.Motheraskedaboutchoiceofpositionfordelivery 1 2 8D6.Whoperformedthedelivery a) Doctor Ab) Nurse Bc) Midwife Cd) Interndoctor De) Studentnurse Ef) Studentmidwife Fg) Other(pleasespecify)………………………………………DELIVERY&UTEROTONIC(OXYTOCIN) D7.Asbaby'sheadisdelivered,supportsperineum 1 2 8D8.Recordtimeofthedeliveryofthebaby 1 2 8D9.Checksforanotherbabypriortogivingtheuterotonic(Oxytocin) 1 2 8D10.Administersuterotonic(oxytocin)?IfNo,thenskiptoD13
1 2 8
D11.Whichuterotonicwasgiven?(circleasappropriate)VERIFY
a) Oxytocin Ab) Ergometrine Bc) Syntometrine Cd) Misoprostol D
D12.Timingofadministrationofuterotonic/oxytocin(circleasappropriate)a) Atdeliveryofanteriorshoulder Ab) Within1minofdeliveryofbaby Bc) Within3minofdeliveryofbaby Cd) Morethan3minafterdeliveryofbaby D
D13.Tiesorclampscordwhenpulsationsstop,orby2-3minutesafterbirth(notimmediatelyafterbirth)
1 2 8
D14.Cutscordwithsterilebladeorsterilescissors
1 2 8
D15.Appliestractiontothecordwhileapplyingsuprapubiccountertraction
1 2 8
D16.Performsuterinemassageimmediatelyfollowingthedeliveryoftheplacenta
1 2 8
D17.Assessescompletenessoftheplacentaandmembranes 1 2 8D18.Assessesforperinealandvaginallacerations 1 2 8
D19.Wasvaginalbleedingmonitoredafterthedelivery? 1 2 8D20.WasanydruggiventopreventPPH?IfYes,PleaseSpecify(_______________________________________)
1 2 8
D21.Womaninformedaboutthesexofthenewborn 1 2 8
Page219of248
D22.Outcomeofthebaby
Alive
Complication
s
Dead
D23.Outcomeofthewoman
Alive
Complication
s
Dead
POTENIALLYHARMFULPRACTICES D24.Didyouobserveanyofthefollowingharmfulpracticesdonebyanyhealthworkerinvolvedintheprovisionofcare?(Circleallthatapply)
a. Useofenema Ab. Pubicshaving Bc. Applyfundalpressuretohastenthedeliveryofthebabyorthe
placentaC
d. Uterinelavageafterdelivery De. Slapthenewborn Ef. Holdthenewbornupsidedown Fg. Shoutinsultorthreatenthewomanatanytimeduringlabourand
childbirthG
h. Slap,hitorpinchthewomanatanytimeduringlabourandchildbirth HD25.Didyouseeanyofthefollowingpracticesthatweredonewithoutappropriateindication(Circleallthatapply)
a) Manualexplorationoftheuterusafterdelivery Ab) Useofepisiotomy Bc) Aspirationofthemouthandnoseassoonasthenewbornis
bornC
d) Restrictfoodandfluidduringlabour De) Noneoftheabove. E
ESSENTIALNEWBORNCARED26.Immediatelydriesbabywithtowel 1 2 8D27.Discardsthewettowel 1 2 8D28.Isthebabybreathingorcrying? 1 2 8D29.Placesbabyonmother’sabdomen“skintoskin” 1 2 8D30.Coversbabywithdrytowel 1 2 8D31.Apgarscorecheckedafteroneminute,Ifyes,pleaseindicateintheboxASKANDVERIFYFROMRECORDS
1 2 8
D32.Apgarscorecheckedafterfiveminutes?Ifyes,indicateintheboxASKANDVERIFYFROMRECORDS
1 2 8
D33.Motherandnewbornkeptinsameroomafterdelivery(rooming-in)
1 2 8
D34.Wasbreastfeedinginitiatedwithinthefirsthourafterbirth 1 2 8D35.Wastheweightofthebabymeasured?Ifyes,thenSpecify(_____________________)
1 2 8
Fieldnotes:
Page220of248
Appendix2:ToolforassessmentofmanagementpracticesinmaternityfacilitiesinUttarPradeshin2015InterviewDetails HospitalandManager’sInformationa) HospitalName: b) Name:c) HospitalID d) Position:e) InterviewerName: f) Specialty:g) Date(DD/MM/YY): h) Tenureinpost(numberofyears):i) Time(24-hourclock): j) Tenureinhospital(numberofyears):k) Runninginterview Listeningtointerview
l) Howoldisyourhospital(numberofyears)?ManagementQuestions
1. LayoutofPatientFlow
Testshowwellthematernity
carepathwayisconfiguredat
thefacilityandwhetherstaff
pro-activelyimprovetheirown
work-placeorganization
Score:
1 2 3 4 5 99
a) Canyoubrieflydescribethepregnantwomen’sjourneyatthefacility?
b) Howcloselylocatedarewards,theatres,diagnosticscentresandconsumables?
c) Howoftendoyourunintoproblemswiththecurrentlayoutandpathwaymanagement?
