Can changes to improve person-centred maternity care be spread across public health facilities in Uttar Pradesh, India?

Figures & data

Table 1. Examples of successful change package interventions for Person-centred Maternity Care (PCMC)

PCMC topic	Examples of successful change interventions
Staff introductions	Train staff on specific PCMC issue Reminders – posters, briefing during staff handovers Targeted endorsement of change by line managers to uncooperative staff Promotion of change to specific staff groups Introductions to whole ward when coming on duty Introduction after delivery for women presenting in 2nd stage of labour
Cleanliness	Train staff on specific PCMC issue Appointment of dedicated cleaner Senior staff member outlines cleaner’s duties, clarifies roles and expectations Cleanliness reviewed by staff or senior staff member 2–3 times daily and cleaner called to rectify if required Patients’ supporters (ASHAs) requested to encourage patients to help keep areas clean; posters used to remind ASHAs Buckets of water made available and refilled regularly when piped water disconnected
Patient privacy and confidentiality	Train staff on specific PCMC issue Dedicated sheets or blankets made available by examination table & replaced regularly Facility gauze or clean cloth brought by patients used to cover them during examinations Curtains around beds in the labour ward kept closed Labour ward curtains are fast-tracked when needing to be laundered
Patient education and autonomy	Train staff on specific PCMC issue A standard script for each test and medicine administered during labour, delivery and in post-natal care is developed and memorised by all relevant staff The purpose for giving oxytocin is repeated after the placenta is delivered Relatives collecting drugs from pharmacy on behalf of the patient are briefed by a member of staff as to their purpose and encouraged to pass this on to the patient
Administering pain medication on request	Train staff on specific PCMC issue Staff ask patients about their pain whenever visiting the post-natal care ward The maternity area holds a small stock of pain medication A register of pain medication held in maternity is used to avoid stock-outs
Supportive care	Train staff on specific PCMC issue Junior staff members transporting patients to the post-natal ward show them the toilet area on arrival and stress they must ask for assistance to walk there
Position of choice during delivery	Train staff on specific PCMC issue The member of staff delivering a patient advises them they can request an alternative position

Table 2. Characteristics of participants, by spread/control and survey round

	Baseline			Endline
	Spread sites	Control sites	p-Value	Spread sites	Control sites	p-Value
Total number in group	300	300		300	300
Age
15–19 years	8	14	.417	3	8	.036
	(2.7%)	(4.7%)		(1.0%)	(2.7%)
20–29 years	254	247		258	269
	(84.7%)	(82.3%)		(86.0%)	(89.7%)
30–40 years	38	39		39	23
	(12.7%)	(13.0%)		(13.0%)	(7.7%)
Number of births
1	124	112	.021	92	119	.093
	(41.3%)	(37.3%)		(30.7%)	(39.7%)
2	98	83		110	92
	(32.7%)	(27.7%)		(36.7%)	(30.7%)
3	53	56		65	53
	(17.7%)	(18.7%)		(21.7%)	(17.7%)
4 or more	25	49		33	36
	(8.3%)	(16.3%)		(11.0%)	(12.0%)
Wealth quintiles
1 – Poorest	48	111	<.001	36	43	<.001
	(16.0%)	(37.0%)		(12.0%)	(14.3%)
2 – Poorer	68	76		39	49
	(22.7%)	(25.3%)		(13.0%)	(16.3%)
3 – Middle	60	48		57	68
	(20.0%)	(16.0%)		(19.0%)	(22.7%)
4 – Richer	47	32		78	96
	(15.7%)	(10.7%)		(26.0%)	(32.0%)
5 – (Richest)	77	33		90	44
	(25.7%)	(11.0%)		(30.0%)	(14.7%)
Religion
Hindu	284	278	.303	281	277	.522
	(94.7%)	(92.7%)		(93.7%)	(92.3%)
Muslim	15	22		19	23
	(5.0%)	(7.3%)		(6.3%)	(7.7%)
None	1	0		0	0
	(0.3%)	(0.0%)		(0.0%)	(0.0%)
Caste
Scheduled Caste	128	152	<.001	139	112	.160
	(42.7%)	(50.7%)		(46.3%)	(37.3%)
Scheduled Tribe	1	14		2	2
	(0.3%)	(4.7%)		(0.7%)	(0.7%)
General Caste	48	38		39	49
	(16.0%)	(12.7%)		(13.0%)	(16.3%)
OBC	123	96		120	137
	(41.0%)	(32.0%)		(40.0%)	(45.7%)
Highest grade/class completed
No education	39	85	<.001	30	121	<.001
	(13.0%)	(28.3%)		(10.0%)	(40.3%)
Primary or post-primary	112	120		136	126
	(37.3%)	(40.0%)		(45.3%)	(42.0%)
Secondary or higher	149	95		134	53
	(49.7%)	(31.7%)		(44.7%)	(17.7%)
Number of ANC visits
No ANC visits	1	1	.014	0	2	.006
	(0.3%)	(0.3%)		(0.0%)	(0.7%)
1–4	98	66		107	123
	(32.7%)	(22.0%)		(35.7%)	(41.0%)
4 or 5	96	127		146	153
	(32.0%)	(42.3%)		(48.7%)	(51.0%)
6 plus	105	106		47	22
	(35.0%)	(35.3%)		(15.7%)	(7.3%)
Problems during pregnancy
No	184	160	.048	209	254	<.001
	(61.3%)	(53.3%)		(69.7%)	(84.7%)
Yes	116	140		91	46
	(38.7%)	(46.7%)		(30.3%)	(15.3%)
Facility type
Government health centre	200	300	<.001	200	300	<.001
	(66.7%)	(100.0%)		(66.7%)	(100.0%)
Government hospital	100	0		100	0
	(33.3%)	(0.0%)		(33.3%)	(0.0%)
Delivery assistant
Nurse/Doctor	112	0	<.001	11	72	<.001
	(37.3%)	(0.0%)		(3.7%)	(24.0%)
Midwife/Dai	153	119		18	37
	(51.0%)	(39.7%)		(6.0%)	(12.3%)
ASHA/Angawali	32	6		191	182
	(10.7%)	(2.0%)		(63.7%)	(60.7%)
Other/non-skilled attendant	3	175		80	9
	(1.0%)	(58.3%)		(26.7%)	(3.0%)

