Assessment of Delivery Points in a Tribal District of  Maharashtra” - an Observational Study 

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There is a need for comprehensive evaluation of delivery points, focusing on infrastructure, supplies, adherence to protocols, and overall quality of care provided during childbirth. Methods - A community-based study conducted in Palghar district where 15 delivery points were selected, by convenient sampling. Data was collected through observations and record reviews through LaQshya checklist. Indicators like service provision, patients’ rights, clinical services, inputs, support services, infection control services, quality management were used to score the delivery points. Results - L3 level delivery points scored the highest in-service provision, with an average score of 19(88.18%) and highest in the area of provision patients’ rights38(95%) as compared to other levels. L3 delivery points scored was 98.2 (90.92%) in in the area of inputs, 59.2 (95.48%) in support services, 176.4 (95.8%) in clinical services, 71(95.94%) in infection control and 48.57% in quality management services. Conclusion – L3 delivery points scored highest than all the levels in all the criteria of LaQshya checklist and L1 delivery points scored the least. Major areas of improvement were quality management, infection control and inputs. Figures Figure 1 INTRODUCTION India accounts for nearly a fifth of all maternal deaths worldwide, so it is an important target country in global efforts to reduce maternal mortality. National policies and programs, such as the National Population Policy and Reproductive and Child Health Program II, have outlined ambitious goals, including increasing institutional deliveries to 80%, ensuring 100% of deliveries are attended by trained personnel, and reducing the maternal mortality ratio to less than 100 per 100,000 live births by 2010. 1 Despite these targets, a substantial proportion of maternal deaths, stillbirths, and neonatal deaths occur in health facilities, underscoring the urgent need to improve the quality of care provided at delivery points. Quality assurance standards have been developed for various healthcare facilities, and their implementation through initiatives like the National Quality Assurance Program holds promise for reducing these adverse outcomes. 2 Quality of care is paramount for policymakers and public health practitioners, serving as a vital tool for optimizing resource utilization, improving health outcomes, and ensuring client satisfaction. The government has established quality indicators to uphold national standards of care delivery, recognizing that anything less is unacceptable. 3 The quality of care might be improved through paying more attention to the perspectives of clients, improving the competencies and skills of providers and provision of medical equipment and supplies. 4 Suboptimal healthcare quality not only results in loss of lives but also impacts revenue, material resources, staff morale, and community trust in health services. Vulnerable groups, such as mothers and children, bear a disproportionate burden of morbidity and mortality as a consequence. Thus, it is imperative to prioritize service provision at delivery points and address gaps in quality of care. 5 RATIONALE The purpose of this research was to focus on the, functioning of the labour rooms and the provision of essential services for neonatal and maternal care and infection control practices at delivery points. The inspection of conducting deliveries in labour rooms to rule out any malpractices is essential in developing countries like India. Thus, through this research, gaps in service provision and delivery of healthcare services can be highlighted and can lead to a fundamental pathway for improving the quality of maternal and child healthcare services and eventually leading to decrease in the burden of labour room associated mortality and morbidity in developing countries. The main goal of national health mission’s guidelines is to improve birthing practices in rural and hard to reach areas where tertiary care is not accessible to the general population. Through this research the description of availability of services, equipment and their judicial use along with the practice of infection control practices in the delivery care centres provides a scope for improvement in infrastructure and human resources in India thus offering better health related outcomes in mothers and neonates in villages and districts of India. METHODOLOGY This study employed a community-based observational design to assess the quality of delivery points in Palghar, a tribal district of Maharashtra, India. Palghar is a tribal district which comprises of eight talukas: Mokhada, Talasari, Vasai, Vikramgad, Palghar, Dahanu, and Wada. Delivery points were selected from each taluka to ensure representation across the district. The study was conducted over a period of 1.5 years to gather comprehensive data on the quality of care provided at delivery points in the district. A stratified random sampling approach was employed to select delivery points from each taluka in Palghar district. Within each taluka, delivery points were selected based on their accessibility, patient load, and representation of different healthcare facilities, including primary health centers (PHCs), community health centers (CHCs), and sub-centres. The sample size for this study was determined based on guidelines provided in the Maternal and New-born Health toolkit (January 2013) by the Maternal Health Division, Ministry of Health and Family Welfare, Government of India. According to these guidelines, delivery points are categorized into three levels: Level 1 (L1): Basic healthcare facilities providing essential maternal and newborn care services. Level 2 (L2): Intermediate healthcare facilities equipped to handle more complex obstetric and neonatal cases. Level 3 (L3): Advanced healthcare facilities, such as district hospitals or tertiary care centers, offering comprehensive maternal and newborn care services, including emergency obstetric and newborn care. A study sample and a total of 15 delivery points were selected 5 from each level by convenient sampling. Health care facilities classified under L1, L2, and L3 delivery points for which permission was granted by the respective authorities in Palghar district, were included in the study but private hospitals and delivery points situated under municipal corporations in Palghar district were excluded from the study. We used the LaQshya program's checklist, which is validated by Ministry of health and family welfare as a quality improvement initiative in labor room and maternity OT was selected for evaluation as our study tool. It is aimed at improving the quality of care for mothers and newborns during the intrapartum and immediate postpartum period. Data collection was conducted daily at each delivery point from June 1st to June 18th, 2021 and information was gathered through direct observation and record reviews. Checkpoints were scored based on compliance: where in full Compliance: All requirements of a checkpoint were met (score = 2), Partial Compliance: At least 50% or more requirements were met (score = 1) and non-compliance: Less than 50% of requirements were met (score = 0). Data was entered into Microsoft Excel for ease of interpretation. Quantitative data, such as facility characteristics and adherence to quality standards, were analyzed using descriptive statistics. Ethical approval was obtained from the ethics committee prior to the commencement of the study. RESULTS ASSESSMENT OF SERVICE PROVISION CRITERIA IN LABOUR ROOM- We observed curative, Reproductive, Maternal Neonatal, Child, Adolescent health and diagnostic Services of all the levels of delivery points where our results showed that all L3 level delivery points scored the highest in-service provision, with an average score of 19.4 out of 22, achieving an average score percentage of (88.18%). Major non-compliance was seen in the area of “RMNCHA Services (availability of pre-term services, management of retained placenta, postpartum hemorrhage, septic delivery and eclampsia)”. 2 ASSESSMENT OF PATIENT RIGHTS CRITERIA IN LABOUR ROOM. The criteria observed were “provision of information that is sensitive to gender, religious and cultural needs, no barrier on account of physical economic, cultural or social reasons, maintaining privacy, confidentiality and dignity of patient, has a system for guarding patient related information, informed decision making, financial protection given from the cost of hospital services”. 