Score1:Lay-outofhospitaland
organizationofworkplaceisnot
conducivetopatientflow(e.g.wardison
differentlevelfromtheatreor
consumablesareoftennotavailablein
therightplaceattherighttime)
Score3:Lay-outofhospitalhasbeenthought-
throughandoptimizedasfaraspossible;work
placeorganisationisnotregularly
challenged/changed(orviceversa)
Score5:Hospitallayouthasbeen
configuredtooptimizepatientflow;
workplaceorganizationischallenged
regularlyandchangedwheneverneeded
2) Isthereastandardisedmaternitycarepathwayatthefacility?Ifyes,whatwastherationaleforIntroducingStandardisation/PathwayManagement?
Teststhemotivationand
impetusbehindchangesto
operationsandwhatchange
storywascommunicated
Score:
a) Howdidyoumakeimprovementstothematernitycarepathway?Canyoudescribearecentexampletome?
b) Howoftendoyouchangethematernitycarepathway?
c) Whatfactorsledtotheadoptionofthesepractices?
d) Whotypicallydrivesthesechanges?
Score1:Changeswereimposedtop-down
orbecauseotherdepartmentswere
Score 3: Changes were made because of
financialpressureandtheneedtosavemoney
Score5:Changesweremadetoimprove
overallperformance,bothclinicaland
Page221of248
1 2 3 4 5 99
making(similar)changes;rationalewas
notcommunicatedorunderstoodbyall.
or as a (short-term) measure to achieve
governmentand/orexternaltargets
financial,withbuy-infromallaffected
staffgroups;thechangeswere
communicatedinacoherentchangestory.
3) Standardisationand
ProtocolsTestsifthereare
standardisedprocedures,
guidelinesandprotocolsfor
managementoflabourand
childbirththatareapplied
andmonitored
systematically
Score:
1 2 3 4 5 99
a) Howstandardisedarethemainclinicalprocesses?
b) Howclearareclinicalstaffsonhowspecificproceduresshouldbecarriedout?
c) Whattoolsandresourcesdoestheclinicalstaffemploy(e.g.checklists)toqualitycareduringlabourandchildbirth?
d) Howaremanagersabletomonitorwhetherclinicalstaffarefollowingestablishedprotocols?
Score 1: Little standardisation and few
protocolsexists
Score3:Protocolshavebeencreated,butare
notcommonlyusedbecausetheyaretoo
complicated,haven’tbeendisseminatedand
notmonitoredadequately
Score5:Protocolsareknownandused
byallclinicalstaffandregularlyfollowed
uponthroughsomeformofmonitoring
oroversight
4) GooduseofHuman
Resources
Testswhetherstaffaredeployed
todowhattheyarebest
qualifiedfor,butnevertheless
helpoutelsewherewhenneeded
Score:
1 2 3 4 5 -99
a) Withrespecttoyourstaff,whathappenswhenthereisahighvolumeofwomencomingtodeliveratyourhospital?
b) Howdoyouknowwhichtasksarebestsuitedtodifferentstaff?Fore.g.:whoconductsnormaldeliveriesorcaesareansor
providesanaesthesia?
Score1:Staffoftenendupundertaking
tasksforwhichtheyarenotqualifiedor
over-qualifiedwhentheycouldbeused
elsewhere;staffarenotutilised
effectively,andtendtobegenerally
underutilised
Score3:Seniorstafftrytousetherightstaff
fortherightjob,butdonotgotogreat
lengthstoensurethis;staffmaymovebut
ofteninanuncoordinatedmanner
Score5:Staffrecogniseeffectivehuman
resourcedeploymentasakeyissueand
willgotosomelengthstomakeit
happen;shiftingstafffromlessbusyto
busyareasisdoneroutinelyandina
coordinatedmanner,basedonthe
documentedskills
Page222of248
5) ContinuousImprovement
Testsprocessesforandattitudes
towardscontinuous
improvement,andwhether
learningsarecapturedand
documented
Score:
1 2 3 4 5 -99
a) Howdoproblemstypicallygetexposedandfixedatthismaternityfacility?
b) Canyoutalkmethroughtheprocessforarecentproblemthatyoufaced?
c) Whenprocessesdochange,whatisthemaindriverofchange?
d) Whowithinthehospitaltypicallygetsinvolvedinchangingorimproving?Howdo/candifferentstaffgroupsgetinvolvedin
thisprocess?Canyouthinkofanyexamples?
