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Background: Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India.Methods: Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival.Results: Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results.Conclusions: From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives. [ABSTRACT FROM AUTHOR]

Background: Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India.Methods: Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses' knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets.Results: Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience.Conclusions: This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India.Trial Registration: This study is registered at clinicaltrials.gov, Identifier No. NCT02004912 , November 27, 2013. [ABSTRACT FROM AUTHOR]

Background: Despite the reduction in the maternal mortality ratio, barriers in obstetric care services (OCS) remain a significant risk factor for adverse maternal and perinatal outcomes in India. This review covers the 'continuum of care' (ANC, child delivery, and PNC services) and identifies multiple barriers in provisioning as well as utilization of OCS in India. We conducted a systematic review to understand the barriers using a mixed-methods approach. Methods: PubMed, Scopus, Web of Science, Google Scholar, and Science Direct databases were searched from 1 January 2000 to 30 June 2022. The methodological quality of the included studies was assessed using appropriate tools. After a full-text review of 164 studies, total of 56 studies (33 quantitative, 18 qualitative, and 5 mixed-methods studies) were finally included in the review. All the barriers were classified into five major themes: (i) individual and interpersonal barriers, (ii) social and cultural barriers, (iii) structural barriers, (iv) logistical barriers, and (v) organizational barriers. A thematic synthesis approach was used to present the findings of the included studies. Results: Lack of knowledge and awareness and less family support in availing the required OCS were key individual and interpersonal barriers. Negative social and cultural practices, such as belief in traditional herbs/healers, dietary restrictions, and discarding colostrum were frequently reported barriers, especially in rural settings. Poor economic status and high health service costs were the most often cited barriers to low institutional delivery and delayed ANC services. Long distances to health facilities and poor road conditions were the most frequently reported logistical barriers. On the provisioning side, poor quality of treatment, shortage of drugs and equipment, and non-cooperative attitude of health professionals were the most significant barriers. Conclusion: This review identified several important barriers ranging from individual and cultural to structural, logistical, and organizational, which are prevalent in India. To mitigate the barriers, the governments need to develop strategies at the individual and organizational levels. Innovative interventions and program implementation at the community and village levels could also be contributory steps towards improving OCS utilization in India. [ABSTRACT FROM AUTHOR]

Background: In 2005-06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this.Methods: In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data.Results: Our findings suggest that women's increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for 'safe' and 'easy' delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women's choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities.Conclusions: In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities. [ABSTRACT FROM AUTHOR]

Background: Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It's unknown if simulation facilitation skills can be adopted through a train of trainers' cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge, attitudes and skills of a third generation of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in 40 primary healthcare facilities in Bihar, India. Methods: We performed a 1 year before–after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 701 nurses in Bihar, India. The data included 701 pre-post knowledge and attitudes self-assessments; videos of simulations and associated debriefs conducted by 701 providers at 40 primary healthcare centers. Results: We observed a statistically significant difference in knowledge and attitude scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs. Conclusion: This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 701 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgment require practice. [ABSTRACT FROM AUTHOR]

Background: Better quality of care around the time of childbirth can significantly improve maternal and newborn survival. In countries like India, where the private sector contributes to a considerable proportion of institutional deliveries, it is important to assess the quality of maternity care offered by private sector healthcare facilities. This study seeks to fill that information gap by analysing baseline assessments conducted for the Manyata program, which aims to improve the quality of maternity care at private facilities.Methods: An observation checklist based on 16 clinical standards endorsed by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) was used to assess 201 private sector healthcare facilities in Maharashtra, Jharkhand, and Uttar Pradesh. Data on facility characteristics came from profiles completed when facilities enrolled in Manyata. Differences in the mean number of standards met were analysed by facility characteristics and the availability of essential supplies.Results: Around half (47.1%) of all nursing staff engaged in maternity care services at these private healthcare facilities were under qualified. The mean number of clinical standards met by facilities was 3.2 (SD 2.4). Facilities with a monthly delivery load between 20 and 50 met a significantly higher number of standards, as did facilities that had more than 70% of essential supplies available. Both these factors were also significant in a multiple linear regression analysis.Conclusions: The overall quality of maternity care in private healthcare facilities is poor in all three states, especially for clinical standards related to management of complications. [ABSTRACT FROM AUTHOR]

Background: Expanding institutional deliveries is a policy priority to achieve MDG5. India adopted a policy to encourage facility births through a conditional cash incentive scheme, yet 28% of deliveries still occur at home. In this context, it is important to understand the care experience of women who have delivered at home, and also at health facilities, analyzing any differences, so that services can be improved to promote facility births. This study aims to understand women's experience of delivery care during home and facility births, and the factors that influence women's decisions regarding their next place of delivery.Method: A community-based cross-sectional survey was undertaken in a district of Jharkhand state in India. Interviews with 500 recently delivered women (210 delivered at facility and 290 delivered at home) included socio-demographic characteristics, experience of their recent delivery, and preference of future delivery site. Data analysis included frequencies, binary and multiple logistic regressions.Results: There is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage, injection and low cost of delivery for those having home births. 75% women wanted to deliver their next child at a facility, main reasons being availability of medicine (29.4%) and perceived health benefits for mother and baby (15%). Women with higher education (AOR = 1.67, 95% CI = 1.04-3.07), women who were above 25 years (AOR = 2.14, 95% CI = 1.26-3.64), who currently delivered at facility (AOR = 5.19, 95% CI = 2.97-9.08) and had health problem post-delivery (AOR = 1.85, 95% CI = 1.08-3.19) were significant predictors of future facility-based delivery.Conclusion: The predictors for facility deliveries include, availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. There is a growing preference for facility delivery particularly among women with higher age group, education, income and those who had antennal checkup. In order to uptake facility births, the quality improvement initiatives should regularly assess and address women's experiences of care. [ABSTRACT FROM AUTHOR]