2 L3 delivery points in patient rights criteria scored 38(95%) which was the highest out of a total score of 40 in the area of provision patients’ rights as compared to other levels of delivery points. Major non-compliance was seen in the area of “maintaining privacy (availability of partition between delivery tables and availability of frosted glasses at windows)”. 2 ASSESSMENT OF INPUTS CRITERIA IN LABOUR ROOM The criteria observed were whether the “facility has infrastructure for delivery of assured services, ensures the physical safety of the infrastructure, established program for fire safety, disaster, adequate qualified and trained staff, provides drugs and consumables, equipment and instruments, procedure for evaluation of competence and performance of staff”. 2 Average Score of L3 delivery points in inputs was 98.2 (90.92%) in the area of provision of inputs which was highest than all levels of delivery point out of total score of 108. Major non-compliance was seen in the area of “infrastructure (labor room in proximity to Operation theatre), adequate staff availability of gynecologist and pediatrician), drugs and consumables (availability of uterotonic drugs), competence of staff”. 2 ASSESSMENT OF SUPPORT SERVICES CRITERIA IN LABOUR ROOM The criteria observed was “whether the facility has program for inspection, testing and maintenance of Equipment, procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas, secure and comfortable environment for staff, patients and visitors ; The facility ensures 24X7 water and power backup as per requirement of service delivery, and the facility ensures clean linen to the patient; Roles of administrative and clinical staff are determined as per govt. regulations and standards operating procedure for maintenance and upkeep of the facility”. 2 The average Score of L3 delivery points was 59.2 (95.48%) which was the highest out of a total score of 62. Major non-compliance was seen in the area of “secure and comfortable environment for staff, patients and visitors’ temperature control and ventilation in patient care areas, security arrangement in labour room”. 2 ASSESSMENT OF CLINICAL SERVICES CRITERIA IN LABOUR ROOM The criteria observed was whether the “facility had defined procedures for registration, consultation and admission of patients, established procedures for clinical assessment, procedures for continuity of care of patient and referral; Defined procedures for nursing care, procedure to identify high risk and vulnerable patients, follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use, and procedures for safe drug administration; Procedures for maintaining, updating of patients‘ clinical records and their storage, established procedures of diagnostic services antenatal, Intranatal care, postnatal care as per guidelines and blood bank services”. 2 In our results it was seen that average Score of L3 delivery points in clinical services provision was 176.4 (95.8%) out of total score of 184 which was the highest among all the levels of delivery points. Where major non- compliance was seen in the area of “diagnostic services (Nursing station provided with critical value of different test), blood bank services (procedure blood transfusion monitoring), Intranatal services (criteria for distinguishing between new-born death and still birth) Management of Retained Placenta, Anti-Retroviral therapy for seropositive mothers and Nevirapine to newborns of HIV seropositive mothers) and post-natal (facilitates specialist care in new born, established criteria for shifting new born to SNCU)”. 2 ASSESSMENT OF INFECTION CONTROL SERVICES CRITERIA IN LABOUR ROOM The criteria observed was whether the “facility has infection control Programs and procedures in place and has defined and Implemented procedures for ensuring hand hygiene practices ,antisepsis, standard practices and materials for personal protection, has standard practices and materials for personal protection, has physical layout and environmental control of the patient care areas ensures infection prevention ,and have defined and established procedures for segregation, collection, treatment and disposal of Bio-Medical and hazardous Waste”. 2 Here also L3 delivery point scored the highest with an average score of 71(95.94%) out of a total score of 74. Major area of non-compliance was “Surface and environment samples being taken for microbiological surveillance, Shaving done during part preparation/delivery cases and no use of elbow length gloves for obstetrical purpose’. 2 ASSESSMENT OF QUALITY MANAGEMENT CRITERIA IN LABOUR ROOM The criteria observed were whether the “facility has established organizational framework for quality improvement and a system for patient and employee satisfaction, whether the facility has established internal and external quality assurance programs, wherever it is critical to quality and maintained Standard Operating Procedures for all key processes and support services, it maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages and has a system of periodic review as internal assessment, medical & death audit and prescription audit. And has defines mission, values, Quality policy & objectives & prepared a strategic plan to achieve them and seeks continually improvement by practicing Quality method and tools”. 2 Although all the levels of delivery points scored less in this area an average score of 34.6 (48.57%) which was the highest out of total score of 70 was scored by L3 delivery points in quality management criteria of LaQshya Guideline checklist. Major non-compliance was seen in all the areas of quality management DISCUSSION The present study was a community-based study which used LaQshya guidelines checklist for labour room assessment. A total of 18 delivery points were selected in which L1 delivery points were 5, L2 delivery points were 6, and L3 delivery points were 7 in number. These were assessed on the criteria of service provision, patients’ rights, input, support services, infection control services and quality management. The criteria observed were curative, RMNCHA Services and diagnostic Services. In our study in L1 delivery points the average score percentage was 53.36%, in L2 delivery points it was 63.63% and in L3 Delivery points it was 85.45% in the area of service provision. Major non-compliance was seen in the area of RMNCHA Services (availability of pre-term services, management of retained placenta, postpartum haemorrhage, septic delivery and eclampsia). In other study by Upadhyay K et.al. 5 The mean total score for facility assessment parameter was 81.7(86.9%). The mean service delivery score for antenatal care assessment, postnatal care assessment, and immunization is 74.9(78.9%), 24.7(98.6%), and 40.2(87.3%), respectively, with an overall score of 139.8(84.2%). Dodwad SS et.al 6 in other similar study regarding the process of service delivery, more than two-thirds of facilities in Ahmednagar (67%) and about 45% of the facilities in Tumkur scored C or D grade. On the contrary Sharma J et.al 7 in other study found that both primary and secondary level facilities failed to meet the basic standards for provision of intrapartum care. It can be concluded that better service provision scores that indicated higher performance of health-care delivery system which was comparatively higher in most of L3 delivery points. When it came to provision of patient’s rights in our study the average score of L1 delivery points was the lowest than all other delivery points an average score percentage of 88.50% in the area of provision of patients’ rights. Our results were compatible with Sharma G et.al 8 in which that total mistreatment scores were higher amongst women attending district hospitals. Hajizadeh K et.al 18 in other study found that the mean respectful maternity care score was 62.58 with a range of 15 to 75 and a statistically significant direct correlation was found between respectful maternity care and a positive childbirth experience ( P < 0.001). On the other hand, Raval H et.al 9 in another study found that, the PHC demonstrated higher Respectful Maternal care performance compliance than DH and the CHC. Most often violations of Respectful Maternity Care standards included beneficiaries were not greeted, privacy not maintained, they were not encouraged to ask questions, and support not provided during labour. Hence it was seen that provision of patients’ rights was comparatively lower in L1 delivery points out of all delivery levels the