Facilitators & barriers for effective implementation of Dakshata programme to improve the quality of institutional maternal care in tribal blocks of Maharashtra

Sir,

India made significant progress in reducing maternal mortality in the last two decades1. A part of the efforts focussed on promoting institutional deliveries through Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram. As per recent studies, about 80 per cent of mothers in India deliver at a health facility2-4. However, the rise in institutional deliveries has not been commensurate with the fall in maternal deaths. Persistent high mortality despite a high institutional delivery rate emphasizes the need to improve quality of maternity care services3.

In order to strengthen the quality of intra-partum and immediate post-partum care, the Government of India launched the Dakshata programme in 2015. Its objectives are to strengthen the capacity of healthcare providers, improve adherence to evidence-based critical practices, ensure availability of essential supplies and improve data keeping and implement maternal and new-born health (MNH) tool kit3. Utilization of safe childbirth checklist (SCC), a simple tool to enhance compliance to essential practices during childbirth (on admission of mother, just before birth, immediately after birth and on discharge), is an important component of the programme. Since its launch, the programme has been rolled out in 2000 facilities in India and 290 facilities in the western State of Maharashtra. Despite this, 500 maternal deaths were reported from nine districts of Maharashtra with substantial Scheduled Tribe (ST) population5.

There is a paucity of data documenting the facilitators and barriers that the health system and providers face while implementing the Dakshata programme in tribal areas. The objective of the present study was to understand these factors in the tribal district of Palghar in Maharashtra at four public health facilities.

The study was approved by the Institutional Ethics Committee of the Indian Council of Medical Research (ICMR)–National Institute for Research in Reproductive and Child Health (NIRRH), Mumbai. It was conducted from January to August 2021 and had two components – a cross-sectional facility assessment (FA) and qualitative interviews (QIs) of healthcare providers. FA was carried out at four high delivery load public health facilities chosen purposively following consultations with the State and district health authorities. The selected health facilities cater to about 60 per cent of the district’s ST population. Supervision and resource availability checklists of the Dakshata Programme Guidelines were used for assessing human resource, infrastructure, essential drugs and training status. Availability of essential drugs and functionality of equipments were physically verified. Adherence to critical practices was observed at four pause points – on admission, before delivery, after delivery and before discharge. Five randomly selected case records in the labour ward were assessed for completion of partograph and SCC. Using a semi-structured questionnaire, 17 interviews were conducted. Medical superintendent, gynaecologist, labour room in-charge (LRIC) and a staff nurse were interviewed at each facility. A descriptive approach was used to elicit knowledge about Dakshata, factors affecting the conduct of deliveries, administrative support, availability of essentials and human resource and infrastructure and laboratory facilities. This approach was preferred as it provided a direct description of the actual situation at the public health facilities under consideration.

Interviews were audio-recorded, transcribed, translated, anonymized and checked for accuracy. Emerging explanations and connotations were identified and encoded. Crucial narratives were marked for future citations. The identified themes and coded statements were compared systematically. The FA data were entered and analyzed using Microsoft Excel (2016).

FA revealed that full-time gynaecologists were present at three while, anaesthetists were present at two facilities, respectively. Three master trainers were available across the four sites. LRICs at all the facilities had received the Dakshata training. Essential drugs and commodities were in adequacy at the facilities. The staffs were actively filling the partograph and followed all the critical practices. Staffs’ behaviour was polite. Birth companion was allowed in the delivery room at three facilities.

Facilities had a 10-15 bed combined ward for antenatal, post-natal and post-partum care with the absence of a separate antenatal care (ANC) clinic. Limited ward space necessitated the use of floor-beds. All the facilities reported a staff shortfall (Table I). Despite of having functional ultrasonography machines, none of the facilities had a sonologist. Need analysis of resources, dashboard of indicators and facility-specific action matrices were not available. Only about 40 per cent of the SCCs were completely filled.

The maternal care providers, on an average, were in government service for 16 years (range 5-25 years). All the participants knew that Dakshata was related to maternal health, but a majority (about 70%) were unaware about its objectives. A nurse responded ‘To improve the quality of service given to the ANC and the infants is the aim of Dakshata’ while a LRIC said ‘In Dakshata, we take various trainings, maintain registers and learn how to behave with patients’.

