Evaluation of 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

Background: Dakshata program in India aims to improve resources, providers’ competence and accountability in labour wards of public sector secondary care hospitals. It is based on the WHO Safe Childbirth Checklist coupled with mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems and supported solutions; supported state in monitoring. We (a third party) evaluated the effectiveness and factors contributing to success and sustainability. Methods: We conducted three repeat mixed-method surveys across 24 hospitals which were at different stage of program implementation when evaluation initiated: Group 1-trainings started and Group 2-one round of mentoring completed. We followed them over 18 months. Data was collected by directly observing obstetric assessments and childbirth, extracting information from casesheets and registers, and interviewing postnatal women. Theory-driven qualitative assessment included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from external partner. Results: Average adherence to practices increased, saw a dip and then again improved. Significant improvement noted in several practices in the two groups—more in pause points 1, 2 and 3 but less in 4. Overall average adherence improved: Group 1, 55% to 72%; and Group 2, 69% to 79% (p<0.001). Stillbirth rate reduced: Group 1, 1.5/1,000 to 0.2; and Group 2, 2.5 to 1.1 (p<0.001). The mentoring with periodic assessments were highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered while involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported. The competence, consistency and support from the technical partner were highly appreciated. Conclusion: Dakshata program was successful in improving resources and competencies. The program is sustainable and scalable. The states with low capacities will require intensive external support for a head start.