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

Background: After 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.
Methods: The 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.
Results: Use 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.
Conclusions: An 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.

Dr Sharad D. Iyengar
Chief Executive,
Action Research & Training for Health (ARTH),
G1-2, Satyam, Ramgiri, Badgaon, Udaipur 313011, Rajasthan, India
Tel: +91-294-2980075; Website:

Adjunct Professor

Sanford School of Public Policy, Duke University, Durham, NC, USA