Staffs gave positive feedback about the training package and hands on practice using mannequins. A nurse told, ‘I have attended many trainings, but Dakshata training was the best’. Another response was ‘Dakshata training refreshed knowledge. It was very helpful for me. I could do things that I never did before in the facility’.

Absence of a training centre in Palghar was reported as an issue. A gynaecologist said ‘There is no proper training centre here. We have to go to Thane/Nashik and stay there for three days’. Process of seeking approval for training was reported to be protracted. A response was ‘When the letter comes from district, then only we send staff for training’.

The informants reported staff shortage as a crucial barrier to cater to the heavy workload. A response was ‘Staff is recruited as per 30-bed hospital norms. With increase in population, flow of patients has increased, but the staff is same’. Only one facility followed the policy of non-rotation of labour room staff. Nursing staffs were supportive of rotation. A nurse responded ‘If rotation is done, staff learns everything. Not just labour and delivery. If there is some kind of emergency (non-obstetric), how will she manage?’

The need for having an obstetric intensive care unit (ICU) was emphasized by a gynaecologist, ‘We do not have an Obstetric ICU in the district. There is no expert medicine consultant’.

Absence of laboratory technicians made emergency investigations difficult.

An obstetrician said ‘In emergencies, investigations cannot be done here. If the patient deteriorates, we do not have any reports to show’

Availability of essential drugs was affected by issues related to distribution. A gynaecologist responded ‘Some PHCs having 20-25 deliveries per year receive thousand vials of oxytocin and we get less in spite of high delivery load’. The staff prioritized service provision over documenting maternal health data. A nurse replied ‘If a delivery is there while we are doing paperwork, we always choose to attend to the delivery. Paperwork can be done later but not delivery’. Dakshata mandates appointing mentors to aid in supportive supervision and post-training follow-up. However, such appointments were lacking. Health authorities provided help, but the staff expected more timely support. A gynaecologist told,

‘Sometimes, they do not understand the seriousness. We tell them our problems; they start telling us theirs’.

The MNH toolkit provides support and guidance to doctors and nursing staff to improve the quality of maternal care services. It was reported that none of the 17 participants were aware about the toolkit.

The present study documented the facilitators and barriers to implementation of the Dakshata programme (Table II). Availability of skilled human resource is essential to improve the output in healthcare6. Shortage of doctors, staff nurses and allied staff has largely affected the quality of care delivered at these facilities7. A study in a public hospital in Mumbai8 observed that about six women per 1000 deliveries require obstetric intensive care and 22 per cent of those requiring intensive care die reiterating the need for developing obstetric ICUs.

A multi-country analysis reported that redistribution of human resource plays a critical role in dealing with increasing healthcare demand9. The MNH toolkit aims at such rational redistribution. Ignorance about the toolkit eight years after its launch reiterates the need for awareness generation for such a key resource. Utilisation of SCC has been reported to improve maternal and new-born outcomes10. Use of simple yet important job aid like the SCC therefore needs to be encouraged. It is possible that the presence of an observing investigator would have resulted in better adherence to practices. Furthermore, the availability of essential drugs was verified just on the day of the visit and past shortages, if any, would have been missed. To the best of our knowledge, this is the first study in India to document the facilitators and barriers pertaining to Dakshata programme in a tribal setting. This study addresses top research priorities ascribed by ICMR-INCLEN collaboration for research prioritization in maternal health for the decade 2016-202511.

To conclude, Dakshata programme aims to improve the quality of maternal care at public health facilities. Prioritizing training of staff, adherence to SCC, development of obstetric ICUs, availability of human resource and emergency laboratory investigations and promotion of coherence between various levels of healthcare can aid the providers in delivering quality maternal care. These findings are relevant for policymakers to strengthen the implementation of the Dakshata programme in the underserved tribal areas.

Acknowledgment: The authors acknowledge the support of Dr Geetanjali Sachdeva, Director, ICMR-NIRRCH, Mumbai. Authors acknowledge Drs Padmini Kashyap, Assistant Commissioner, Maternal Health, MoHFW; Shridhar Pandit, Program Officer, LaQshya, and Rupak Mukhopadhyay, Inclen Trust International for their valuable inputs to the study. We also acknowledge Dr Mangalam Varadha, Senior Research Fellow; Mrs Anamika Akula, Senior Technician, Department of Clinical Research; health staff and, the participants for their support.