Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Uttar Pradesh, India

Dale A. Barnhart; Donna Spiegelman; Corwin M. Zigler; Nabihah Kara; Megan Marx Delaney; Tapan Kalita; Pinki Maji; Lisa R. Hirschhorn; Katherine E. A. Semrau

doi:10.9745/GHSP-D-19-00317

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FIGURE 1
Study Populations from the BetterBirth Trial for Analysis on (a) Essential Birth Practice Adherence and (b) Health Outcomes,^a Uttar Pradesh, India
^aSample includes 436 births that were excluded from main the randomized controlled trial analysis due to being involved in baseline collection.
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FIGURE 2
Coaching Intensity Over Time^a
^aEach colored line reflects the coaching intensity at a given facility over time with the bolded black line reflecting the average coaching intensity across all facilities. Each panel provides the mean and (standard deviation) for the exposure in the EBP adherence and health outcome samples.
Abbreviations: BA, birth attendant; SD, standard deviation.
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FIGURE 3
Effect Modification of the Association Between Mean Coaching Visits Among Birth Attendants (Cumulative) and EBP Adherence Over Months of the Intervention (N=2,083)^a
Abbreviation: EBP, essential birth practice.
^aEffect sizes for coaching phases plotted at 2, 6, 12 months since the start of the intervention. Test for interaction: P<.01. Overall test for all coaching terms: P=.04.

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TABLE 1.

Eighteen Essential Birth Practices From the World Health Organization Safe Childbirth Checklist^a

At Admission	Before Pushing	After Birth	Any Time
Partograph started	Hand hygiene	Oxytocin administered within 1 minute	Maternal temperature taken
Birth companion present	Clean towel available	Birth companion present	Maternal blood pressure taken
	Clean blade available	Baby weighed
	Cord tie available	Baby temperature taken
	Mucus extractor available	Skin-to-skin warming initiated
	Neonatal bag available	Skin-to-skin warming maintained for 1 hour
	Clean pads available	Breastfeeding initiated

↵a Independent observers assessed the birth attendant's adherence to essential birth practices but not their technical skill or quality in performing the practice.

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TABLE 2.

Descriptive Statistics for the EBP Adherence and Health Outcomes Study Populations

	EBP Adherence Sample	Health Outcomes Sample
Facility-level variables	N=15	N=60
Research hub, No. (%)
Agra	–	9 (15.0)
Gorakhpur	–	11 (18.3)
Lucknow	15 (100.0)	19 (31.7)
Meerut	–	7 (11.7)
Varanasi	–	14 (23.3)
High priority district, No. (%)	7 (46.7)	7 (11.7)
Distance to district hospital (km), mean (SD)	29.5 (12.0)	29.5 (14.0)
Number of skilled birth attendants, mean (SD)	4.5 (1.1)	4.4 (1.2)
Annual delivery load, mean (SD)	1,795 (468.0)	1,599 (435.0)
Birth-level variables	N=2,083	N=80,234
Birth occurred on coaching day, No. (%)	107 (5.1)	7,533 (9.4)
Months since intervention started at facility, mean (SD)	8.5 (5.8)	6.7 (2.8)
EBP adherence (of 18 practices), mean (SD)	12.1 (2.4)	–
Primary composite,^a No. (%)	–	12,062 (15.0)
Secondary composite, No. (%)	–	3,907 (4.9)

Abbreviations: EBP, essential birth practices; SD, standard deviation.
↵a 457 births are missing data on maternal morbidity, and therefore, are missing data on the primary composite outcome.

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TABLE 3.

Association Between Coaching Intensity and EBP Adherence Among BAs During Births in 15 Health Facilities, Uttar Pradesh, India (N=2,083 Births)

Coaching Domain	Units in IQR Increase	Model 1^a			Model 2^b
Coaching Domain	Units in IQR Increase	Change in Practices Adhered to Associated With 1-Unit Increase (95% CI)	Change in Practices Adhered to Associated With IQR Increase (95% CI)	P Value	Change in Practices Adhered to Associated With 1-Unit Increase (95% CI)	Change in Practices Adhered to Associated With IQR Increase (95% CI)	P Value
Coaching frequency
Visits in the past month	6.0	0.2 (0.1, 0.3)	1.3 (0.6, 1.9)	<.01	0.2 (−0.0, 0.4)	1.0 (−0.1, 2.2)	.10
Mean visits in the past month per BA	1.3	1.0 (0.6, 1.4)	1.2 (0.7, 1.8)	<.01	0.9 (0.2, 1.6)	1.2 (0.3, 2.1)	.01
BAs receiving ≥1 visit in past month, %	70	2.8 (1.4, 4.2)	2.0 (1.0, 2.9)	.01	3.4 (1.0, 5.8)	2.4 (0.7, 4.0)	.03
Standard deviation in visits among BAs past month	1.3	0.9 (0.5, 1.4)	1.2 (0.6, 1.8)	.01	0.7 (0.0, 1.5)	1.0 (-0.0, 1.9)	.08
Cumulative coaching
Total visits	8.0	−0.0 (−0.1, 0.0)	−0.4 (−0.8, 0.1)	.09	0.1 (0.0, 0.1)	0.6 (0.3, 0.9)	.07
Mean visits per BA	5.3	−0.2 (−0.4, 0.0)	−1.0 (−2.1, 0.1)	.09	0.2 (0.0, 0.4)	1.0 (0.0, 2.0)	.21
BAs receiving ≥10 visits, %	40	−3.0 (−5.9, −0.1)	−1.2 (−2.4, 0.0)	.12	0.3 (−3.5, 4.1)	0.1 (−1.4, 1.6)	.89
Standard deviation in visits among BAs	3.5	−0.2 (−0.4, 0.1)	−0.6 (−1.5, 0.2)	.12	0.3 (0.0, 0.5)	0.9 (0.2, 1.7)	.08
Scheduling adherence
Current scheduling nonadherence	NA^c	0.3 (−0.7, 1.3)	–	.55	-0.5 (−1.3, 0.4)	–	.27
Cumulative scheduling nonadherence	12	−0.0 (−0.1, 0.0)	−0.5 (−1.0, 0.1)	.08	0.1 (0.0, 0.1)	0.8 (0.0, 1.6)	.11

