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Table 4 Select quotes form the stakeholders’ interviews conducted from Barmer and Dholpur districts of Rajasthan

From: Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys

Theme/ Sub-themes

Illustrative Comments

EFFECTIVENESS

Knowledge and Competencies

-“There are changes in conducting delivery and methods of baby care which was not done prior to Dakshata, we were unaware about the processes and required care to be given during childbirth.” Staff nurse

-“The process and practices of shifting patient from ANC to the ward and labour table, including usual and routine check-ups… the importance of these checkups was not known to us before Dakshata…In SBA (skilled birth attendance training) we were not told to handle in detail about high risk or complication for mother. In Dakshata we have been told very nicely about PPH, APH. In SBA there is no monitoring.” Staff nurse

-“after Dakshata came, we came to know that hand wash should be done before wearing gloves and hand wash should be done after removing gloves”, Staff nurse

-“Dakshata is ensuring that standard protocols are followed and staffs are well-trained....other MCH programs are not so specific, Dakshata is focused on Intra-Partum care.… Even after UNICEF program, there were not many changes which were possible after Dakshata..” Principal Medical Officer (PMO)

Perception of Quality and service delivery

- More awareness and sensitization is seen among the service providers towards improving practices, in turn leads to providing quality services.” PMO

-“After the delivery, all the instruments are dipped in the hypochlorite solution and the instruments are not used without sterilization.” MO.

-“…through examination and investigation like BP, FHS, fundal height, HB, sugar we are able to find the risk in mother and the new born and if we are able to manage we do it or else we refer due to which the chance of death gets reduced..” Staff nurse

-“Dakshata trains us and our staff how to deliver quality services with limited resources… It covers all aspects of care and services from registration to discharge, it also covers Emergency Obstetric Care…” Medical Officer

Effectiveness

-“..The golden minute after delivery of the baby and in case of any complication, we are doing all the mentioned practices according to what we have learned from Dakshata. In a way, this has reduced the chances of mother and baby death.” Staff nurse

-“Now all the practices seem easier to us and it has become our habit to do them. We feel nice to do it for the benefit of the patient. After the patient comes, immediately we check their weight, BP, pulse, temperature, FHS which is also for our own benefit. This enables us to identify IUD, and high-risk mothers.” Staff nurse

“we used to refer in case of PPH management but now we make use of balloon tamponade for its management.” Staff nurse

Outcomes of Dakshata program

-“…Now all the facility is available here and we provide baby care, they (clients) aren’t facing money loss and time waste (due to referral) as earlier…Still birth has also become less than before.” Staff nurse

-“Due to the good services and decreased referral rate, patient load has increased and credit goes to Dakshata training.” MO

-“MMR and NMR are reduced by improving labour room practices, neonatal complications also reduced.” Chief Medical Health Officer (CMHO)

PROGRAM IMPLEMENTATION AND STATES OWNERSHIP

Leadership

-“I have realized that getting sanction from the district for the advanced instruments and machines will take long time. So I have requested some donors and got NIBP machines for critical patients, and pulse-oximetry.” PMO

-“..Local body committee is formed at our CHC, asks the labour room staff and themselves to assess their own practices and mistake through internal assessment. This was possible due to the constant efforts of, JHPIEGO mentor.” MO

Mentoring and Supervision visits and periodic assessment

-“Reformation took place in our facility after Dakshata which includes infrastructural and supply related changes like installation of elbow taps, L shaped entrance from the Labour Room, Autoclave Drum etc.,…. change in attitude of our staff as well as change in practices is due to the practical mock-drills conducted under Dakshata.” PMO

-“Mentoring and supervision visits (MSVs) have improved quality of care in labour room.” Staff nurse

-“MSVs are responsible for improved accountability amongst staff.” PMO

-“We are unable to give more time because we continuously work in OPD… mentoring once in a month can tell us the gap which can help in our improvement.” MO

-“Microanalysis of labour room and charts and checklists are different in Dakshata comparing to other programs… Remarkable changes in last few years after Dakshata, as compared to 2010.” CMHO

Motivation and encouragement

-“… but now after getting the training everyone is doing it (service delivery as per protocol) because all these things come under routine and it doesn’t feel good if we don’t do it.” Staff nurse

-“There’s lack of motivation amongst the staff because of no capitation method of payment like that in private sector. Fee for service motivates the staff to work harder which is why they (private hospitals) are better on Quality front.”