Score1:Processimprovementsare
madeonlywhenproblemsoccur,oronly
involveonestaffgroup
Score3:Improvementsaremadeinirregular
meetingsinvolvingallstaffgroups,to
improveperformanceintheirareaofwork
(e.g.wardortheatre)
Score5:Exposingproblemsina
structuredwayisintegraltoan
individualsresponsibilitiesand
resolutioninvolvesallstaffgroups,along
theentirepatientpathway;exposingand
resolvingproblemsisapartofaregular
businessprocessratherthanbeingthe
resultofextraordinaryefforts
6) Whodecideshowworkisallocatedacrossclinicalstaff?Allmanagers Mostlymanagers Aboutthesame Mostlyclinicalleaders Allclinical
leaders -9
7) PerformanceTracking:
Testswhetherperformanceis
trackedusingmeaningful
metricsandwithappropriate
regularity
Score:
1 2 3 4 5 -99
a) Whatkindofperformanceorqualityindicatorswouldyouuseforperformancetracking?
b) Howfrequentlyarethesemeasured?
c) Whogetstoseethesedata?
d) If I were to walk through your hospital wards and operating rooms, could I tell how you were doing against your
performancegoals?
Score1:Measurestrackeddonot
indicatedirectlyifoverallobjectivesare
beingmet(onlygovernmenttargetsare
tracked);trackingisanad-hocprocess
(certainprocessesaren’ttrackedatall)
Score3:Mostimportantperformanceor
qualityindicatorsareformallytrackedand
overseenbyseniorstaff
Score5:Performanceorquality
indicatorsarecontinuouslytrackedand
communicatedagainstmostcritical
measures,bothformallyandinformally,
Page223of248
toallstaffusingarangeofvisual
managementtools
8) PerformanceReview:
Tests whether performance is
reviewed withappropriate
frequency and communicated
to staff
Score:
1 2 3 4 5 -99
a) Howdoyoureviewyourmainperformanceindicators?
b) Canyoutellmeaboutarecentreviewmeeting?
c) Whoisinvolvedinthesemeetings?Whogetstoseetheresultsofthisreview?
d) Whatisatypicalfollow-upplanthatresultsfromthesemeetings?
Score1:Performanceisreviewed
infrequentlyorinanun-meaningfulway
(e.g.onlysuccessorfailureisnoted)
Score3:Performanceisreviewed
periodicallywithbothsuccessesandfailures
identified;resultsarecommunicatedto
seniorstaff;noclearfollowupplanis
adopted
Score5:Performanceiscontinually
reviewed,basedontheindicators
tracked;allaspectsarefollowedupon,to
ensurecontinuousimprovement;results
arecommunicatedtoallstaff
9) PerformanceDialogue:
Tests the quality of review
meetings.
Score:
1 2 3 4 5 -99
a) Howarethesereviewmeetingsstructured?Howistheagendadetermined?Couldyougivemearecentexample?
b) Duringthesemeetings,doyoufindthatyougenerallyhaveenoughinformationforreview?
c) Howusefuldoyoufindthesemeetings?Whattypeoffeedbackoccursinthesemeetings?
d) Foragivenproblem,howdoyougenerallyidentifytherootcause?
Score1:Therightinformationfora
constructivediscussionisoftennot
presentorthequalityistoolow;
conversationsfocusoverlyondatathat
isnotmeaningful;aclearagendaisnot
knownandpurposeisnotexplicitly
stated;nextstepsarenotclearlydefined
Score3:Reviewconversationsareheldwith
theappropriatedatapresent;objectivesof
meetingsarecleartoallparticipatinganda
clearagendaispresent;conversationsdonot,
drivetotherootcausesoftheproblems;next
stepsarenotwelldefined
Score5:Regularreview/performance
conversationsfocusonproblemsolving
andaddressingrootcauses;purpose,
agendaandfollow-upstepsareclearto
all;meetingsareanopportunityfor
constructivefeedbackandcoaching
Page224of248
10) Consequence
Management:
Testswhetherdifferinglevelsof
performance(NOTpersonalbut
plan/processbased)leadto
differentconsequence.
Score:
1 2 3 4 5 -99
a) Let’ssayyou’veagreedtoafollow-upplanatoneofyourmeetings,whatwouldhappeniftheplanweren’tenacted?
b) Howlongisitbetweenwhenaproblemisidentifiedtowhenitissolved?Canyougivemearecentexample?
c) Howdoyoudealwithrepeatedfailuresinobstetriccare?
