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BackgroundHome-based newborn care has been found to reduce neonatal mortality in rural areas. Study evaluated effectiveness of home-based care delivered by specially recruited newborn care workers- Shishu Rakshak (SR) and existing workers- anganwadi workers (AWW) in reducing neonatal and infant mortality rates.MethodsThis three-arm, community-based, cluster randomised trial was conducted in five districts in India. Intervention package consisted of pregnancy surveillance, health education, care at birth, care of normal/low birthweight neonates, identification and treatment of sick neonates and young infants using oral and injectable antibiotics and community mobilisation. The package was similar in both intervention arms—SR and AWW; difference being healthcare provider. The control arm received routine health services from the existing health system. Primary outcomes were neonatal and young infant mortality rates at ‘endline’ period (2008–2009) assessed by an independent team from January to April 2010 in the study clusters.FindingsA total of 6623, 6852 and 5898 births occurred in the SR, AWW and control arms, respectively, during the endline period; the proportion of facility births were 69.0%, 64.4% and 70.6% in the three arms. Baseline mortality rates were comparable in three arms. During the endline period, the risk of neonatal mortality was 25% lower in the SR arm (adjusted OR 0.75, 95% CI 0.57 to 0.99); the risks of early neonatal mortality, young infant mortality and infant mortality were also lower by 32%, 27%, and 33%, respectively. The risks of neonatal, early neonatal, young infant, infant mortality in the AWW arm were not different from that of the control arm.InterpretationHome-based care is effective in reducing neonatal and infant mortality rates, when delivered by a dedicated worker, even in settings with high rates of facility births.Trial registration numberThe study was registered with Clinical Trial Registry of India (CTRI/2011/12/002181).

Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of “medicinal dietary items” referred to as desi dawai, or “country medicine,” and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples’ beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.

Summary Background The need for multiple clinical visits remains a barrier to women accessing safe legal medical abortion services. Alternatives to routine clinic follow-up visits have not been assessed in rural low-resource settings. We compared the effectiveness of standard clinic follow-up versus home assessment of outcome of medical abortion in a low-resource setting. Methods This randomised, controlled, non-inferiority trial was done in six health centres (three rural, three urban) in Rajasthan, India. Women seeking early medical abortion up to 9 weeks of gestation were randomly assigned (1:1) to either routine clinic follow-up or self-assessment at home. Randomisation was done with a computer-generated randomisation sequence, with a block size of six. The study was not blinded. Women in the home-assessment group were advised to use a pictorial instruction sheet and take a low-sensitivity urine pregnancy test at home, 10–14 days after intake of mifepristone, and were contacted by a home visit or telephone call to record the outcome of the abortion. The primary (non-inferiority) outcome was complete abortion without continuing pregnancy or need for surgical evacuation or additional mifepristone and misoprostol. The non-inferiority margin for the risk difference was 5%. All participants with a reported primary outcome and who followed the clinical protocol were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01827995. Findings Between April 23, 2013, and May 15, 2014, 731 women were recruited and assigned to clinic follow-up (n=366) or home assessment (n=365), of whom 700 were analysed for the main outcomes (n=336 and n=364, respectively). Complete abortion without continuing pregnancy, surgical intervention, or additional mifepristone and misoprostol was reported in 313 (93%) of 336 women in the clinic follow-up group and 347 (95%) of 364 women in the home-assessment group (difference −2·2%, 95% CI −5·9 to 1·6). One case of haemorrhage occurred in each group (rate of adverse events 0·3% in each group); no other adverse events were noted. Interpretation Home assessment of medical abortion outcome with a low-sensitivity urine pregnancy test is non-inferior to clinic follow-up, and could be introduced instead of a clinic follow-up visit in a low-resource setting. Funding Swedish Research Council and Swedish International Development Agency.

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women’s reproductive health needs. Inspired by Foucault’s power idiom and Bandura’s agency framework, we explore young women’s opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women’s reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of “modern” contraception. This approach could prevent unintended pregnancies and expand young women’s agency.

Objective To assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group). Methods In an individually randomised multicentre trial, we enrolled 906 children aged 6–59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥−2 SD and absence of oedema of feet). Results Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >−2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ

Trial designThree feeding regimens—centrally produced ready-to-use therapeutic food, locally produced ready-to-use therapeutic food, and augmented, energy-dense, home-prepared food—were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6–59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks.MethodsCosts were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting.ResultsNo significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (ConclusionHome-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM.Trial registration numberNCT01705769; Pre-results.

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India’s goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health.