-“To maintain accountability among the staff, I don’t believe giving them monetary incentives is a good option. But I have nominated the names of the good performers to the district and also on the occasion of Republic day and Independence day I awarded them with a memento and garland so that it will also motivate other staff.” PMO

SUSTAINABILITY

Improved infrastructure and demand supply chain

-“After Dakshata everything has improved very much. Drug supply, instruments all A to Z is available… if there is a problem then PMO sir (facility leader) makes the purchase and brings it to us.” Staff nurse.

-“There are many problems, no proper washing and drying area, not even place to wash baby towels. There is no changing area. No separate cleaning staff for labour room, shortage of staff for labour room. There is problem every where…” Staff nurse

Improved competence and quality of service delivery

-“..Now even if we get support of 1–2 staff we are able to provide proper services and care to the mothers and the newborns and follow practices mostly according to Dakshata protocols … … .we could see the good results, so we felt good and started performing it on a regular routine..”

-… … we will try that the same practice continues in the future, whoever comes for institutional delivery should get the proper service….”

Continued skill upgradation

-“We got trained completely in all aspects of Dakshata. If any new things come up in Dakshata, and if we are reoriented and upgraded from the Government’s side, then we will work accordingly … now it is embedded into our routine and with daily practices we are following Dakshata guidelines.”

Mentoring and Periodic assessments

-“In other programmes there is no supervision and follow up but in this program there is follow up, which help us to realize our mistakes and also scope to rectify them.” Staff Nurse

-“MSV given by JHPIEGO is very useful, but I am skeptical about the future when the role would be fulfilled by a Government personnel as staff beleves follow-up by government is usually futile….. Government MSV will be limited to paper and would not be in any comparison with existing JHPIEGO mentors.” PMO, MO

Motivation and accountability

-“We have formed a local body committee at our facility level, consisting of OT in-charge, MO, Anesthetist, Pediatrician and Gynecologist and staff nurse. Their duty is to look after the quality of the labour room …” MO, PMO

-“… local body committee asks the labour room staff and themselves to assess their own practices and mistakes. We conduct internal assessment. This was possible due to the constant efforts of JHPIEGO mentors.” PMO

Link to other programs

-“Monetary incentives to the mothers which they are getting from the programmes like JSY can reduce issues like Leaving against medical advice and in turn reduce MMR and NMR.” MO

CHALLENGES

Community level

-“More of anaemic patients come here with 4 to 5 g Hb as there is no proper ANC so there could be more chances of PPH.” PMO

-“… when mothers come for the delivery, they don’t want to wait for a longer duration and sometimes they want the delivery as soon as possible…” Staff nurse

-“… Since the Free Drug Scheme has started, self-prescription has become common …” MO

Shortage of staff and inadequate resources

-“In such a vast district like Barmer, LR practices are highly burdened due to lack of manpower and inadequate infrastructure.” CMHO

-“We face a demand-supply gap. When we raise a purchase of more number of drugs (like Vitamin-K), only a limited amount of drugs are delivered from the District Warehouse. We are struggling to establish pathways for procurement and sometimes are compelled to buy drugs like Oxytocin from market at a higher rate.” PMO

Local political influence and interference

-“ Political influence and polarization impacts the program implementation. There is also discrimination among the staff on the basis of caste, power, role and gender. Sometimes medical officers cannot interfere in these issues, as they (service providers) get him transferred from there using their connections….” PMO, Mentor

Unmotivated staff and reluctant doctors

-“Doctors in DH don’t sit in OPD. To get excused from OPD they go for rounds of PN ward for about 3–4 hours. After OPD hours, they call the patients to visit them in their private clinics. Back in the DH, doctors are taking care of their respective patients who have visited them in their residents… Specialist doctors (O&G) and MOs are not attending the Dakshata training or mentoring, as they have assumed that it is meant only for the nursing staff.” Mentor

Inconsistent support from the administration

- “… … ..government doesn’t maintain consistency, fails to reinforce training, and depends largely on paper-work. They also do not show familiarity with staff and remain as an authoritative figure.” PMO, MO