reason could be because lower levels of healthcare facilities might lack operational guidelines on provision of respectful maternal care. In our study it was also seen that in the area of provision of Inputs, L3 delivery points scored 90.92% which was highest of all the levels of delivery points where major non-compliance was seen in the area of infrastructure (labor room in proximity to Operation theatre), adequate staff availability of gynecologist and pediatrician), drugs and consumables (availability of uterotonic drugs), competence of staff. Our results were consistent with Chavda P et.al 10 where mean obtained score for facilities in Input section was 65%. Highest score was obtained for Drugs and Consumables (86%) followed by Equipment and Supplies (74%). The score obtained for Infrastructure facility was 65%, Personnel and training was 56% and Essential protocols and guidelines scored 43%. Similarly, Sachan D et.al 11 in other study found that the infrastructure of the facilities was the best for medical college followed by district hospitals, Community Health Centers (CHCs), Primary Health Centers (PHCs) and subcenters. The differences in the findings of the study can be due to healthcare funding challenges and poor maintenance attitude. In our study all the L3 delivery points scored 95.48% in the area of provision of support services, where major non-compliance was seen in the area of secure and comfortable environment for staff, patients and visitors’ temperature control and ventilation in patient care areas, security arrangement in labour room. Our results were consistent with Saravanakumar Vet.al 12 where scores in support service are more than 70 percent in all the districts. Similarly study by Verma VR et.al 13 , indicated poor readiness for peripheral rural facilities with a composite score of 41% and 24% for subcentres and new type primary health centres respectively hence it was seen that level of health care provided in primary health facilities is dependent on the availability of adequate basic amenities, basic equipment and essential medicines. The difference in the scores can be due to lack of focus of policymakers in the problem areas and lack of funding. It is safe to say that the focus of improvement should be centered on the betterment of structure and services provided at lower level of delivery points. It was also seen that all the L3 delivery points scored 95.8% in the area of provision clinical services. Our results were consistent with Sharma J et.al 7 who found that about 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77 vs 0.74). Also, Sodani PR et.al 14 saw that more than 90% of the study primary health centres lacked availability of both antenatal and post-natal services. However, other services like emergency services, management of fractures, cataract, medical termination of pregnancy, management of low-birth-weight babies, tubectomy and vasectomy, were poor at PHCs which need to be addressed for their further strengthening.It highlights that the provision of clinical services score is seen to better in higher level of delivery points which can be because in higher-level healthcare delivery systems, skilled personnel often exhibit a greater tendency to remain employed due to several factors, including enhanced compensation packages and heightened job satisfaction. In our study if was seen that all the L3 delivery points scored 48.57% in the area quality management services which was the highest amongst all the levels of delivery points where major non-compliance was seen in all the areas of quality management Our results were consistent with Dodwad SS et.al 6 where Sixty-four percent were of good quality, about one-third were average, while a small proportion (6%) were of poor quality. Karkee R et.al 15 also found that mean scores of total quality and sub-scales health facility and health care delivery for women attending private hospital were higher (p < 0.001) than those using birth centre or public hospital. Results of Van Berkel R et.al 18 showed that high education levels and lengthy stay in healthcare facilities were negatively associated with the satisfaction with the free delivery services. Which can be the reason why score was higher in private than in public hospitals. It was also seen that in our study all the L3 delivery points scored 95.4% in the area of infection control services. Our results were consistent with Saravana kumar V et.al 19 found that public health facilities namely Sub district hospitals (SDH), CHC/Block PHC, Primary Health Centre (PHC), Urban Primary Health Centre (UPHC) one each scored above 70 percent Regarding infection control in the hospitals. Similarly Cloete B et.al 16 also in audits of 60 primary health-care facilities in the Western Cape Province of South Africa. At baseline, 25% of 60 facilities were ―noncompliant (audit score 50 80%)and Isah HO et.al 17 also found that found that the facilities‘ mean score on measures and frameworks for ensuring the implementation of Universal Precautions was 53.12% ± 21.68% with only 56.52% scoring above 50%. This also highlights the need for Interventions to improve safety environment and creation of safe climate are essential to protect primary health care workers against occupational hazards. Limitations of our study was that information on the outcome criteria of the LaQshya guidelines checklist couldn’t be assessed due to non-availability of records in some delivery points and our study also provided no scope of health education and intervention to improve the service delivery in labour rooms of delivery points. CONCLUSION The study concludes that majority of L1 delivery points scored comparatively lower than all levels of delivery points in the criteria of service provision, patients’ rights, inputs, quality management services, clinical services and infection control services. L3 Delivery points scored comparatively higher than all three levels of delivery points in all the criteria It was seen that major areas of noncompliance which needed improvement was, Quality Management, since all the levels of delivery points scored less in the criteria of quality management. Infection control and supplies of inputs also needed improvement. Declarations ETHICAL CONSIDERATION: The study was conducted after obtaining permission from the Institutional Ethics Committee (IEC) from Grant Govt. Medical college and JJ group of hospitals. In letter no. _______IEC/PG/ 4/NOV/2019_ All the data collected was kept strictly confidential and used for the purpose of this study. Appropriate permissions were taken before the initiation of study. Any deviations from the below given methods/procedure were informed to the IEC and only after the IEC‘s approval any changes were made. The proforma for the written informed consent is given herewith. Informed consent Informed consent were taken from the necessary participating centres . Author Contribution 1. Dr. Gauri Bharadwaj - Data collection Data analysis and interpretation 2. Dr. Lalit Sankhe -Study conception, Study Design,Interpretation of results 3. Dr . Shubhendra Bharadwaj - Manuscript preparation Acknowledgement special thanks to Dr. Chhaya Rajguru Dr. Pallavi Uplap and the Department of Community Medicine Grant Govt. Medical College, and JJ group of hospitals Data Availability The data contains sensitive information and should have restricted access to any public data repository .Data is provided within the manuscript or supplementary information files. References Mehta R, Mavalankar DV, Ramani KV, Sharma S, Hussein J. Infection control in delivery care units, Gujarat state, India: A needs assessment. BMC Pregnancy Childbirth. 2011 Dec;11(1):1–8. LaQshyaGuidelines.pdf[Internet]. [cited2022Feb8].Availablefrom: https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/LaQshya-Guidelines.pdf National Quality Assurance Standards. 2020.pdf [Internet]. [cited 2022 Feb 8].Availablefrom: http://qi.nhsrcindia.org/sites/default/files/National%20Quality%20Assurance%20Standards % 202020.pdf. Turkson PK. Perceived quality of healthcare delivery in a rural district of Ghana. Ghana Med J. 2009;43(2). Upadhyay K, Pentapati SS, Singh R, Goel S. Assessment of grassroot level health care service delivery system in a community development block of Haryana: A cross sectional study. Indian journal of public health. 2021 Apr 1;65(2):124. Dodwad SS. Quality management in healthcare. Indian journal of public health. 