Discussion
pains, pain
REGRESSION
The study was designed to investigate the effectiveness of a set of interventions in improving the quality of intrapartum care in Nigerian referral hospitals. The interventions which were co-designed and implemented by healthcare providers and administrators addressed multiple challenges associated with inadequate delivery of intrapartum care in the hospitals. No adverse or simultaneous intervention took place in the experiment and control hospitals during the period of this study. Contrary to expectation, the results showed that the aggregate assessment of the quality of intrapartum care was higher in the control sites as compared to the intervention sites in both adjusted and unadjusted regression. However, an analysis of the trend over three months showed significant improvement in the intervention site at the mid and end periods of the intervention.In this study, we assessed ten quality of intrapartum care indicators from the WHO recommendations for positive childbirth experience[Overall, the interventions showed 6% increase in overall quality of care and demonstrated beneficial effects in five principal areas. These include (1) perceptions by women that they were well attended in labour; (2) higher rates of vaginal delivery as compared to caesarean delivery; (3) prompt repair of episiotomies; (4) better pain management in labour; (5) delayed bath of the baby after delivery.The mode of delivery showed considerable improvement in the intervention sites as compared to the control sites. While the WHO recommends worldwide caesarean section rates not exceed 15% , published studies conducted in referral hospitals in Nigeria have repeatedly shown that cesarean section rates are over this average [The intervention also had effects on the use of episiotomy in the hospitals. Why the WHO now does not recommend routine use of episiotomy [A major outcome of the intervention was its beneficial effects in improving women’s experiences of labour pains. Up to 73% of the women in both sites reported experiences of severe pains during labour. However, the report showed that women in the intervention sites were more likely to report that they were happier with the ways health workers managed labour pains as compared to the control sites. Overall, the women in the intervention sites reported higher odds of not being satisfied with how the health workers helped to reduce pain during labour at baseline, but significantly higher odds during the intervention. This indicates that women in the intervention sites were progressively more satisfied with intrapartum care. A previous assessment of overall satisfaction with maternal care after the intervention shows women in the intervention sites were 54% more likely to be satisfied than those in the control site[Another positive outcome of the intervention was the report of delayed bath of the babies after delivery. The WHO recommends that babies be bathed not sooner than 24 h after delivery [In contrast to the positive outcomes specified above, the results of this analysis showed that the intervention had no or limited effects in ameliorating at least five signal functions. These include (1) reports of the use of clean delivery packs being lower in the intervention sites as compared to the control sites; (2) women reporting that something was applied to the umbilical cord after the birth of the baby lower in the intervention sites; (3) baby placed in the belly with odds lower in the intervention sites; (4) the lack of effects of the intervention in reducing the incidence of routine episiotomy, and (5) reports by women that verbal and written information were less likely to be provided in the intervention sites as compared to the control sites.These limited effects of the intervention may be due to the imperfect implementation of some of the intervention activities or poor integration of the activities into care provision in the intervention hospitals. For example, women who did not receive antenatal care in the hospitals but were referred during labour did not receive the training and information given to women in antenatal clinics and weekly health talks. It is important to ensure all women receive all components of quality care regardless of the timing of their admission into the hospital care system [Recall bias may not have accounted for some of these differences as women in intervention and control sites are equally likely to experience the same level of bias, given that they were recruited and interviewed during the same period.