Score1:Failuretoachieveagreed
objectivesdoesnotcarryany
consequences
Score3:Failuretoachieveagreedresultsis
toleratedforaperiodbeforeactionistaken
Score5:Afailuretoachieveagreed
targetsdrivesretraininginidentified
areasofweaknessormovingindividuals
towheretheirskillsareappropriate
11) TargetBalance:
Testswhethertargetscovera
sufficientlybroadsetofmetrics
Score:
1 2 3 4 5 -99
a) Whattypesoftargetsaresetforthematernityunit?
b) Arethereanygoalsthatarenotsetexternally(e.g.bythegovernment,regulators)?
Score1:Goalsfocusedonlyon
governmenttargetsandachievingthe
budget
Score3:Goalsarebalancedsetoftargets
(includingquality,waitingtime,operational
efficiency,andfinancialbalance);goalsform
partoftheappraisalforseniorstaffonlyor
donotextendtoallstaffgroups;realinter
dependencyisnotwellunderstood
Score5:Goalsareabalancedsetof
targetscoveringallfourdimensions(see
Score3);interplayofallfourdimensions
isunderstoodbyseniorandjuniorstaff
(cliniciansaswellasnursesand
managers)
12) TargetInter-Connection
Testswhethermaternityunits
targetsaretiedtooverall
hospitalobjectivesandcascade
downtodifferentstaffgroupsor
members.
Score:
1 2 3 4 5 -99
a) Whatisthemotivationbehindthesegoals?
b) Howarethesegoalscascadeddowntothedifferentstaffgroupsortoindividualstaffmembers?
c) Howarematernityunittargetslinkedtooverallhospitalperformanceanditsgoals?
Score1:Goalsdonotcascadedownthe
organisation
Score 3: Goals do cascade, but only to some
staffgroups(e.g.nursesonly)
Score 5: Goals increase in specificity as
they cascade, ultimately defining
individualexpectationsforallstaffgroups
Page225of248
13) TimeHorizonofTargets
Testswhetherhospitalhasa‘3
horizons’approachtoplanning
andtargets
Score:
1 2 3 4 5 -99
a) Whatkindoftimescaleareyoulookingatwithyourtargets?
b) Whichgoalsreceivethemostemphasis?
c) Arethelong-termandshort-termgoalssetindependently?
d) Couldyoumeetallyourshort-rungoalsbutmissyourlong-rungoals?
Score1:Thestaff’smainfocusison
achievingshort-termtargets
Score3:Thereareshortandlong-termgoals
foralllevelsoftheorganisation;goalsareset
independentlyandthereforearenot
necessarilylinkedtooneanother
Score5:Long-termgoalsaretranslated
intospecificshort-termtargetssothat
short-termtargetsbecomea‘staircase’to
reachlong-termgoals
14) TargetStretch:
Testswhethertargetsare
appropriatelydifficultto
achieve
Score:
1 2 3 4 5 -99
a) Howtoughareyourtargetsformaternitycare?Howpushedareyoubythetargets?
b) Onaverage,howoftenwouldyousaythatyoumeetyourtargets?Howareyourtargetsbenchmarked?
Score1:Goalsareeithertooeasyor
impossibletoachieve,atleastinpart
becausetheyaresetwithlittleclinician
involvement(e.g.simplyoffhistorical
performance)
Score3:Seniorstaffpushforaggressivegoals
basedonexternalbenchmarksbutwithlittle
buy-infromclinicalstaff.
Score5:Goalsaregenuinelydemanding
forallpartsoftheorganisationand
developedinconsultationwithsenior
staff(e.g.toadjustexternalbenchmarks
appropriately)
15) ClarityandComparability
ofTargets:
Testshoweasilyunderstandable
performancemeasuresareand
whetherperformanceisopenly
communicated
Score:
1 2 3 4 5 -99
a) IfIaskedsomeoneonyourstaffdirectlyaboutindividualtargets,whatwouldheorshetellme?
b) Doesanyonecomplainthatthetargetsaretoocomplex?
c) Howdopeopleknowhowtheirownperformancecomparestootherpeople’sperformance?Isthispublishedorpostedinany
way?
Score1:Performancemeasuresare
complexandnotclearlyunderstood,or
onlyrelatetogovernment/regulator
targets;individualperformanceisnot
madepublic
Score3:Performancemeasuresarewell
definedandcommunicated;performanceis
publicatalllevelsbutcomparisonsare
discouraged
Score5:Performancemeasures arewell
defined, strongly communicated and
reinforced at all reviews; performance
and rankings aremade public to induce
competition
Page226of248
16) RewardingHigh
Performers
Testswhethergoodperformance
isrewardedproportionately
Score:
1 2 3 4 5 -99
a) Howdoesyourstaffappraisalsystemwork?Canyoutellmeaboutyourmostrecentone?
b) Howdoesyourstaff’spayrelatetotheresultsofthisreview?Howdoesthebonussystemwork?
c) Aretherenon-financialrewardsforthebestperformersacrossallstaffgroups?
d) Howdoesyourrewardsystemcomparetothatatothercomparablehospitals?