This case study has used the results of a review of literature to understand the persistence of poor maternal health in Rajasthan, a large state of north India, and to make some conclusions on reasons for the same. The rate of reduction in Rajasthan’s maternal mortality ratio (MMR) has been slow, and it has remained at 445 per 1000 livebirths in 2003. The government system provides the bulk of maternal health services. Although the service infrastructure has improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health (phase 1 and 2), have attempted to improve maternal health; however, they have not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. Thirty-two percent of women delivered in institutions in 2005-2006. A 2006 government scheme to give financial incentives for delivering in government institutions has led to substantial increase in the proportion of institutional deliveries. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The recent scheme of Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed.

Background Abortion services were legalized in India in 1972, however, the access to safe abortion services is restricted, especially in rural areas. In 2002, medical abortion using mifepristone- misoprostol was approved for termination of pregnancy, however, its use has been limited in primary care settings. Methods This paper describes a service delivery intervention for women attending with unwanted pregnancies over 14 years in four primary care clinics of Rajasthan, India. Prospective data was collected to document the profile of women, method of abortion provided, contraceptive use and follow-up rates after abortion. This analysis includes data collected during August 2001-March 2015. Results A total of 9076 women with unwanted pregnancies sought care from these clinics, and abortion services were provided to 70 % of these. Most abortion seekers were married, had one or more children. After 2003, the use of medical abortion increased over the years and ultimately accounted for 99 % of all abortions in 2014. About half the women returned for a follow-up visit, while the proportion using contraceptives declined from 74 % to 52 % from 2001 to 2014. Conclusions The results of our intervention indicate that integrating medical abortion into primary care settings is feasible and has a potential to improve access to safe abortion services in rural areas. Our experience can be used to guide program managers and service providers about reducing barriers and making abortion services more accessible to women.

INTRODUCTION: Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol as compared to clinic misoprostol in a low-resource setting.MATERIAL AND METHODS: This was a secondary analysis of a randomised controlled trial conducted in 6 primary care clinics in India. Women seeking medical abortion up to 9 gestational weeks (n= 731) received mifepristone in the clinic, and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days.RESULTS: Of 731 participants, 73% were rural and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2% and 94.4% respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion, than the proportion of clinic users (79.7%) that would opt for misoprostol at the clinic, in a similar situation (p=0.0002). Ninety six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience.CONCLUSIONS: Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities. This article is protected by copyright. All rights reserved.

India allows abortion up to 20 weeks of pregnancy but places restrictions on abortion facilities and providers. Abortion services are especially deficient in rural areas. Although vacuum aspiration is safer, sharp curettage continues to be used by providers as they lack relevant training. This paper describes the provision of first trimester abortion services using manual vacuum aspiration (MVA) in a rural clinic in the state of Rajasthan over a four-year period. Non-use of anaesthesia increased safety and allowed women to return early to a normal routine. Of 534 women, none suffered major complications; 16 required repeat evacuation and the procedure failed in two. We recommend that models based on MVA and including medical methods be piloted in rural areas of a number of states of the country, to establish the feasibility of delivering first trimester abortion as a primary health service. Ways to increase access to second trimester procedures are also required. Current requirements for certification of private facilities are excessive and the process of obtaining certification is arduous. The law in India does not extend these norms to government facilities, which remain under-equipped and lack trained providers. We recommend that certification of facilities be liberalised and applied equally to government and private institutions. There is also a need to rapidly increase training capacity across the country.

The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. This study protocol describes a study that is a randomised, controlled, non-superiority trial. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. The randomisation list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. Randomization of the study participants will occur after the first clinical encounter with the doctor. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study this study protocol describes is to evaluate the efficacy of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10–14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This resulted in an optimized, tailor-made intervention and in the development of the pictorial instruction sheet with a guide on how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion. In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10–14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor. Clinicaltrials.gov NCT01827995 . Registered 04 May 2013.

The study presented in this paper demonstrates how nurse midwives used video on mobile phones to support patient education in a maternal and child health project in rural India. The main goals of the study were to understand how the technology impacted the workflow of the nurses and to assess the acceptability of the use of video during patient encounters. The study was based on interviews of the midwives, observation of patient visits, and an analysis of logs from the mobile devices. The overall results were positive; the midwives accepted use of mobile video as part of the workflow for postnatal care examinations. Using video changed the process of patient education, in some cases making it a more focused activity. The use of video also led to midwife multitasking, which was enabled by the technology. The study suggests that the midwives felt that their authority was enhanced by the use of video.

A culture-appropriate and simple test battery consisting of 67 test items was developed and field tested in Haryana, India, in 1987-89. Trained field workers administered the tests to 3731 preschool children in 47 randomly selected villages of a district, irrespective of their physical/mental status. Centile age values were constructed for various developmental milestones included in the cultural-appropriate test battery. The locally relevant, simple, and low cost developmental tests and reference values will be used for early detection of developmental disabilities at primary care level.