2013 Jul 1;57(3):138. Sharma J, Leslie HH, Regan M, Nambiar D, Kruk ME. Can India‘s primary care facilities deliver? A cross-sectional assessment of the Indian public health system‘s capacity for basic delivery and newborn services. BMJ open. 2018 Jun 1;8(6):e020532. Sharma G, Penn-Kekana L, Halder K, Filippi V. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reproductive health. 2019Dec;16(1):1–6. Raval H, Puwar T, Vaghela P, Mankiwala M, Pandya AK, Kotwani P. Respectful maternity care in public health care facilities in Gujarat: A direct observation study. J Family Med Prim Care. 2021 Apr;10(4):1699. Chavda P, Misra S. Evaluation of input and process components of quality of child health services provided at 24× 7 primary health centers of a district in Central Gujarat. Journal of family medicine and primary care. 2015 Jul;4(3):352. Sachan D, Kumar D, Gangwar A, Jain PK, Kumar S, Shukla SK, Srivastava DK, Kharya P, Bajpai PK, Pathak P, Rao TR. Are the labour rooms of primary healthcare facilities capable of providing basic delivery and newborn services? A cross-sectional study. Journal of Family Medicine and Primary Care. 2021 Oct 1;10(10):3688-99. Saravanakumar V, Ravichandran S. Assessing the reasons for poor performance of Public Health Facilities in Tamil Nadu, in Kayakalp Award. Verma VR, Dash U. Supply-side Readiness for Universal Health Coverage: Assessing Service Availability and Barriers in Remote and Fragile Setting. J Health Manage. 2021 Sep;23(3):441–69. Sodani PR, Sharma K. Strengthening primary level health service delivery: lessons from a state in India. J family Med Prim care. 2012 Jul;1(2):127. Karkee R, Lee AH, Pokharel PK. Women‘s perception of quality of maternity services: a longitudinal survey in Nepal. BMC Pregnancy Childbirth. 2014 Dec;14(1):1–7. Cloete B, Yassi A, Ehrlich R. Repeat auditing of primary health-care facilities against standards for occupational health and infection control: a study of compliance and reliability. Safety and health at work. 2020 Mar 1;11(1):10 – 8. Isah HO, Sabitu K, Ibrahim MT. Profile of institutional infrastructure for implementing universal precautions in primary health care facilities in Sokoto State, Nigeria: Implication for occupational safety. Afr J Clin experimental Microbiol. 2009;10(3). Hajizadeh K, Vaezi M, Meedya S, Mohammad Alizadeh Charandabi S, Mirghafourvand M. Respectful maternity care and its relationship with childbirth experience in Iranian women: a prospective cohort study. BMC Pregnancy Childbirth. 2020;20(1):1–8. Ministry of Health and Family Welfare (MoHFW), Government of India. (2019). LaQshya: Labour Room Quality Improvement Initiative. https://nhm.gov.in/New_Updates_2018/Report_PMSMA_LaQshya.pdf World Health Organization. (2016). Standards for improving quality of maternal and newborn care in health facilities. https://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/ c4a2b508-. 8407-4b4c-bbe5-2c5d94d9d572. Tables TABLE.1 AVERAGE SCORE PERCENTAGE OF ALL LEVELSOF DELIVERY POINTS LaQshya checklist criteria LEVEL OF DELIVERY POINTS L1 (5) L2 (5) L3 (5) SERVICE PROVISION AVERAGE SCORE N (%) 12.4(56.36%) 13.8 (62.72%) 19.4(88.18%) PATIENT’S RIGHTS AVERAGE SCORE N(%) 35.4 (88.50%) 33.6 (84%) 38(95%) INPUTS AVERAGE SCORE N(%) 82.6 (76.48%) 85.8 (79.44%) 98.2(90.92%) SUPPORT SERVICES AVERAGE SCORE N(%) 51.4 (82.90%) 50.8(81.93%) 59.2(95.48%) CLINICAL SERVICES AVERAGE SCORE N(%) 158.6(86.19%) 156.8(85.21%) 176.4(95.8%) INFECTION SERVICES AVERAGE SCORE N(%) 60.2 (81.35%) 65.2(88.10%) 71(95.94%) QUALITY MANAGEMENT AVERAGE SCORE N(%) 14.2(20.28%) 18.4(26.28%) 34.6(48.57%) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4761165","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":343100444,"identity":"640e62df-8a22-4061-9aac-7ec9843dd679","order_by":0,"name":"gauri bharadwaj","email":"data:image/png;base64,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","orcid":"","institution":"Grant Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals","correspondingAuthor":true,"prefix":"","firstName":"gauri","middleName":"","lastName":"bharadwaj","suffix":""},{"id":343100445,"identity":"93da0922-ec6d-481c-b453-1835298c9f06","order_by":1,"name":"Dr Lalit Sankhe","email":"","orcid":"","institution":"Grant Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals","correspondingAuthor":false,"prefix":"Dr","firstName":"Lalit","middleName":"","lastName":"Sankhe","suffix":""},{"id":343100446,"identity":"35c7bd65-3770-4cfa-9669-e0187c5ad077","order_by":2,"name":"Dr Shubhendra bharadwaj","email":"","orcid":"","institution":"Lala Lajpat Rai Memorial Medical College","correspondingAuthor":false,"prefix":"Dr","firstName":"Shubhendra","middleName":"","lastName":"bharadwaj","suffix":""}],"badges":[],"createdAt":"2024-07-18 08:48:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4761165/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4761165/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63417820,"identity":"68f1507c-28b1-4d78-8456-6cd663dc0325","added_by":"auto","created_at":"2024-08-28 02:07:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16483,"visible":true,"origin":"","legend":"\u003cp\u003eGRAPHICAL REPRESENTATION OF SCORE PERCENTAGE OF DELIVERY POINTS\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4761165/v1/dd4370e6417737bc59e5b7fe.png"},{"id":67440795,"identity":"ccddeb8c-21f3-4f75-a15f-82517434a46a","added_by":"auto","created_at":"2024-10-25 05:55:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4761165/v1/51346ef2-0a93-44d0-a83a-6b4f301cf215.pdf"},{"id":63417821,"identity":"97e8c0b8-06f5-47ed-814e-76c0b6bd7b7a","added_by":"auto","created_at":"2024-08-28 02:07:58","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31304,"visible":true,"origin":"","legend":"","description":"","filename":"thesismasterchart.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4761165/v1/7008c33b67dcf209341489bf.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Delivery Points in a Tribal District of Maharashtra” - an Observational Study ","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIndia accounts for nearly a fifth of all maternal deaths worldwide, so it is an important target country in global efforts to reduce maternal mortality. National policies and programs, such as the National Population Policy and Reproductive and Child Health Program II, have outlined ambitious goals, including increasing institutional deliveries to 80%, ensuring 100% of deliveries are attended by trained personnel, and reducing the maternal mortality ratio to less than 100 per 100,000 live births by 2010.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite these targets, a substantial proportion of maternal deaths, stillbirths, and neonatal deaths occur in health facilities, underscoring the urgent need to improve the quality of care provided at delivery points. Quality assurance standards have been developed for various healthcare facilities, and their implementation through initiatives like the National Quality Assurance Program holds promise for reducing these adverse outcomes.\u003csup\u003e2\u003c/sup\u003e Quality of care is paramount for policymakers and public health practitioners, serving as a vital tool for optimizing resource utilization, improving health outcomes, and ensuring client satisfaction. The government has established quality indicators to uphold national standards of care delivery, recognizing that anything less is unacceptable.\u003csup\u003e3\u003c/sup\u003e The quality of care might be improved through paying more attention to the perspectives of clients, improving the competencies and skills of providers and provision of medical equipment and supplies.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSuboptimal healthcare quality not only results in loss of lives but also impacts revenue, material resources, staff morale, and community trust in health services. Vulnerable groups, such as mothers and children, bear a disproportionate burden of morbidity and mortality as a consequence. Thus, it is imperative to prioritize service provision at delivery points and address gaps in quality of care.