Score1:Staffmembersarerewardedin
thesamewayirrespectiveoftheirlevel
ofperformance
Score3:Thereisanevaluationsystemforthe
awardingofperformancerelatedrewards
thatarenon-financialattheindividuallevel;
rewardsarealwaysorneverachieved
Score5:Thereisanevaluationsystem
whichrewardsindividualsbasedon
performance;thesystemincludesboth
personalfinancialandnon-financial
awards;rewardsareawardedasa
consequenceofwell-definedand
monitoredindividualachievements17) RemovingPoor
Performers
Testswhetherhospitalisableto
dealwithunderperformers
Score:
1 2 3 4 5 -99
a) Ifyouhadaclinicianoranursewhocouldnotdohis/herjob,whatwouldyoudo?Couldyougivemearecentexample?
b) Howlongisunder-performancetolerated?Howdifficultisittoterminateanurse/clinician?
Score1:Poorperformersarerarely
removedfromtheirpositionsScore3:Suspectedpoorperformersstayina
positionformorethanayearbeforeactionis
taken
Score5:Wemovepoorperformersoutof
theunitortolesscriticalrolesassoonas
aweaknessisidentified
18) PromotingHigh
Performers
Testswhetherpromotionis
performancebased
Score:
1 2 3 4 5 -99
a) Canyoutellmeaboutyourcareerprogression/promotionsystemwithinthehospital?
b) Howdoyouidentifyanddevelopyourstarperformers?Whattypesofprofessionaldevelopment/trainingopportunities
areprovided?
c) Howdoyoumakedecisionsregardingprogression/promotionswithintheunit/hospital?
d) Arebetterperformerslikelytobepromotedfasterorarepromotionsgivenonthebasisoftenure/seniority?Score1:Peoplearepromotedprimarily
onthebasisoftenure(yearsofservice)Score3:Peoplearepromoteduponthebasis
ofperformance
Score5:Weactivelyidentify,developand
promoteourtopperformers
Page227of248
19) ManagingHR/Talent
Testswhatemphasisisputon
talent/Humanresource
management
Score:
1 2 3 4 5 -99
a) Doyouhaveauthoritytohireordismissadditionalhealthworkers?
b) Howdoyouensureyouhaveenoughstaff/nursesoftherighttypeinthehospital?
c) Howdoseniormanagersshowthatattractingtalentedindividualsanddevelopingtheirskillsisatoppriority?
d) Doseniorstaffmembersgetanyrewardsforbringinginandkeepingtalentedpeopleinthehospital?Score1:Seniorstaffdonot
communicatethatattracting,retaining
anddevelopingtalentthroughoutthe
organisationisatoppriority
Score3:Seniorstaffbelieveand
communicatethathavingtoptalent
throughouttheorganisationiskeytogood
performance
Score5:Seniorstaffareevaluatedand
heldaccountableonthestrengthofthe
talentpooltheyactivelybuild
20) RetainingTalent:
Testswhetherhospitalwillgo
outofitswaytokeepitstop
talent
Score:
1 2 3 4 5 -99
a) Ifyouhadatopperformingmanager,nurseorclinicianthatwantedtoleave,whatwouldthehospitaldo?
b) Couldyougivemeanexampleofastarperformerbeingpersuadedtostayafterwantingtoleave?
c) Couldyougivemeanexampleofastarperformerwholeftthehospitalwithoutanyonetryingtokeepthem?Score1:Wedolittletotryandkeepourtoptalent
Score3:Weusuallyworkhardtokeepour
toptalent
Score5:Wedowhateverittakesto
retainourtoptalentacrossallstaff
groups
21) AttractingTalent
Teststhestrengthofthe
employeevalueproposition
Score:
1 2 3 4 5 -99
a) Whatmakesitattractivetoworkatthishospital,asopposedtoothersimilarhospitals?
b) IfIwasatopnurse/clinicianandyouwantedtopersuademetoworkatyourhospital,howwouldyoudothis?
c) Whatdoyouthinkpeoplemaynotlikeaboutworkingatyourhospital?Score1:Competinghospitalsoffer
strongerreasonsfortalentedpeopleto
jointheirorganizations
Score3:Ourvaluepropositioniscomparable
tothoseofferedbyotherhospitals
Score5:Weprovideauniquevalue
propositiontoencouragetalented
individualstojoinourhospitalcompared
toourcompetition
a) Canyoutellmeabouttherolethatclinicians(e.g.doctors/consultants)haveinimprovingperformanceandachieving
targets?
b) Howareindividualcliniciansresponsiblefordeliveryoftargets?Doesthisapplytocosttargetsaswellasquality
targets?.c) Howdoclinicianstakeonrolestodelivercostimprovements?Aretheyselectedforthisroleordotheyvolunteer?Can
youthinkofexamples?
