Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study

Beena Varghese; Jayanna Krishnamurthy; Blaze Correia; Ruchika Panigrahi; Maryann Washington; Vinotha Ponnuswamy; Prem Mony

doi:10.9745/GHSP-D-16-00143

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FIGURE 1.
Flow Chart Depicting Study Design, Timeline, Tools, and Study Outcomes
Abbreviations: OSCE, objective structured clinical examination; PIH, pregnancy-induced hypertension; PPH, postpartum hemorrhage.
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FIGURE 2.
Post-Intervention OSCE Scores for Providers in Intervention and Comparison Sites by Obstetric and Newborn Content
Abbreviations: ENC, essential newborn care; LBW, low birthweight; NB, newborn; NRP, neonatal resuscitation procedure; OB, obstetric; OSCE, objective structured clinical examination; PIH, pregnancy-induced hypertension; PPH, postpartum hemorrhage.

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TABLE 1.

Characteristics of Intervention and Comparison Facilities, Selected Districts of Karnataka, India, July 2013 to September 2014

Parameters	Intervention (n = 4)	Comparison (n = 4)
Type of facility
Sub-district hospital	3	3
Community health center	1	1
Human resource capacity
Obstetrician/trained in EmOC	6	3
Pediatrician	0	3
Physician	2	2
Anesthetist	1	1
Nurses	64	68
No. of deliveries per quarter, 2013, mean	1,840	1,680
No. of cesarean deliveries per quarter, 2013, mean	119	98

Abbreviation: EmOC, emergency obstetric care.

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TABLE 2.

Delivery Outcomes and Use of Delivery and Complication Case Sheets, Selected Districts of Karnataka, India, November 2013 to October 2014

Parameters	Intervention (N = 6452 deliveries)	Comparison (N = 6329 deliveries)	P Value
No. (%) of completed and analyzable records	5615 (87.0)	5204 (82.2)	<.05
No. (%) of deliveries
Spontaneous vaginal	4369 (77.8)	3496 (67.2)	<.05
Ventouse/forceps	82 (1.5)	64 (1.2)	.86
Cesarean	423 (7.5)	621 (11.9)	<.05
No. of stillbirths (rate per 1,000 births)	62 (9.6)	79 (12.4)	.87
No. of fresh stillbirths (% of total stillbirths)	15 (24.2)	24 (30.4)	.52
No. (%) of complications recorded
PIH	229 (3.5)	331 (5.2)	.35
PPH	69 (1.1)	41 (0.6)	.44
Birth asphyxia	107 (1.7)	104 (1.6)	.98
No. of complication case sheets completed (% of complications recorded)
PIH	179 (78.2)	172 (52.0)	<.05
PPH	51 (73.9)	26 (63.4)	.56
Birth asphyxia	99 (92.5)	88 (84.6)	.09

Abbreviations: PIH, pregnancy-induced hypertension; PPH, postpartum hemorrhage.

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TABLE 3.

Diagnosis and Management of Maternal and Newborn Complications, Selected Districts of Karnataka, India, November 2013 to October 2014

Parameter	Intervention n/N (%)^a	Comparison n/N (%)^a	P Value
Correct diagnosis
PIH	107/165 (64.8)	77/128 (60.2)	.43
PPH	37/42 (88.1)	23/25 (92.0)	.79
Birth asphyxia	72/90 (80.0)	63/72 (87.5)	.29
Correct diagnosis and management
PIH	29/165 (17.6)	25/128 (19.5)	.79
PPH	25/42 (59.5)	13/25 (52.0)	.72
Birth asphyxia	52/90 (57.8)	35/72 (48.6)	.40

Abbreviations: PIH, pregnancy-induced hypertension; PPH, postpartum hemorrhage.
↵a Denominator is the total number of delivery records and complication sheets reviewed.

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TABLE 4.

Maternal and Newborn Knowledge and Skills of Providers, Selected Districts of Karnataka, India, Before (August 2013) and After (September 2014) the Skills and Drills Intervention

Parameter	Intervention		Comparison		P Value
Parameter	Mean (SD)	%	Mean (SD)	%	P Value
Knowledge scores^a
Pre-test	N = 73		N = 36
Obstetric (maximum score = 29)	14.2 (4.3)	49	15.2 (3.6)	52	.21
Newborn (maximum score = 21)	10.2 (3.9)	48	11 (3.0)	52	.30
Post-test	N = 50		N = 36
Obstetric (maximum score = 29)	16.4 (4.3)	57	16.6 (3.9)	57	.84
Newborn (maximum score = 21)	11.6 (3.3)	56	10.4 (3.3)	49	.09
OSCE scores
Post-test	N = 50		N = 35
Obstetric (maximum score = 50)	27.5 (4.9)	55	22.9 (5.8)	46	<.001
Newborn (maximum score = 50)	29 (5.2)	58	24.2 (6.2)	48	<.001

Abbreviations: OSCE, objective structured clinical examination; SD, standard deviation.
↵a There was a significant increase between pre- and post-test knowledge scores in the intervention group for both obstetric content (49% vs. 57%, respectively; P=.006) and newborn content (48% vs. 56%, respectively; P=.034). In contrast, there were no significant changes between pre- and post-test knowledge scores in the comparison group: obstetric content (52% vs. 57%, respectively; P=.12); newborn content (52% vs. 49%, respectively; P=.42).