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eRATIONALE\u003c/h2\u003e \u003cp\u003eThe purpose of this research was to focus on the, functioning of the labour rooms and the provision of essential services for neonatal and maternal care and infection control practices at delivery points. The inspection of conducting deliveries in labour rooms to rule out any malpractices is essential in developing countries like India. Thus, through this research, gaps in service provision and delivery of healthcare services can be highlighted and can lead to a fundamental pathway for improving the quality of maternal and child healthcare services and eventually leading to decrease in the burden of labour room associated mortality and morbidity in developing countries. The main goal of national health mission\u0026rsquo;s guidelines is to improve birthing practices in rural and hard to reach areas where tertiary care is not accessible to the general population. Through this research the description of availability of services, equipment and their judicial use along with the practice of infection control practices in the delivery care centres provides a scope for improvement in infrastructure and human resources in India thus offering better health related outcomes in mothers and neonates in villages and districts of India.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis study employed a community-based observational design to assess the quality of delivery points in Palghar, a tribal district of Maharashtra, India. Palghar is a tribal district which comprises of eight talukas: Mokhada, Talasari, Vasai, Vikramgad, Palghar, Dahanu, and Wada. Delivery points were selected from each taluka to ensure representation across the district. The study was conducted over a period of 1.5 years to gather comprehensive data on the quality of care provided at delivery points in the district.\u003c/p\u003e \u003cp\u003eA stratified random sampling approach was employed to select delivery points from each taluka in Palghar district. Within each taluka, delivery points were selected based on their accessibility, patient load, and representation of different healthcare facilities, including primary health centers (PHCs), community health centers (CHCs), and sub-centres. The sample size for this study was determined based on guidelines provided in the Maternal and New-born Health toolkit (January 2013) by the Maternal Health Division, Ministry of Health and Family Welfare, Government of India. According to these guidelines, delivery points are categorized into three levels: Level 1 (L1): Basic healthcare facilities providing essential maternal and newborn care services. Level 2 (L2): Intermediate healthcare facilities equipped to handle more complex obstetric and neonatal cases. Level 3 (L3): Advanced healthcare facilities, such as district hospitals or tertiary care centers, offering comprehensive maternal and newborn care services, including emergency obstetric and newborn care. A study sample and a total of 15 delivery points were selected 5 from each level by convenient sampling. Health care facilities classified under L1, L2, and L3 delivery points for which permission was granted by the respective authorities in Palghar district, were included in the study but private hospitals and delivery points situated under municipal corporations in Palghar district were excluded from the study. We used the LaQshya program's checklist, which is validated by Ministry of health and family welfare as a quality improvement initiative in labor room and maternity OT was selected for evaluation as our study tool. It is aimed at improving the quality of care for mothers and newborns during the intrapartum and immediate postpartum period. Data collection was conducted daily at each delivery point from June 1st to June 18th, 2021 and information was gathered through direct observation and record reviews. Checkpoints were scored based on compliance: where in full Compliance: All requirements of a checkpoint were met (score\u0026thinsp;=\u0026thinsp;2), Partial Compliance: At least 50% or more requirements were met (score\u0026thinsp;=\u0026thinsp;1) and non-compliance: Less than 50% of requirements were met (score\u0026thinsp;=\u0026thinsp;0). Data was entered into Microsoft Excel for ease of interpretation. Quantitative data, such as facility characteristics and adherence to quality standards, were analyzed using descriptive statistics. Ethical approval was obtained from the ethics committee prior to the commencement of the study.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e \u003cb\u003eASSESSMENT OF SERVICE PROVISION CRITERIA IN LABOUR ROOM-\u003c/b\u003eWe observed curative, Reproductive, Maternal Neonatal, Child, Adolescent health and diagnostic Services of all the levels of delivery points where our results showed that all L3 level delivery points scored the highest in-service provision, with an average score of 19.4 out of 22, achieving an average score percentage of (88.18%). Major non-compliance was seen in the area of \u0026ldquo;RMNCHA Services (availability of pre-term services, management of retained placenta, postpartum hemorrhage, septic delivery and eclampsia)\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eASSESSMENT OF PATIENT RIGHTS CRITERIA IN LABOUR ROOM.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe criteria observed were \u0026ldquo;provision of information that is sensitive to gender, religious and cultural needs, no barrier on account of physical economic, cultural or social reasons, maintaining privacy, confidentiality and dignity of patient, has a system for guarding patient related information, informed decision making, financial protection given from the cost of hospital services\u0026rdquo;. \u003csup\u003e2\u003c/sup\u003e L3 delivery points in patient rights criteria scored 38(95%) which was the highest out of a total score of 40 in the area of provision patients\u0026rsquo; rights as compared to other levels of delivery points. Major non-compliance was seen in the area of \u0026ldquo;maintaining privacy (availability of partition between delivery tables and availability of frosted glasses at windows)\u0026rdquo;. \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF INPUTS CRITERIA IN LABOUR ROOM\u003c/h2\u003e \u003cp\u003eThe criteria observed were whether the \u0026ldquo;facility has infrastructure for delivery of assured services, ensures the physical safety of the infrastructure, established program for fire safety, disaster, adequate qualified and trained staff, provides drugs and consumables, equipment and instruments, procedure for evaluation of competence and performance of staff\u0026rdquo;. \u003csup\u003e2\u003c/sup\u003e Average Score of L3 delivery points in inputs was 98.2 (90.92%) in the area of provision of inputs which was highest than all levels of delivery point out of total score of 108. Major non-compliance was seen in the area of \u0026ldquo;infrastructure (labor room in proximity to Operation theatre), adequate staff availability of gynecologist and pediatrician), drugs and consumables (availability of uterotonic drugs), competence of staff\u0026rdquo;. \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF SUPPORT SERVICES CRITERIA IN LABOUR ROOM\u003c/h2\u003e \u003cp\u003eThe criteria observed was \u0026ldquo;whether the facility has program for inspection, testing and maintenance of Equipment, procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas, secure and comfortable environment for staff, patients and visitors ; The facility ensures 24X7 water and power backup as per requirement of service delivery, and the facility ensures clean linen to the patient; Roles of administrative and clinical staff are determined as per govt. regulations and standards operating procedure for maintenance and upkeep of the facility\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e The average Score of L3 delivery points was 59.2 (95.48%) which was the highest out of a total score of 62. Major non-compliance was seen in the area of \u0026ldquo;secure and comfortable environment for staff, patients and visitors\u0026rsquo; temperature control and ventilation in patient care areas, security arrangement in labour room\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF CLINICAL SERVICES CRITERIA IN LABOUR ROOM\u003c/h2\u003e \u003cp\u003eThe criteria observed was whether the \u0026ldquo;facility had defined procedures for registration, consultation and admission of patients, established procedures for clinical assessment, procedures for continuity of care of patient and referral; Defined procedures for nursing care, procedure to identify high risk and vulnerable patients, follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs \u0026amp; their rational use, and procedures for safe drug administration; Procedures for maintaining, updating of patients\u0026lsquo; clinical records and their storage, established procedures of diagnostic services antenatal, Intranatal care, postnatal care as per guidelines and blood bank services\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e In our