Page228of248
22) ClearlyDefined
Accountabilityfor
Clinicians
Testswhetherthereisformal
leadershiprolesand
accountabilityamongclinicians
fordeliveryofhospitaltargets
andobjectives
Score:
1 2 3 4 5 -99
Score1:Formalaccountabilityfor
clinicalperformance(quality)
only
Score3:Thereissomeaccountabilityfordelivery
beyondclinicalqualitybutthismightbediffusedwithin
ateamornotcarrysignificantconsequences;clinical
performancestillconsideredtobethemainpartofthe
job
Score5:Formalaccountabilityacross
qualityserviceandcostdimensions
witheffectiveperformance
managementandconsequencesfor
good/poorperformance
Post-Interview
23) Interviewduration(minutes)_________________
24) Intervieweeknowledgeof
managementpractices
Score:1 2 3 4 5
Score1:Someknowledge
aboutmanagementof
maternityfacilities.
Score3:Expertknowledgemanagementofmaternity
unit
Score5:Expertknowledgeabouthis
specialtyandalsotherestofthe
hospital.
25) Intervieweewillingnessto
revealinformation
Score:1 2 3 4 5
Score1:Veryreluctantto
providemorethanbasic
information
Score3:Providesallbasicinformationandsomemore
confidentialinformation
Score5:Totallywillingtoprovide
anyinformationaboutthehospital!
26) Intervieweepatience
Score:1 2 3 4 5
Score1:Littlepatience-wants
toruntheinterviewasquickly
aspossible.Ifeltheavytime
pressure
Score3:Somepatience-willingtoproviderichnessto
answersbutalsotimeconstrained.Ifeltmoderatetime
pressure
Score5:Lotofpatience-willingto
talkforaslongasrequired.Ifeltno
timepressure27) Didthemanagermention
thatthehospitalwasa
teachinghospital?
Yes No
28) Ageofinterviewee
(don'task)-guessifnot
told
29) Numberoftimesrescheduled(0=never
rescheduled)
30) Genderofinterviewee:
Male Female
31) Seniorityofinterviewee:
1. CEO
2. Multi-specialtymanager
3. SpecialtyManager
32) Didtheintervieweehaveadegree-guessifnot
told
33) Interviewlanguage
Hindi
English
Page229of248
4. Withinspecialtymanagement
5. Technicianwithoutmanagementrole(e.g.nurseorjunior
doctor)
Page230of248
Appendix3:Informationsheetsandconsentforms
3.1:InformationSheetforhealthworkersforclinicalpracticeobservation
DearMadam/Sir,
Weare conducting a study tounderstand thequality ofmaternal andnewbornhealth servicesprovided atseveralhealthfacilitiesinUP,Indiaincludingthishealthfacility.Thissheetprovidesyouwithinformationaboutthisresearch.ThisstudyhasbeenapprovedbythePublicHealthcareSociety(PHS)EthicsReviewBoardinIndiaandtheLondonSchoolofHygiene&TropicalMedicineintheUK(LSHTMEthicsRef:8858).ThestudyprotocolalsoreceivedclearancefromtheNationalHealthMissioninUttarPradesh.Wehavealsoobtainedpermissionfromthefacilityincharge/hospitaldirectortoobservethecareprovidedatthisfacilitytoday.
Whyisthisimportant?
Asyouknow,manywomenandbabiesdieduetocomplicationsduringpregnancyandchildbirthinUP.Hence,weareconductingthisresearchtounderstandmoreaboutthequalityofservicesofferedathealthfacilitiessothatwecanimprovethequalityofobstetricandneonatalcareservices.
Whoiscarryingoutthestudy?
ThisstudyisfundedbyMerckforMothers.ItisbeingrunbyasmallteamofresearchersfromSambodhiandtheLondonSchoolofHygieneandTropicalMedicine(LSHTM).
Whatisinvolved?
Aclinicallyqualifiedresearcherwillobservethequalityofservicesofferedtowomenandneonatesduringlabourandchildbirthandtheimmediatepostnatalperiod.Theobserverisnottheretosupportyouorinterferewithanyaspectsofclinicalcareprovision.
