Strengthening Fetal Heart Rate Monitoring during Labor with a Standard Handheld Doppler - Implementation Experience from India

BACKGROUND

India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states.

METHODS

Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators.

RESULTS

Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98-2.07, P < 0.01) and in Community Health Centers (14.7-1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6-1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings.

CONCLUSION

The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring.

A Novel Approach to Promote Evidence-Based Development of District Maternal and Newborn Health Plans in Two States in India

Background:

Maternal and child health implementation plan development in districts of India lacks systematic process and capacity resulting in suboptimal health improvements. There is ineffective and limited participation and lack of autonomy to effect changes in district priorities.

Objectives:

Primary objective was to demonstrate a systematic planning approach to develop evidence-based district implementation plans for mothers and children.

Methods:

A planning tool named RAASTA (RMNCH + A Action Agenda using Strategic Approach for evidence-based district work plans) adapted from WHO (World Health Organization) program review tools was used in the states of Uttarakhand and Jharkhand. The tool was implemented in the two states for the development of implementation plans in a 6-step process by prioritizing district health goals; reviewing maternal, neonatal, child, and family planning intervention coverage; and linking them with activity implementation status; assessing strengths, and weaknesses of previous implementation plans and developing solutions based on current gaps in intervention coverage's.

Results:

Tool was used for capacity building of 59 participants and also identification of prioritized activities based on their available data. Several newer activities were identified. The districts mainstreamed them as action plans, many of which were incorporated in the state Program Implementation Plan for budgetary provisions under state NHM (National Health Mission) funds.

Conclusion:

The use of a tool facilitated the systematic development of evidence-based district implementation plans.

Safe Delivery application with facilitation increases knowledge and confidence of obstetric and neonatal care among frontline health workers in India

Background:

Methods:

Results:

Conclusion:

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India

OBJECTIVES

To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device.

DESIGN

The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained.

SETTING

Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall.

PARTICIPANTS

Under-5 children presenting with ARI symptoms at the OPD.

RESULTS

Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting.

CONCLUSION

Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India

BACKGROUND

With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival.

METHODS

The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated.

RESULTS

Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%.

CONCLUSION

The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

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

Background:

The effective implementation of evidence-based practices including the use of partograph to improve maternal and newborn outcomes is critical on account of increased institutional delivery. However, despite clear guidelines, partograph use in India is not widely practiced.

Materials and Methods:

Quality improvement (QI) efforts along with training and mentoring were operationalized in a total of 141 facilities across 26 high priority districts of India. Assessments were conducted across baseline, intervention period, and end line. These included reviewing the availability of partograph and staff competency in filling them at baseline and end line, as well as reviewing monthly data for use and completeness of filling. The monthly data were tabulated quarter wise to study trends. Competency scores were tabulated to show the difference across assessments.

Results:

An overall upward trend from 29% to 61% was seen in the practice of partograph use. Simultaneously, completeness in filling up the partograph increased from 32% to 81%. Staff competency in filling partograph improved considerably: proportion of staff scoring low decreased over the intervention period from 63% to 2.5% (P < 0.0001), and the proportion scoring high increased from 13% to 72% (P < 0.0001) from baseline to end line.

Conclusion:

The integrated approach of training, mentoring, and QI can be used in similar settings to strengthen partograph use.

Improving Adolescent Health Services across High Priority Districts in 6 States of India: Learnings from an Integrated Reproductive Maternal Newborn Child and Adolescent Health Project

Background

India has been at the forefront of designing adolescent health (AH) policies. The National Adolescent Reproductive and Sexual Health policy (2006), the Reproductive, Maternal, Newborn Child, and AH strategy (2013), and the "Rashtriya Kishor Swasthya Karyakram (RKSK)" (2014) have been the critical milestones in this direction. However, despite policies being available, the AH outcomes need improvement through operationalization of focused and need-based AH interventions.

Objectives

The objectives of this study were to improve services for RKSK interventions across select geographies of India.

Materials and Methods

USAID's VRIDDHI Project has been providing technical support at the national level and in six focus states to improve uptake of evidence-based high-impact reproductive, maternal, newborn, child, and AH interventions. To improve AH services and outcomes, two approaches were implemented, namely (a) strengthen the functioning of adolescent-friendly health clinics in 95 high caseload health facilities in 26 high priority districts across six states and (b) demonstrate other operational strategies outlined in RKSK program including strengthening of district committees on AH, undertaking formative research for developing adolescent-focused communication strategy, and operationalizing weekly iron and folic acid supplementation program.

Results

As a result of ongoing technical support over 2-year period (January 2016-December 2017), improvements were noted across multiple AH indicators. In addition, evidence-based learnings were also generated from the demonstration models for potential scale up to other geographies.

Conclusion

The project was successful in improving AH services in the intervention facilities through an integrated approach which is replicable, sustainable, and scalable for driving the AH program in India.