results it was seen that average Score of L3 delivery points in clinical services provision was 176.4 (95.8%) out of total score of 184 which was the highest among all the levels of delivery points. Where major non- compliance was seen in the area of \u0026ldquo;diagnostic services (Nursing station provided with critical value of different test), blood bank services (procedure blood transfusion monitoring), Intranatal services (criteria for distinguishing between new-born death and still birth) Management of Retained Placenta, Anti-Retroviral therapy for seropositive mothers and Nevirapine to newborns of HIV seropositive mothers) and post-natal (facilitates specialist care in new born, established criteria for shifting new born to SNCU)\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF INFECTION CONTROL SERVICES CRITERIA IN LABOUR ROOM\u003c/h2\u003e \u003cp\u003eThe criteria observed was whether the \u0026ldquo;facility has infection control Programs and procedures in place and has defined and Implemented procedures for ensuring hand hygiene practices ,antisepsis, standard practices and materials for personal protection, has standard practices and materials for personal protection, has physical layout and environmental control of the patient care areas ensures infection prevention ,and have defined and established procedures for segregation, collection, treatment and disposal of Bio-Medical and hazardous Waste\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e Here also L3 delivery point scored the highest with an average score of 71(95.94%) out of a total score of 74. Major area of non-compliance was \u0026ldquo;Surface and environment samples being taken for microbiological surveillance, Shaving done during part preparation/delivery cases and no use of elbow length gloves for obstetrical purpose\u0026rsquo;.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF QUALITY MANAGEMENT CRITERIA IN LABOUR ROOM\u003c/h2\u003e \u003cp\u003eThe criteria observed were whether the \u0026ldquo;facility has established organizational framework for quality improvement and a system for patient and employee satisfaction, whether the facility has established internal and external quality assurance programs, wherever it is critical to quality and maintained Standard Operating Procedures for all key processes and support services, it maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages and has a system of periodic review as internal assessment, medical \u0026amp; death audit and prescription audit. And has defines mission, values, Quality policy \u0026amp; objectives \u0026amp; prepared a strategic plan to achieve them and seeks continually improvement by practicing Quality method and tools\u0026rdquo;.\u003csup\u003e2\u003c/sup\u003e Although all the levels of delivery points scored less in this area an average score of 34.6 (48.57%) which was the highest out of total score of 70 was scored by L3 delivery points in quality management criteria of LaQshya Guideline checklist. Major non-compliance was seen in all the areas of quality management\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study was a community-based study which used LaQshya guidelines checklist for labour room assessment. A total of 18 delivery points were selected in which L1 delivery points were 5, L2 delivery points were 6, and L3 delivery points were 7 in number. These were assessed on the criteria of service provision, patients\u0026rsquo; rights, input, support services, infection control services and quality management. The criteria observed were curative, RMNCHA Services and diagnostic Services. In our study in L1 delivery points the average score percentage was 53.36%, in L2 delivery points it was 63.63% and in L3 Delivery points it was 85.45% in the area of service provision. Major non-compliance was seen in the area of RMNCHA Services (availability of pre-term services, management of retained placenta, postpartum haemorrhage, septic delivery and eclampsia). In other study by Upadhyay K et.al.\u003csup\u003e5\u003c/sup\u003e The mean total score for facility assessment parameter was 81.7(86.9%). The mean service delivery score for antenatal care assessment, postnatal care assessment, and immunization is 74.9(78.9%), 24.7(98.6%), and 40.2(87.3%), respectively, with an overall score of 139.8(84.2%). Dodwad SS et.al\u003csup\u003e6\u003c/sup\u003e in other similar study regarding the process of service delivery, more than two-thirds of facilities in Ahmednagar (67%) and about 45% of the facilities in Tumkur scored C or D grade.\u003c/p\u003e\n\u003cp\u003eOn the contrary Sharma J et.al\u003csup\u003e7\u003c/sup\u003e in other study found that both primary and secondary level facilities failed to meet the basic standards for provision of intrapartum care. It can be concluded that better service provision scores that indicated higher performance of health-care delivery system which was comparatively higher in most of L3 delivery points.\u003c/p\u003e\n\u003cp\u003eWhen it came to provision of patient\u0026rsquo;s rights in our study the average score of L1 delivery points was the lowest than all other delivery points an average score percentage of 88.50% in the area of provision of patients\u0026rsquo; rights.\u003c/p\u003e\n\u003cp\u003eOur results were compatible with Sharma G et.al\u003csup\u003e8\u003c/sup\u003e in which that total mistreatment scores were higher amongst women attending district hospitals. Hajizadeh K et.al\u003csup\u003e18\u003c/sup\u003e in other study found that the mean respectful maternity care score was 62.58 with a range of 15 to 75 and a statistically significant direct correlation was found between respectful maternity care and a positive childbirth experience (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). On the other hand, Raval H et.al\u003csup\u003e9\u003c/sup\u003e in another study found that, the PHC demonstrated higher Respectful Maternal care performance compliance than DH and the CHC. Most often violations of Respectful Maternity Care standards included beneficiaries were not greeted, privacy not maintained, they were not encouraged to ask questions, and support not provided during labour. Hence it was seen that provision of patients\u0026rsquo; rights was comparatively lower in L1 delivery points out of all delivery levels the reason could be because lower levels of healthcare facilities might lack operational guidelines on provision of respectful maternal care. In our study it was also seen that in the area of provision of Inputs, L3 delivery points scored 90.92% which was highest of all the levels of delivery points where major non-compliance was seen in the area of infrastructure (labor room in proximity to Operation theatre), adequate staff availability of gynecologist and pediatrician), drugs and consumables (availability of uterotonic drugs), competence of staff.\u003c/p\u003e\n\u003cp\u003eOur results were consistent with Chavda P et.al\u003csup\u003e10\u003c/sup\u003e where mean obtained score for facilities in Input section was 65%. Highest score was obtained for Drugs and Consumables (86%) followed by Equipment and Supplies (74%). The score obtained for Infrastructure facility was 65%, Personnel and training was 56% and Essential protocols and guidelines scored 43%.\u003c/p\u003e\n\u003cp\u003eSimilarly, Sachan D et.al\u003csup\u003e11\u003c/sup\u003e in other study found that the infrastructure of the facilities was the best for medical college followed by district hospitals, Community Health Centers (CHCs), Primary Health Centers (PHCs) and subcenters. The differences in the findings of the study can be due to healthcare funding challenges and poor maintenance attitude. In our study all the L3 delivery points scored 95.48% in the area of provision of support services, where major non-compliance was seen in the area of secure and comfortable environment for staff, patients and visitors\u0026rsquo; temperature control and ventilation in patient care areas, security arrangement in labour room.\u003c/p\u003e\n\u003cp\u003eOur results were consistent with Saravanakumar Vet.al\u003csup\u003e12\u003c/sup\u003e where scores in support service are more than 70 percent in all the districts.