Isthisresearchconfidential?
Yes.Anyinformationobtainedfromthisresearchisconfidentialandwillonlybeseenbythemembersoftheresearch team. All information will be stored securely. This means any findings obtained from the clinicalobservationswillnotbelinkedtoanyindividualhealthworkerorfacility.
Whatarethebenefitsoftakingpartinthisresearch?
There arenodirect benefits to you for participating in this research.However,wewill use the informationobtainedfromthissurveytoimprovethehealthcareservicesatselectedhealthfacilitiesinUP,India.
Whataretherisksintakingpart?
Therearenorisksbecauseoftakingpartinthisresearch.Yourpersonalidentitywillbeprotectedatalltimesandthiswillhavenoimpactonyourworkatthishealthfacility.
Page231of248
DoIhavetotakepartinthisresearch?
No.Ifyoudecidenottoparticipateinthestudy,itwillnothaveanyeffectonanyoftheservicesthatyoureceive.
Howwilltheresearchfindingsbeused?
ThefindingsoftheresearchwillbeusedtodevelopareportwhichwillhighlighttheexistingqualityofmaternalandneonatalhealthservicesprovidedatselectedhealthfacilitiesinthreedistrictsinUttarPradesh,India.
Thankyoufortakingthetimetoreadthisinformation.Wereallyappreciateyourparticipationinthisresearch.
Theresearchwillonlyproceedonceyouhaveaskedanyotherquestionsthatyoumayhaveandhavesignedtherelevantconsentforms.Youcankeepthisinformationsheetwithyou.
Ifyouhaveanyquestionsoropinionsaboutthisstudy,pleasecontact:
LSHTM:GAURAVSHARMA,+ +918601882687;[email protected]
Page232of248
3.2:Consentformforhealthworkeronclinicalpracticeobservation
Instructions:Whenhealthworkerarrivestoconductadelivery,pleaseprovidehimorherwiththeinformationsheet.Itisessentialthatyouobtainaninformedconsentfromthehealthworkerbeforebeginningtheobservation.Pleaseaskthehealthworkertosignanddatetheconsentformoncetheyhavereadtheinformationbelowandagreetoparticipateinthestudy.
I_________________________________________agreetotakepart inthisstudyonthequalityofmaternalandnewborncareservicesprovidedatthishealthfacility.
Iunderstandthat:
• Iamagreeingtoallowaclinicallyqualifiedresearchertoobserveaspectsofclinicalcareprovision.• All the findings from this research are confidential andwill not be linked tomy name or any personal
information.• Myparticipationiscompletelyvoluntaryandrefusaltoparticipatewillnothaveanyimplicationsonmeor
myworkatthishealthfacility.• Ihavebeenprovidedwiththenecessaryinformationaboutthisresearchandhavealsohadanopportunity
toclarifyallmyquestions.
Myquestionshavebeenansweredby___________________________________
Signatureofthehealthworker_______________________
Date:_______________________________
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3.3:WomanconsentformforclinicalpracticeobservationfpfdRlh; O;ogkj vkCtosZ'ku ds fy, lsokxzkgh ¼Dyk,aV½ dh lgefr
INSTRUCTIONSTOOBSERVER
vkCtoZj ds fy, funsZ'k
Whenapregnantwomanarrivesattheemergencyroomorwaitingroomofthelabouranddeliveryward,pleaseprovidehertheinformationsheetbeforeenrollingherinthestudy.Itisessentialthatyouobtainaninformedconsentfromtheclientbeforebeginningtheobservation.Iftheclientcannotreadathumbprintshouldbeobtained.Consentforclientcannotbegivenbyhealthworkerorfacilityin-charge.
tc dksbZ xHkZorh efgyk vkikRdkyhu d{k esa ;k izlo vkSj izlwfr okMZ ds izrh{kk d{k esa vk;s rks ;bl v/;;u esa ukekafdr djus ls igys mls ;g tkudkjh 'khV nsaA ;g vko';d gS fd vkCtosZ'ku ¼i;Zos{k.k½ djus ls igys vki lsokxzkgh ¼Dyk,aV½ dh tkudkjh;qDr lgefr izkIr dj ysaA vxj lsokxzkgh i<+ fy[k ugha ldrh rks mlds vaxwBs dk fu'kku fy;k tkuk pkfg,A Dyk,aV ds fy, LokLF; dk;ZdrkZ ;k LokLF; lqfo/kk dk izHkkjh lgefr ugha ns ldrkA
Iunderstandthat:
eSa le>rh gwa fd%
IamagreeingtoallowaclinicallyqualifiedresearchertoobservethequalityofservicesthatIreceiveatthishealthfacilitytoday.
