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Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Background: Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India.Methods: A community-based cross-sectional survey was conducted between June-October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery.Results: Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06-1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46-1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04-1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46-1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07-8.08).Conclusion: The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

Background: Caesarean section delivery is a major life-saving obstetric surgical intervention for mothers and babies from pregnancy and childbirth related complications. This paper attempts to investigate the geographical variations and correlating factors of caesarean section delivery in India, particularly focusing on the states of Bihar and Tamil Nadu, accounting for one of the lowest and highest prevalence states of caesarean section delivery respectively.Methods: This study is based on secondary data, collected from the fourth round of the National Family Health Survey (NFHS-4), 2015-16. We utilized 190,898 women aged 15-49 years who had a living child during the past 5 years preceding the survey. In this study, caesarean section delivery was the outcome variable. A variety of demographic, socio-economic, and pregnancy- and delivery-related variables were considered as explanatory variables. Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed to draw the inferences from data.Results: Of participants, about 19% of women had undergone caesarean section delivery in the country. The state-wise distribution shows that Telangana (60%) followed by Andhra Pradesh (42%) and Tamil Nadu (36%) represented the topmost states in caesarean delivery, while Bihar (7%), Madhya Pradesh (10%), and Jharkhand (11%) placed at the bottom end. Multivariate logistic models show that the likelihood of caesarean delivery was higher among older women (35-49 years), women with higher levels of education, Muslims, women belonging to the upper quintiles of the household wealth, and those who received antenatal care (ANC), experienced pregnancy loss and delivery complications. Moreover, the odds of caesarean section delivery were remarkably greater for the private health sector than the public health sector in both focused states: Bihar (odds ratio [OR] = 12.84; 95% confidence interval [CI]: 10.90, 15.13) and Tamil Nadu (OR = 2.90; 95% CI: 2.54, 3.31).Conclusion: Findings of this study suggest that improvement in female education, providing economic incentives, and spreading awareness through mass media could raise the caesarean section delivery among women whose vaginal delivery could be unsafe for them as well as for their babies. Moreover, providing adequate ANC and well-equipped public healthcare services would facilitate caesarean delivery among needy women. [ABSTRACT FROM AUTHOR]

Background: Maternal deaths among young women (15-24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India.Methods: The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992-93, 1998-99, 2005-06 and 2015-16. Young married women aged 15-24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05.Results: The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992-2016. SBA utilization was 88 and 83% during 2015-16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time.Conclusions: In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states. [ABSTRACT FROM AUTHOR]

Background: The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. Methods: Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015–16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. Results: Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015–16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was − 0.161 [95% CI, − 0.158, − 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. Conclusion: Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. Methods: This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. Findings: All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. Conclusions: Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers. [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: India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).Methods: A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.Results: EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.Conclusions: The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector. [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: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/ non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death. [ABSTRACT FROM AUTHOR]

Background: In places with poor vital registration, measurement of maternal mortality and monitoring the impact of interventions on maternal mortality is difficult and seldom undertaken. Mortality ratios are often estimated and policy decisions made without robust evidence. This paper presents a prospective key informant system to measure maternal mortality and the initial findings from the system. Methods: In a population of 228 186, key informants identified all births and deaths to women of reproductive age, prospectively, over a period of 110 weeks. After birth verification, interviewers visited households six to eight weeks after delivery to collect information on the ante-partum, intra-partum and post-partum periods, as well as birth outcomes. For all deaths to women of reproductive age they ascertained whether they could be classified as maternal, pregnancy related or late maternal and if so, verbal autopsies were conducted. Results: 13 602 births were identified, with a crude birth rate of 28.2 per 1000 population (C.I. 27.7-28.6) and a maternal mortality ratio of 722 per 100 000 live births (C.I. 591-882) recorded. Maternal deaths comprised 29% of all deaths to women aged 15-49. Approximately a quarter of maternal deaths occurred ante-partum, a half intra-partum and a quarter post-partum. Haemorrhage was the commonest cause of all maternal deaths (25%), but causation varied between the ante-partum, intra-partum and post-partum periods. The cost of operating the surveillance system was US$386 a month, or US$0.02 per capita per year. Conclusion: This low cost key informant surveillance system produced high, but plausible birth and death rates in this remote population in India. This method could be used to monitor trends in maternal mortality and to test the impact of interventions in large populations with poor vital registration and thus assist policy makers in making evidence-based decisions. [ABSTRACT FROM AUTHOR]

Background: Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities. Methods: This paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women's experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities. Results: The exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust. Conclusions: The results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices. [ABSTRACT FROM AUTHOR]