A retrospective cross-sectional survey was conducted to assess key practices and costs relating to home- and institutional delivery care in rural Rajasthan, India. One block from each of two sample districts was covered (estimated population–279,132). Field investigators listed women who had delivered in the past three months and contacted them for structured case interview. In total, 1,947 (96%) of 2,031 listed women were successfully interviewed. An average of 2.4 and 1.7 care providers attended each home- and institutional delivery respectively. While 34% of the women delivered in health facilities, modern care providers attended half of all the deliveries. Intramuscular injections, intravenous drips, and abdominal fundal pressure were widely used for hastening delivery in both homes and facilities while post-delivery injections for active management of the third stage were administered to a minority of women in both the venues. Most women were discharged prematurely after institutional delivery, especially by smaller health facilities. The cost of accessing home-delivery care was Rs 379 (US$ 8) while the mean costs in facilities for elective, difficult vaginal deliveries and for caesarean sections were Rs 1,336 (US$ 30), Rs 2,419 (US$ 54), and Rs 11,146 (US$ 248) respectively. Most families took loans at high interest rates to meet these costs. It is concluded that widespread irrational practices by a range of care providers in both homes and facilities can adversely affect women and newborns while inadequate observance of beneficial practices and high costs are likely to reduce the benefits of institutional delivery, especially for the poor. Government health agencies need to strengthen regulation of delivery care and, especially, monitor perinatal outcomes. Family preference for hastening delivery and early discharge also require educational efforts.

This paper documents the experience of two health centres in a primary health service located in interior rural areas of southern Rajasthan, northern India, where trained nurse-midwives are providing skilled maternal and newborn care round the clock daily. The nurse-midwives independently detect and manage complications and decide when to refer women to the nearest hospital for emergency care, in telephonic consultation with a doctor if required. From 2000-2008, 2,771 women in labour and 202 women with maternal emergencies who were not in labour were attended by nurse-midwives. Of women in labour, 21% had a life-threatening complication or its antecedent condition and 16% were advised referral, of which two-thirds complied. Compliance with referral was higher for maternal conditions than fetal conditions. Among the 202 women who came with complications antenatally, post-abortion or post-partum, referral was advised for 70%, of whom 72% complied. The referral system included counselling, arranging transport, accompanying women, facilitating admission and supporting inpatient care, and led to higher referral compliance rates. There was only one maternal death in nine years. We conclude that trained nurse-midwives can significantly improve access to skilled maternal and neonatal care in rural areas, and manage maternal complications with and without the need for referral. Protocols must acknowledge that some families might not comply with referral advice, and also that initial care by nurse-midwives can reverse progression of certain complications and thereby avert the need for referral.

This paper summarizes lessons learned from formative research conducted in Bangladesh, Ghana, India, Mali and Nepal to inform the development of newborn health interventions, mostly in the context of field trials. Current practices, constraints to the adoption of optimal practices and implications for implementing inventions to improve newborn survival are discussed for: optimal care during pregnancy; skilled care at birth; optimal delivery and newborn care practices; special care of low birth weight babies; and timely and appropriate care seeking for newborn illness. General lessons concerning target audiences and intervention strategy are also drawn. In brief, interventions to reduce neonatal mortality need to start during pregnancy not only to promote birth preparedness and institutional delivery, but also to start the process of change concerning early newborn care practices. Their target audience should not only be pregnant or recently delivered women, but also include the main gatekeepers, particularly traditional birth attendants, grandmothers and other family members. Health providers' opinions also matter as care practices are less likely to change if families receive conflicting messages from different sources. Interventions are more likely to succeed if they are not simply message based, but include problem solving approaches, and a behavior change component to address community norms. Although antenatal care (ANC) is theoretically a good channel for newborn interventions, capitalising on its potential is not straightforward, and will require considerable investment and intervention development in its own right in order to improve ANC counselling, which will need to extend beyond training and tackle the many working day constraints encountered by ANC providers. Removing or subsidising the cost of deliveries may be a necessary action to increase institutional deliveries, but it is unlikely to be sufficient; measures will need to be put in place to ensure the basic quality of institutional deliveries and newborn care, and to change staff attitudes and practices. Post-natal visits should include observation of the baby, referral and counselling of the mother concerning danger signs in addition to promoting optimal care practices. The lessons learned should guide the development of interventions in other contexts, and ensure that key essential elements are not overlooked. They do not, however, mean that formative research will not be needed in other contexts, although the list of questions to address should be considerably reduced; successful intervention strategies require adaptation to make them local, context-specific if they are to be effective, and ongoing process monitoring to ensure the quality of intervention delivery, to check that it is having its intended effect, and to respond to any concerns from its implementers, recipients or the community. Finally, major gaps in evidence are highlighted. These include: establishing levels of recognition of asphyxiated babies and effectiveness of local solutions for resuscitation; clarifying the extent of the overlap between community perceptions of 'at risk' babies and low birthweight babies; developing and evaluating effective interventions to enable ANC services to deliver effective behaviour change counselling for pregnant and newborn health; evaluating effectiveness of delivering community-based newborn interventions at scale through routine services.