eSa ,d fpfdRlh; :i ls ;ksX; 'kks/kdrkZ dks vkt bl lqfo/kk esa eq>s izkIr gksus okyh lsokvksa dh xq.koÙkk dks vkCtoZ djus ;k ns[kus dh vuqefr ns jgh gwaA
Allthefindingsfromthisresearchareconfidentialandwillnotbelinkedtomynameoranypersonalinformation.
bl 'kks/k ds lHkh fu"d"kZ xksiuh; gSa vkSj mUgsa esjs uke ;k fdlh O;fDrxr tkudkjh ls ugha tksM+k tk;sxkA
MyparticipationiscompletelyvoluntaryandwillnothaveanyimplicationsontheservicesthatIreceivetoday.
esjh Hkkxhnkjh iwjh rjg ls LoSfPNd gS vkSj eSa tks lsok,a izkIr dj jgh gwa mu ij bldk dksbZ izHkko ugha iM+sxkA
Ihavebeenprovidedwiththenecessaryinformationaboutthisresearchandhavealsohadanopportunitytoclarifyallmyquestions.
eq>s bl 'kks/k ds ckjs esa vko';d tkudkjh ns nh xbZ gS vkSj eq>s iz'u iwNus dk volj Hkh feyk gSA
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Myquestionshavebeenansweredby___________________________________esjs iz'uksa ds mÙkj
IattestthatIreadtheconsentformtotheparticipantandshehasagreedtoparticipate.eSa ;g izekf.kr djrk gwa fd eSaus lgHkkxh dks lgefr i= i<+dj lquk;k gS vkSj og Hkkx ysus ds fy, lger gSA
Thumbprint____________________________vaxwBs dk fu'kku
Researcher’ssignature:_______________________'kks/kdrkZ ds gLrk{kj%
Signed_______________________gLrk{kj
Date:_______________________________frfFk%
Date:_______________________________frfFk
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Appendix4:Ethicalapprovallettersandpermissions
Observational / Interventions Research Ethics Committee
LSHTM
18 May 2015
Dear
Study Title: Quality of Care for normal labour and childbirth at maternity facilities in Uttar Pradesh, India: A Cross‑Sectional Study
LSHTM Ethics Ref: 8858
Thank you for responding to the Observational Committee’s request for further information on the above research and submitting revised documentation.
The further information has been considered on behalf of the Committee by the Chair.
Confirmation of ethical opinion
On behalf of the Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the application form, protocol and supporting documentationas revised, subject to the conditions specified below.
Conditions of the favourable opinion
Approval is dependent on local ethical approval having been received, where relevant.
Approved documents
The final list of documents reviewed and approved by the Committee is as follows:
Document Type File Name Date Version
Covering Letter Covering letter after resubmission 14.5.15 14/05/2015 2
Protocol / Proposal Consent and info sheet combined 5.5.15 14/05/2015 2
Information Sheet Consent and info sheet combined 5.5.15 14/05/2015 2
After ethical review
The Chief Investigator (CI) or delegate is responsible for informing the ethics committee of any subsequent changes to the application. These must be submitted to the Committee for reviewusing an Amendment form. Amendments must not be initiated before receipt of written favourable opinion from the committee.
The CI or delegate is also required to notify the ethics committee of any protocol violations and/or Suspected Unexpected Serious Adverse Reactions (SUSARs) which occur during the projectby submitting a Serious Adverse Event form.
At the end of the study, the CI or delegate must notify the committee using an End of Study form.
All aforementioned forms are available on the ethics online applications website and can only be submitted to the committee via the website at: http://leo.lshtm.ac.uk
Additional information is available at: www.lshtm.ac.uk/ethics
Yours sincerely,
Professor John DH PorterChair
[email protected]://www.lshtm.ac.uk/ethics/
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Appendix5:PublishedmanuscriptforChapter6
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Appendix6:Tableshowingfrequencyofmistreatmentbysector
Itemsofmistreatment Publicsector Privatesector N(%) N(%)1. Anyitemofmistreatment 211(100.0) 64(100.0)2. Twoitemsofmistreatment 10(4.7) 3(4.7)3. Threeitemsofmistreatment 41(19.4) 10(15.6)4. Fouritemsofmistreatment 44(20.9) 17(26.6)5. Fiveitemsofmistreatment 43(20.4) 19(29.7)6. Sixitemsofmistreatment 32(15.2) 9(14.1)7. Sevenitemsofmistreatment 21(10.0) 4(6.3)8. Eightitemsofmistreatment 14(6.6) 0(0.0)9. Nineitemsofmistreatment 3(1.4) 2(3.1)10. Tenitemsofmistreatment 3(1.4) 0(0.0)