What's Happening at the Frontline?: Assessment and Quality Improvement of Bedside Maternal Care in Rural India

Background: In an effort to reduce maternal mortality (MM), India initiated one of the largest maternal health programs worldwide in 2005. Despite a substantial increase in facility-based deliveries, India has not seen a significant reduction in MM and still accounts for 15% of the world's maternal deaths. There is an urgent global need to address stagnant MM rates by ensuring that facilities and birth attendants have the required skills and knowledge to save lives. Purpose: The purpose of this project is to explore intrapartum and postpartum care practices and identify opportunities for quality improvement at a rural hospital in Gujarat, India. Method: This project took place at a rural community health center in Gujarat, India. Maternal care practices were observed and compared to World Health Organization (WHO) maternal care standards for five weeks in June-August 2017. Ninety-four maternity charts from January through May 2017 were reviewed for care documentation, and 10 nurses completed self-assessment surveys in perceived knowledge and skills of obstetric care. Following this needs assessment, collaboration with local stakeholders occurred to identify areas for quality improvement and initiate interventions. Interventions included implementation of the adapted WHO's Safe Childbirth Checklist (SCC), two weeks of on-site clinical coaching, and one two-hour training for bedside caregivers on maternal assessments. Pre and post-tests were used to evaluate effectiveness of training. Follow up observations and chart reviews occurred four months after implementation of quality measures. Results: Observations and chart reviews revealed that care does not currently adhere to WHO peripartum care standards. Chart reviews revealed that 21% (20/94) of laboring mothers had blood pressure, less than 3% (3/94) had pulse, 32% (30/94) had fetal heart tones, and 3% (3/94) had temperatures recorded on admission. These charting gaps were mirrored by observed practices for 23 deliveries. Numerous opportunities for improvement were revealed, while some care met WHO care standards. Of note: 100% (23/23) of women were accompanied by family or community support during the first stage of labor and 100% (13/13) of women received uterotonics immediately after delivery. Of the nurses who completed the aptitude survey, only 33% felt confident in recognition of the leading causes of maternal mortality worldwide, pre-eclampsia and too much bleeding after birth. After initiation of one PDSA-cycle of quality improvement measures, significant differences were seen in the pre and post-test scores and chart reviews. All assessments, except for heart rate, increased by over 100% post-intervention. Going Forward: This assessment identified significant gaps in knowledge and obstetric care delivery among frontline nurses in India. A series of interventions to improve care quality are highly recommended. Addressing the knowledge gap through continuation and expansion of quality improvement measures should be pursued to improve maternal morbidity and mortality.