\u003c/p\u003e\n\u003cp\u003eSimilarly study by Verma VR et.al\u003csup\u003e13\u003c/sup\u003e, indicated poor readiness for peripheral rural facilities with a composite score of 41% and 24% for subcentres and new type primary health centres respectively hence it was seen that level of health care provided in primary health facilities is dependent on the availability of adequate basic amenities, basic equipment and essential medicines. The difference in the scores can be due to lack of focus of policymakers in the problem areas and lack of funding. It is safe to say that the focus of improvement should be centered on the betterment of structure and services provided at lower level of delivery points.\u003c/p\u003e\n\u003cp\u003eIt was also seen that all the L3 delivery points scored 95.8% in the area of provision clinical services. Our results were consistent with Sharma J et.al\u003csup\u003e7\u003c/sup\u003e who found that about 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77 vs 0.74). Also, Sodani PR et.al\u003csup\u003e14\u003c/sup\u003e saw that more than 90% of the study primary health centres lacked availability of both antenatal and post-natal services. However, other services like emergency services, management of fractures, cataract, medical termination of pregnancy, management of low-birth-weight babies, tubectomy and vasectomy, were poor at PHCs which need to be addressed for their further strengthening.It highlights that the provision of clinical services score is seen to better in higher level of delivery points which can be because in higher-level healthcare delivery systems, skilled personnel often exhibit a greater tendency to remain employed due to several factors, including enhanced compensation packages and heightened job satisfaction.\u003c/p\u003e\n\u003cp\u003eIn our study if was seen that all the L3 delivery points scored 48.57% in the area quality management services which was the highest amongst all the levels of delivery points where major non-compliance was seen in all the areas of quality management Our results were consistent with Dodwad SS et.al\u003csup\u003e6\u003c/sup\u003e where Sixty-four percent were of good quality, about one-third were average, while a small proportion (6%) were of poor quality. Karkee R et.al\u003csup\u003e15\u003c/sup\u003e also found that mean scores of total quality and sub-scales health facility and health care delivery for women attending private hospital were higher (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than those using birth centre or public hospital.\u003c/p\u003e\n\u003cp\u003eResults of Van Berkel R et.al\u003csup\u003e18\u003c/sup\u003e showed that high education levels and lengthy stay in healthcare facilities were negatively associated with the satisfaction with the free delivery services. Which can be the reason why score was higher in private than in public hospitals.\u003c/p\u003e\n\u003cp\u003eIt was also seen that in our study all the L3 delivery points scored 95.4% in the area of infection control services. Our results were consistent with Saravana kumar V et.al\u003csup\u003e19\u003c/sup\u003e found that public health facilities namely Sub district hospitals (SDH), CHC/Block PHC, Primary Health Centre (PHC), Urban Primary Health Centre (UPHC) one each scored above 70 percent Regarding infection control in the hospitals.\u003c/p\u003e\n\u003cp\u003eSimilarly Cloete B et.al\u003csup\u003e16\u003c/sup\u003e also in audits of 60 primary health-care facilities in the Western Cape Province of South Africa. At baseline, 25% of 60 facilities were ―noncompliant (audit score\u0026thinsp;\u0026lt;\u0026thinsp;50%), 48% ―conditionally compliant(score\u0026thinsp;\u0026gt;\u0026thinsp;50\u0026thinsp;\u0026lt;\u0026thinsp;80%), and only 27% ―compliant (score\u0026thinsp;\u0026gt;\u0026thinsp;80%)and Isah HO et.al\u003csup\u003e17\u003c/sup\u003e also found that found that the facilities\u0026lsquo; mean score on measures and frameworks for ensuring the implementation of Universal Precautions was 53.12% \u0026plusmn; 21.68% with only 56.52% scoring above 50%.\u003c/p\u003e\n\u003cp\u003eThis also highlights the need for Interventions to improve safety environment and creation of safe climate are essential to protect primary health care workers against occupational hazards. Limitations of our study was that information on the outcome criteria of the LaQshya guidelines checklist couldn\u0026rsquo;t be assessed due to non-availability of records in some delivery points and our study also provided no scope of health education and intervention to improve the service delivery in labour rooms of delivery points.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe study concludes that majority of L1 delivery points scored comparatively lower than all levels of delivery points in the criteria of service provision, patients\u0026rsquo; rights, inputs, quality management services, clinical services and infection control services. L3 Delivery points scored comparatively higher than all three levels of delivery points in all the criteria It was seen that major areas of noncompliance which needed improvement was, Quality Management, since all the levels of delivery points scored less in the criteria of quality management. Infection control and supplies of inputs also needed improvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eETHICAL CONSIDERATION:\u003c/h2\u003e\n\u003cp\u003eThe study was conducted after obtaining permission from the Institutional Ethics Committee (IEC) from Grant Govt. Medical college and JJ group of hospitals. In letter no. _______IEC/PG/ 4/NOV/2019_\u003c/p\u003e\n\u003cp\u003eAll the data collected was kept strictly confidential and used for the purpose of this study. Appropriate permissions were taken before the initiation of study. Any deviations from the below given methods/procedure were informed to the IEC and only after the IEC\u0026lsquo;s approval any changes were made. The proforma for the written informed consent is given herewith.\u003c/p\u003e\n\u003ch2\u003eInformed consent\u003c/h2\u003e\n\u003cp\u003eInformed consent were taken from the necessary participating centres .\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003e1. Dr. Gauri Bharadwaj - Data collection Data analysis and interpretation 2. Dr. Lalit Sankhe -Study conception, Study Design,Interpretation of results 3. Dr . Shubhendra Bharadwaj - Manuscript preparation\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003especial thanks to Dr. Chhaya Rajguru Dr. Pallavi Uplap and the Department of Community Medicine Grant Govt. Medical College, and JJ group of hospitals\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data contains sensitive information and should have restricted access to any public data repository .Data is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMehta R, Mavalankar DV, Ramani KV, Sharma S, Hussein J. Infection control in delivery care units, Gujarat state, India: A needs assessment. BMC Pregnancy Childbirth. 2011 Dec;11(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaQshyaGuidelines.pdf[Internet]. [cited2022Feb8].Availablefrom:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/LaQshya-Guidelines.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/LaQshya-Guidelines.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Quality Assurance Standards. 2020.pdf [Internet]. [cited 2022 Feb 8].Availablefrom:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://qi.nhsrcindia.org/sites/default/files/National%20Quality%20Assurance%20Standards\u003c/span\u003e\u003cspan address=\"http://qi.nhsrcindia.org/sites/default/files/National%20Quality%20Assurance%20Standards\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e % 202020.pdf.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurkson PK. Perceived quality of healthcare delivery in a rural district of Ghana. Ghana Med J. 2009;43(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUpadhyay K, Pentapati SS, Singh R, Goel S. Assessment of grassroot level health care service delivery system in a community development block of Haryana: A cross sectional study. Indian journal of public health. 2021 Apr 1;65(2):124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodwad SS. Quality management in healthcare. Indian journal of public health. 2013 Jul 1;57(3):138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma J, Leslie HH, Regan M, Nambiar D, Kruk ME. Can India\u0026lsquo;s primary care facilities deliver? A cross-sectional assessment of the Indian public health system\u0026lsquo;s capacity for basic delivery and newborn services. BMJ open. 2018 Jun 1;8(6):e020532.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma G, Penn-Kekana L, Halder K, Filippi V. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reproductive health. 