title: Effectiveness of Onsite Nurse Mentoring in Improving Quality of Institutional Births in the Primary Health Centres of High Priority Districts of Karnataka, South India: A Cluster Randomized Trial.
abstract: BACKGROUND
  In India, although the proportion of institutional births is increasing, there are concerns regarding quality of care. We assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 hours a day, 7 days a week) of two high priority districts in Karnataka state, South India. Primary outcomes were improved facility readiness and provider preparedness in managing institutional births and associated complications during child birth.
  
  
  METHODS
  All functional 24/7 PHCs in the two districts were included in the study. We used a parallel, cluster randomized trial design in which 54 of 108 facilities received six onsite mentoring visits, along with an initial training update and specially designed case sheets for providers; the control arm received just the initial training update and the case sheets. Pre- and post-intervention surveys were administered in April-2012 and August-2013 using facility audits, provider interviews and case sheet audits. The provider interviews were administered to all staff nurses available at the PHCs and audits were done of all the filled case sheets during the month prior to data collection. In addition, a cost analysis of the intervention was undertaken.
  
  
  RESULTS
  Between the surveys, we achieved coverage of 100% of facilities and 91.2% of staff nurse interviews. Since the case sheets were newly designed, case-sheet audit data were available only from the end line survey for about 80.2% of all women in the intervention facilities and 57.3% in the control facilities. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with gestational hypertension (19 vs.3, OR (odds ratio) 9.2, 95% C.I 2.5 to33.6), postpartum haemorrhage (29 vs. 12, OR 3.7, 95% C.I 1.6 to8.3); and obstructed labour (25 vs.9, OR 3.4, 95% CI 1.6 to8.3). The providers in the intervention arm had better knowledge of active management of the third stage of labour (82.4% vs.35.8%, AOR (adjusted odds ratio) 10, 95% C.I 5.5 to 18.2); management of maternal sepsis (73.5% vs. 10.9%, AOR 36.1, 95% C.I 13.6 to 95.9); neonatal resuscitation (48.5% vs.11.7%, AOR 10.7, 95% C.I 4.6 to 25.0) and low birth weight newborn care (58.1% vs. 40.9%, AOR 2.4, 95% C.I 1.2 to 4.7). The case sheet audits revealed that providers in the intervention arm showed greater compliance with the protocols during labour monitoring (77.3% vs. 32.1%, AOR 25.8, 95% C.I 9.6 to 69.4); delivery and immediate post-partum care for mothers (78.6% vs. 31.8%, AOR 22.1, 95% C.I 8.0 to 61.4) and for newborns (73.9% vs. 32.8%, AOR 24.1, 95% C.I 8.1 to 72.0). The cost analysis showed that the intervention cost an additional $5.60 overall per delivery.
  
  
  CONCLUSIONS
  The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications. It is feasible to improve the quality of institutional births at a large operational scale, without substantial incremental costs.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT02004912.
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.|Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Krishnamurthy
authors.identifier: http://orcid.org/0000-0002-0224-2543
authors.initials: K
authors.lastname: Jayanna
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Janet
authors.initials: J
authors.lastname: Bradley
authors.affiliation: St John's National Academy of Health Sciences, Bangalore, Karnataka, India.
authors.forename: Prem
authors.initials: P
authors.lastname: Mony
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Troy
authors.initials: T
authors.lastname: Cunningham
authors.affiliation: St John's National Academy of Health Sciences, Bangalore, Karnataka, India.
authors.forename: Maryann
authors.initials: M
authors.lastname: Washington
authors.affiliation: St John's National Academy of Health Sciences, Bangalore, Karnataka, India.
authors.forename: Swarnarekha
authors.initials: S
authors.lastname: Bhat
authors.affiliation: St John's National Academy of Health Sciences, Bangalore, Karnataka, India.
authors.forename: Suman
authors.initials: S
authors.lastname: Rao
authors.affiliation: St John's National Academy of Health Sciences, Bangalore, Karnataka, India.
authors.forename: Annamma
authors.initials: A
authors.lastname: Thomas
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Rajaram
authors.initials: R
authors.lastname: S
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Arin
authors.initials: A
authors.lastname: Kar
authors.affiliation: Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Swaroop
authors.initials: S
authors.lastname: N
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.|Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Ramesh
authors.initials: R
authors.lastname: B M
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.|Karnataka Health Promotion Trust, Bangalore, Karnataka, India.
authors.forename: Mohan
authors.initials: M
authors.lastname: H L
authors.affiliation: IntraHealth International, Chapel Hill, North Carolina, United States of America.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Fischer
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Maryanne
authors.initials: M
authors.lastname: Crockett
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Blanchard
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Stephen
authors.initials: S
authors.lastname: Moses
authors.affiliation: Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Avery