Abbreviations: BA, birth attendant; CI, confidence interval; EBP, essential birth practice; IQR, interquartile range, NA, not applicable.
Effects are reported for a 1-unit increase and for increasing each continuous coaching metric from its 25^th percentile to its 75^th percentile, that is, by 1 IQR. Results are from a generalized linear model with an identity link. Standard errors are estimated using the empirical variance with an exchangeable working covariance structure to account for clustering at the facility level.
↵a Adjusted for whether the facility was in a high-priority district, distance to district hospital, facility staff size, facility delivery load, and whether birth occurred on the same day as a coaching visit.
↵b Adjusted for everything in Model 1 plus months since start of the intervention.
↵c Because current scheduling nonadherence is a binary outcome, we report the effect for nonadherence vs. no adherent, rather than for a 1 IQR increase.

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TABLE 4.

Risk Ratios for the Association Between Coaching and Health Outcomes^a Among BAs During Births in Health Facilities, Uttar Pradesh, India

Coaching Domain	Units in Increase	Primary Composite Maternal Morbidity or Maternal or Infant Mortality (n/N=12,062/79,777)				Secondary Composite Maternal or Infant Mortality (n/N=3,907/80,234)
		Model 1^b		Model 2^c		Model 1^b		Model 2^c
		RR (95% CI)	P Value	RR (95% CI)	P Value	RR (95% CI)	P Value	RR (95% CI)	P Value
Coaching frequency
Visits in past month	6.0	1.03 (0.99, 1.07)	.14	1.03 (0.94, 1.13)	.49	0.98 (0.92, 1.05)	.61	1.01 (0.88, 1.15)	.91
Mean visits in past month per BA	1.3	1.03 (1.00, 1.06)	.10	1.02 (0.97, 1.08)	.36	0.98 (0.93, 1.04)	.54	0.99 (0.92, 1.07)	.84
BAs receiving ≥1 visit in past month, %	0.7	1.05 (1.00, 1.10)	.05	1.06 (0.98, 1.15)	.15	1.00 (0.92, 1.09)	.99	1.07 (0.93, 1.22)	.36
Standard deviation in visits among BAs in past month	1.3	1.02 (0.98, 1.05)	.30	0.99 (0.94, 1.05)	.82	1.00 (0.95, 1.06)	.98	1.06 (0.99, 1.14)	.11
Cumulative coaching
Total visits	8.0	0.99 (0.97, 1.02)	.50	1.02 (0.98, 1.05)	.42	1.01 (0.97, 1.05)	.59	1.00 (0.94, 1.06)	.93
Mean visits per BA	5.3	1.01 (0.96, 1.07)	.70	1.10 (1.03, 1.18)	.03	1.07 (0.98, 1.18)	.18	1.10 (0.98, 1.25)	.16
BAs receiving ≥10 visits, %	0.4	1.00 (0.96, 1.05)	.87	1.04 (0.99, 1.09)	.14	1.04 (0.96, 1.13)	.32	1.04 (0.94, 1.15)	.42
Standard deviation in visits among BAs	3.5	1.00 (0.95, 1.06)	.89	1.04 (0.98, 1.11)	.25	1.04 (0.96, 1.13)	.34	1.04 (0.96, 1.14)	.37
Scheduling adherence
Current scheduling nonadherence^d	1	1.06 (1.01, 1.12)	.04	1.05 (1.00, 1.11)	.08	0.97 (0.86, 1.09)	.58	0.98 (0.87, 1.10)	.69
Cumulative scheduling nonadherence	12	1.00 (0.96, 1.05)	.85	1.06 (0.99, 1.13)	0.10	1.03 (0.98, 1.09)	.23	1.05 (0.99, 1.12)	.12

Abbreviations: BA, birth attendant; CI, confidence interval; RR, risk ratio.
↵a Effects are reported for increasing each continuous coaching metric from its 25^th percentile to its 75^th percentile, that is, 1 interquartile range. Results are from a generalized linear model with a log link and binomial distribution. Standard errors are estimated using the empirical variance with an exchangeable working covariance structure.
↵b Adjusted for hub name, whether the facility was in a high-priority district, distance to district hospital, facility staff size, facility delivery load, whether birth occurred on the same day as a coaching visit.
↵c Adjusted for everything in Model 1 plus months since start of the intervention.
↵d Because current scheduling nonadherence is a binary outcome, we report the effect for infidelity vs. no infidelity, rather than for a 1 interquartile range increase.