2019Dec;16(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaval H, Puwar T, Vaghela P, Mankiwala M, Pandya AK, Kotwani P. Respectful maternity care in public health care facilities in Gujarat: A direct observation study. J Family Med Prim Care. 2021 Apr;10(4):1699.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChavda P, Misra S. Evaluation of input and process components of quality of child health services provided at 24\u0026times; 7 primary health centers of a district in Central Gujarat. Journal of family medicine and primary care. 2015 Jul;4(3):352.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSachan D, Kumar D, Gangwar A, Jain PK, Kumar S, Shukla SK, Srivastava DK, Kharya P, Bajpai PK, Pathak P, Rao TR. Are the labour rooms of primary healthcare facilities capable of providing basic delivery and newborn services? A cross-sectional study. Journal of Family Medicine and Primary Care. 2021 Oct 1;10(10):3688-99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaravanakumar V, Ravichandran S. Assessing the reasons for poor performance of Public Health Facilities in Tamil Nadu, in Kayakalp Award.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma VR, Dash U. Supply-side Readiness for Universal Health Coverage: Assessing Service Availability and Barriers in Remote and Fragile Setting. J Health Manage. 2021 Sep;23(3):441\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSodani PR, Sharma K. Strengthening primary level health service delivery: lessons from a state in India. J family Med Prim care. 2012 Jul;1(2):127.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarkee R, Lee AH, Pokharel PK. Women\u0026lsquo;s perception of quality of maternity services: a longitudinal survey in Nepal. BMC Pregnancy Childbirth. 2014 Dec;14(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCloete B, Yassi A, Ehrlich R. Repeat auditing of primary health-care facilities against standards for occupational health and infection control: a study of compliance and reliability. Safety and health at work. 2020 Mar 1;11(1):10\u0026thinsp;\u0026ndash;\u0026thinsp;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsah HO, Sabitu K, Ibrahim MT. Profile of institutional infrastructure for implementing universal precautions in primary health care facilities in Sokoto State, Nigeria: Implication for occupational safety. Afr J Clin experimental Microbiol. 2009;10(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajizadeh K, Vaezi M, Meedya S, Mohammad Alizadeh Charandabi S, Mirghafourvand M. Respectful maternity care and its relationship with childbirth experience in Iranian women: a prospective cohort study. BMC Pregnancy Childbirth. 2020;20(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health and Family Welfare (MoHFW), Government of India. (2019). LaQshya: Labour Room Quality Improvement Initiative. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/New_Updates_2018/Report_PMSMA_LaQshya.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/New_Updates_2018/Report_PMSMA_LaQshya.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. (2016). Standards for improving quality of maternal and newborn care in health facilities. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/\u003c/span\u003e\u003cspan address=\"https://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan\u003ec4a2b508-. 8407-4b4c-bbe5-2c5d94d9d572.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTABLE.1 AVERAGE SCORE PERCENTAGE OF ALL LEVELSOF DELIVERY POINTS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.005361930294907%\" valign=\"top\"\u003e\n \u003cp\u003eLaQshya checklist criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.99463806970509%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLEVEL OF DELIVERY POINTS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eL1 (5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eL2 (5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eL3\u0026nbsp;(5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSERVICE PROVISION AVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;N (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e12.4(56.36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;13.8 (62.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e19.4(88.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePATIENT\u0026rsquo;S \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRIGHTS AVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e35.4 (88.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e33.6 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e38(95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; INPUTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e82.6 (76.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e85.8 (79.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e98.2(90.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSUPPORT SERVICES\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e51.4 (82.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e50.8(81.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e59.2(95.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCLINICAL SERVICES\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e158.6(86.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e156.8(85.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e176.4(95.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eINFECTION SERVICES\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAVERAGE SCORE N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e60.2 (81.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e65.2(88.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e71(95.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.970548862115127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQUALITY MANAGEMENT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAVERAGE SCORE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; N(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e14.2(20.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.0334672021419%\" valign=\"top\"\u003e\n \u003cp\u003e18.4(26.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96251673360107%\" valign=\"top\"\u003e\n \u003cp\u003e34.6(48.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4761165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4761165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eIntroduction \u003c/strong\u003e\u003c/em\u003e\u003cem\u003e- Quality of healthcare in delivery points, particularly in tribal areas, is crucial for safe childbirth and maternal health. There is a need for comprehensive evaluation of delivery points, focusing on infrastructure, supplies, adherence to protocols, and overall quality of care provided during childbirth.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e- A community-based study conducted in Palghar district where 15 delivery points were selected, by convenient sampling. Data was collected through observations and record reviews through LaQshya checklist. Indicators like service provision, patients’ rights, clinical services, inputs, support services, infection control services, quality management were used to score the delivery points.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e- L3 level delivery points scored the highest in-service provision, with an average score of 19(88.18%) and highest in the area of provision patients’ rights38(95%) as compared to other levels. L3 delivery points scored was 98.2 (90.92%) in in the area of inputs, 59.2 (95.48%) in support services, 176.4 (95.8%) in clinical services, 71(95.94%) in infection control and 48.57% in quality management services.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion \u003c/strong\u003e\u003c/em\u003e\u003cem\u003e– L3 delivery points scored highest than all the levels in all the criteria of LaQshya checklist and L1 delivery points scored the least. Major areas of improvement were quality management, infection control and inputs.\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"Assessment of Delivery Points in a Tribal District of Maharashtra” - an Observational Study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-28 02:07:53","doi":"10.21203/rs.3.rs-4761165/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e46dd45-e7e3-4d0a-8cfc-9d1cc3edcba7","owner":[],"postedDate":"August 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-25T05:39:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-28 02:07:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4761165","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4761165","identity":"rs-4761165","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}