Quality of routine labor and delivery care in Uttar Pradesh, India: Are private facilities better?
Measuring quality of care in public and private facilities
In an effort to address this evidence gap, a recent article from the Bulletin of the World Health Organization (http://www.who.int/bulletin/volumes/95/6/16-179291/en/) assessed the quality of essential obstetric and newborn care during routine labor and delivery in Uttar Pradesh, India. The authors from the London School of Hygiene & Tropical Medicine and Sambodhi Research and Communications conducted clinical observations of 275 mother-newborn pairs at 18 public facilities and eight private facilities in Uttar Pradesh. For each clinical observation, the authors assessed 42 items related to quality of care and, using a comprehensive framework, mapped their observations onto 17 essential obstetric and neonatal care practices:
The researchers found poor quality of care in both public and private facilities. Unqualified personnel were found to provide institutional maternity care in up to 59% of all deliveries, and a number of life-saving clinical practices such as partograph use for monitoring labor, screening for pre-eclampsia/eclampsia and active management of the third stage of labor were rarely observed. Additionally, researchers noted the provision of women-centered, respectful maternity care (https://www.mhtf.org/topics/respectful-maternity-care/) practices in just 4% of deliveries.
Overall, 45% of recommended practices were completed for women giving birth in the private sector compared to 33% in the public sector. For obstetric care, private sector clients received 40% of the recommended practices compared to 28% in the public sector. Similarly, 51% of the recommended neonatal care practices were completed in the private sector compared to 39% in the public sector:
Overall poor quality of care at the time of birth Total Public Private Obstetric care Index (9 items) 30.6% 28.3% 40.0% Neonatal care (8 items) 41.4% 39.0% 51.0% Essential care at birth(17 items) 35.7% 33.3% 45.0% Note: Table made from bar graph.
The authors also found a statistically significant difference between sectors for specific indicators: Regular partograph use for monitoring labor, assessment of maternal blood loss after childbirth and measures for the prevention of maternal infection during childbirth were performed more frequently in the private sector compared to the public sector:
* Enlarge graph (https://www.wider.unu.edu/sites/default/files/Blog/PDF/MHTF%20Blog.pdf)
Implications for research, policy and practice
According to the authors, the findings from this study have several implications for global maternal health research, policy and practice:
'A systematic effort to measure and identify quality gaps during labor and childbirth is required, particularly in high-burden settings in India and elsewhere'.
'There should be further research to identify the reasons for unqualified personnel providing institutional maternity services in both public and private sector facilities'.
'The private sector provides a substantial and increasing proportion of maternity services across the world. Therefore, research, programs, policy and advocacy efforts to improve quality of care at the time of birth should also include private sector facilities',
'We need to develop tailored quality improvement initiatives at facilities in both sectors with regular auditing of the actual care processes and link these to functional accountability mechanisms'.
The views expressed in this piece are those of the author(s), and do not necessarily reflect the views of the Institute or the United Nations University, nor the programme/project donors.
Read more on the papers published in the WHO Bulletin theme issue 'Measuring quality of care' at the UNU-WIDER's lauch event website
This article was originally published by Maternal Health Task Force blog (https://www.mhtf.org/2017/06/23/quality-of-routine-labor-and-delivery-care-in-uttar-pradesh-india-are-private-facilities-better/).
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Table 1. Framework used for the assessment of essential care at birth, India, 2015 Timing Obstetric care Clinical practice Observed items On admission and Regular monitoring Is labour monitored regularly during first stage of labour using a with partograph? of labour partograph Measures for the Are hands washed before prevention of examination and are sterile maternal infection gloves put on before vaginal during admission examination? Screening for Is blood pressure monitored pre-eclampsia and and urine tested for eclampsia proteins? From second Measures for the Are sterile gloves put on stage of labour prevention of before vaginal examination to completion of maternal infection and are vulva and perineum childbirth during childbirth cleaned with antiseptic? Active Is uterotonic given within management of minute of birth, is the cord the third stage of clamped and is there labour controlled cord traction? Assessment of Are the placenta and maternal blood loss membranes checked for completeness, is the vagina checked for tears and is there monitoring of bleeding postpartum? Use of woman- Is process of labour centred respectful explained care practices to the mother or support person at least once, is companion allowed to be with the mother during labour, is mother informed before vaginal examination, is visual privacy ensured and is mother asked about choice of position? Avoidance Is an enema given, is the of harmful or pubic area shaved, is fundal unnecessary pressure applied to hasten interventions for delivery of baby or placenta, mother is there uterine lavage after delivery, is there manual exploration of the uterus after delivery and is there use of episiotomy without any indication? Avoidance Does the health worker of harmful or restrict mother's fluid and unnecessary health food intake during labour; do worker behaviour they insult, shout or threaten the mother during labour and childbirth; and, do they hit, pinch or slap the mother during labour and childbirth? Timing Fetal or neonatal care Clinical practice Observed items On admission and Check fundal Is fundal height checked during first stage height and fetal and is fetal presentation of labour presentation checked? Regular monitoring Is fetal heart rate of fetal heart rate monitored at regular intervals? From second Health workers Is ventilation bag stage of labour prepared for available and is neonatal to completion of resuscitation if mask available and laid childbirth required out? Neonatal cord care Is cord cut with a sterile instrument? Appropriate Is neonate dried properly; thermal care of is skin-to-skin contact neonate between neonate and mother initiated and is the neonate covered with a dry towel? Assessment of Is the Apgar score assessed Apgar score one minute after birth and is it assessed five minutes after birth? Initiation of early Did the mother initiate breastfeeding breastfeeding within hour of birth? Avoidance Is their routine aspiration of harmful or of neonate's nose, is the unnecessary neonate slapped and is the practices for neonate held upside down? neonate Note: We assessed nine obstetric care and eight neonatal care practices.
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|Date:||Jun 1, 2017|
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