Kirti Iyengar

Emergency obstetric care and referral: experience of two midwife-led health centres in rural Rajasthan, India.

Abstract 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. Résumé Dans deux centres de santé d’un service de soins de santé primaires situé dans des zones rurales de l’intérieur du Rajasthan méridional, en Inde septentrionale, des infirmières sages-femmes formées assurent des soins de la mère et du nouveau-né tous les jours, 24 heures sur 24. Les infirmières sages-femmes décèlent et prennent en charge indépendamment les complications et décident quand transférer les femmes à l’hôpital le plus proche pour des soins d’urgence, si nécessaire en consultation téléphonique avec un médecin. De 2000 à 2008, les infirmières sages-femmes se sont occupées de 2771 femmes en couches et de 202 femmes avec d’autres urgences maternelles. Sur les femmes en couches, 21% présentaient une complication pouvant entraîner la mort ou son stade précédent ; et 16% se sont vu conseiller un transfert et les trois quarts l’ont accepté. L’acceptation du transfert était plus élevée pour les problèmes maternels que fłtaux. Un transfert a été conseillé à 70% des 202 femmes présentant des complications prénatales, post-avortement ou post-partum, et 72% d’entre elles l’ont accepté. Le système de transfert comprenait des conseils, l’organisation du transport, l’accompagnement des patientes, l’aide à l’admission et aux soins hospitaliers ; il a accru les taux d’acceptation du transfert. Un seul décès maternel a été enregistré en neuf ans. Nous en concluons que, dans les zones rurales, les infirmières sages-femmes formées peuvent notablement élargir l’accès à des soins maternels et néonatals compétents, et prendre en charge les complications maternelles nécessitant ou non un transfert. Les protocoles doivent reconnaître qu’il arrive que des familles ne suivent pas les recommandations de transfert et aussi que les soins donnés initialement par des infirmières sages-femmes peuvent régler certaines complications et éviter la nécessité d’un transfert de la patiente. Resumen Este artículo documenta la experiencia de dos centros de salud de primer nivel situados en zonas rurales del interior de Rajasthan meridional, en la India septentrional, donde enfermeras-parteras profesionales capacitadas brindan atención calificada a madres y recién nacidos las 24 horas del día. Independientemente, ellas detectan y manejan complicaciones y deciden cuándo remitir a las mujeres al hospital más cercano para que reciban atención de urgencia, en consulta telefónica con un médico si es necesario. Desde 2000 a 2008, 2,771 mujeres en trabajo de parto y 202 con urgencias maternas, que no estaban de parto, fueron atendidas por enfermeras-parteras profesionales. De las que estaban de parto, el 21% presentó una complicación que puso en riesgo su vida, o su afección antecedente, y el 16% fueron aconsejadas referencia y, de éstas, dos terceras partes accedieron. El cumplimiento de la referencia fue más alto para las afecciones maternas que para las fetales. Entre las 202 mujeres que llegaron con complicaciones antenatales, se aconsejó referencia postaborto o posparto al 70%, de las cuales el 72% accedieron. El sistema de referencia incluyó consejería, planes de transporte, acompañar a las mujeres, facilitar admisión y atención con apoyo a las pacientes internadas, por lo cual aumentaron las tasas de cumplimiento de referencias. En nueve años hubo una sola muerte materna. Concluimos que las enfermeras-parteras profesionales capacitadas pueden mejorar considerablemente el acceso a la atención materna y neonatal calificada en zonas rurales, y manejar las complicaciones maternas con o sin la necesidad de referencias. Los protocolos deben reconocer la posibilidad de que algunas familias no sigan el consejo de referencia, y que la atención inicial brindada por enfermeras-parteras profesionales puede detener la evolución de algunas complicaciones y evitar la necesidad de referencia.

Self-assessment of the outcome of early medical abortion versus clinic follow-up in India: a randomised, controlled, non-inferiority trial

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.

Mobile video for patient education: the midwives' perspective

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.

Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India

BackgroundAfter 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.MethodsThe 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.ResultsUse 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.ConclusionsAn 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.

Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa

Objective To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. Design Diagnostic accuracy study. Setting Ethiopia, India and South Africa. Methods Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. Results Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. Conclusion The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.

Perceptions of Options Available for Victims of Physical Intimate Partner Violence in Northern India

We used qualitative methodologies to understand perceptions regarding options available for victims of physical intimate partner violence (IPV) in northern India. We interviewed male and female community members along with IPV experts. Interviews were transcribed, coded, and analyzed using grounded theory. Participants emphasized that a victim of physical IPV should bear the violence, modify her husbands’ behaviors, or seek help from her natal family. Accessing external resources such as the police or nongovernmental organizations was viewed as both socially inappropriate and infeasible. These results have widespread implications and lay the foundation for the development of IPV prevention initiatives in India.

Acceptability of Home-Assessment Post Medical Abortion and Medical Abortion in a Low-Resource Setting in Rajasthan, India. Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial

Background Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. Objective To investigate women’s acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India. Design Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India. Population Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years. Methods Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1:1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible. Main Outcome Measures Women’s acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups. Results 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001). Conclusion Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women’s preference should be offered to foster women’s reproductive autonomy. Trial Registration ClinicalTrials.gov NCT01827995

Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India – study protocol and intervention adaptation of a randomised control trial

BackgroundThe 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.Methods/DesignThis 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.DiscussionIn 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.Trial registrationClinicaltrials.gov NCT01827995. Registered 04 May 2013.

Physical Intimate Partner Violence in Northern India

In this article, we examine perceptions about the definition of physical intimate partner violence (IPV) in northern India utilizing feminist perspectives as a framework. We interviewed 56 women and 52 men affiliated with a health services nongovernmental organization in the Udaipur district of Rajasthan. We transcribed, coded, and analyzed the interviews utilizing grounded theory. We found that perceptions regarding physical IPV were associated with both structural and ideological patriarchal beliefs and microlevel constructs such as alcohol use. We discovered multiple types of physical IPV in the study region, including rationalized violence (socially condoned violence perpetrated by a husband against his wife), unjustified violence (socially prohibited violence perpetrated by a husband against his wife), and majboori violence (violence perpetrated by a wife against her husband). Our results add to the breadth of research available about IPV in India and create a framework for future research and IPV prevention initiatives.

Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial

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 with clinic misoprostol in a low‐resource setting.