Over the years, a de-medicalisation strategy has been adopted for a range of public health interventions and commodities for the reduction of mortality, morbidity and population growth, including those for reproductive, neonatal and child health, communicable diseases, and trauma and emergency care, as a way of enhancing access to essential services. These experiences carry valuable lessons for de-medicalising and simplifying the provision of medical abortion. Like the combined oral pill and emergency contraception, which have become non-prescription drugs despite strident opposition, the abortion pill fundamentally alters the relationship between women and their health care providers. Measures for de-medicalising primary health services include adoption of simpler technology and service protocols, authorisation and training of less qualified providers, simplification or elimination of facility requirements, establishment of robust referral links to hospitals, increasing user control and self-medication, and simplifying arrangements for financing. By applying these measures, medical abortion can be widely provided as a primary health care service. To enable this, however, laws and policies must move beyond the surgical abortion paradigm, drugs must become reliably available at affordable cost, and women must have access to information that de-stigmatises abortion, enhances their options and aims to balance the power between them and their health care providers.

OBJECTIVE: To assess whether training doctors in counselling improves careseeking behaviour in families with sick children. DESIGN: Pair matched, community randomised trial conducted in 12 primary health centres (six pairs). Doctors in intervention centres were trained in counselling, communication, and clinical skills, using the integrated management of childhood illness approach. SETTING: Rural district in Rajasthan, India. PARTICIPANTS: Children aged under 5 years presenting for curative care and their mothers were recruited and visited monthly at home for six months. A total of 2460 children were recruited (1248 intervention, 1212 control). MAIN OUTCOME MEASURES: Careseeking behaviour of mothers for sick children; mothers' knowledge and perceptions of seeking care; counselling performance of doctors. RESULTS: For episodes of illness with at least one reported danger sign, 15% of intervention group mothers and 10% of control group mothers reported having sought care from an appropriate provider promptly; this difference was not statistically significant (relative risk reduction 5%, 95% confidence interval -0.4% to 11%; P = 0.07). One month after training, intervention site doctors counselled more effectively than control group doctors, but at six months their performance had declined. A greater proportion of mothers in the intervention group than in the control group recalled having had at least one danger sign explained (45% v 8%; P = 0.02). CONCLUSIONS: Mothers' appreciation of the need to seek prompt and appropriate care for severe episodes of childhood illness increased, but their careseeking behaviour did not improve significantly.

High unmet need for limiting contraception persists in most states of India despite wide access to sterilisation. Qualitative evidence from a rural community in which child mortality is high and women's autonomy is low suggests that women may seek reversibility in a contraceptive even if they have finished childbearing. This paper describes the introduction of the Copper-T 380A--a contraceptive with an effective life span of ten years--as an alternative to female sterilisation in a rural area of the state of Rajasthan, in a clinic linked to an outreach programme. The intervention addressed women's apprehensions, ensured service standards and guaranteed women's right to have the Copper-T removed at will. Data on 216 insertions over 34 months revealed a preference for the Copper-T 380A among older women and women who had achieved desired family size, especially among tribal women. More than a quarter of the 30 removals in that period were for non-medical reasons, such as family opposition, child death or remarriage. As a long-term but reversible option, the Copper-T 380A allows women room to change their minds in relation to future childbearing until they have reached menopause. Including this option in family planning services can help to meet a portion of the unmet need for contraception among women not willing to choose sterilisation, while reducing dependence on doctors and expensive equipment.

Background After the launch of Janani Suraksha Yojana, a conditional cash transfer scheme in India, the proportion of women giving birth in institutions has rapidly increased. However, there are important gaps in quality of childbirth services during institutional deliveries. The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan. This intervention titled “Parijaat” was designed by Action Research & Training for Health, in partnership with the state government and United Nations Population Fund. Methods The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan, India. These included district hospitals (9), community health centres (32) and primary health centres (3). The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment, feedback, training and action. The adherence to evidence based practices before, during and after this intervention were measured using structured checklists and scoring sheets. Main outcome measures included changes in practices during labour, delivery or immediate postpartum period. Results Use of several unnecessary or harmful practices reduced significantly. Most importantly, proportion of facilities using routine augmentation of labour reduced (p = 0), episiotomy for primigravidas (p = 0.0003), fundal pressure (p = 0.0003), and routine suction of newborns (0 = 0.0005). Among the beneficial practices, use of oxytocin after delivery increased (p = 0.0001) and the practice of listening foetal heart sounds during labour (p = 0.0001). Some practices did not show any improvements, such as dorsal position for delivery, use of partograph, and hand-washing. Conclusions An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practices at health facilities.