Table 3. Mean total PCMC and subdomain scores, by spread/control and survey round^a

Total PCMC score	Baseline					Endline
	Spread sites		Control			Spread sites		Control
	Mean	SD	Mean	SD	p-Value	Mean	SD	Mean	SD	p-Value
PCMC total score	59.49	11.40	65.84	9.24	<.001	86.58	9.78	62.35	12. 2	<.001
Change Package PCMC score (8 items)	42.71	16.15	45.92	10.79	.004	83.36	13.51	52.74	13.97	<.001
Dignity and respect domain score	76.59	15.76	83.04	11.63	<.001	85.96	9.87	74.59	14.24	<.001
Communication and autonomy domain score	36.65	16.38	40.9	14.89	.001	82.69	18.34	48.25	15.79	<.001
Supportive care domain score	68.06	10.74	75.94	12.34	<.001	89.81	7.6	66.81	15.97	<.001

^a Total and subdomain scores were scaled to a 100-point scale.

Figure 1. Mean adjusted PCMC scores, by survey round and spread/control sites

Note: Scores were scaled to a 100-point scale. All estimates adjusted for age, parity, education, wealth, religion, caste, facility type, delivery provider, ANC visits, and pregnancy complications. Robust standard errors were used

Table 4. Difference-in-differences analyses to assess the impact of spread on PCMC scores (total and change package)

	All PCC indicators^a			Change Packet PCMC^b indicators (8 items total)			Dignity and respect domain			Communication and autonomy domain			Supportive care domain
	β	95% CI	p-Value	β	95% CI	p-Value	β	95% CI	p-Value	β	95% CI	p-Value	β	95% CI	p-Value
Survey round
Baseline	0	Ref		0	Ref		0	Ref		0	Ref		0	Ref
Endline	3.04	0.85, 5.23	0.007	9.84	7.40, 12.29	0.000	−0.47	−3.19, 2.24	0.733	14.81	11.61, 18.01	0.000	−4.03	−6.66, −1.41	0.003
Group assignment
Control	0	Ref		0	Ref		0	Ref		0	Ref		0	Ref
Spread sites	−7.59	−9.47, −5.71	0.000	−10.35	−12.58, −8.12	0.000	−0.84	−3.22, 1.54	0.487	−10.91	−13.63, −8.19	0.000	−8.48	−10.77, −6.18	0.000
Group interaction Term	27.14	24.41, 29.88	0.000	33.86	30.91, 36.81	0.000	9.33	5.88, 12.78	0.000	37.08	33.17, 40.98	0.000	28.60	25.32, 31.89	0.000

Note:  Adjusted estimates controlled for age, parity, education, wealth, religion, caste, facility type, delivery provider, ANC visits, and pregnancy complications. Robust standard errors were used.

^a Adjusted R²= 0.605.

^b Adjusted R²= 0.725.

Table 5. Difference-in-differences analyses to assess the impact of the Spread intervention on other outcomes

	Spread sites vs. control
	Survey round baseline vs. endline	Treatment group spread vs. control	Interaction term
Clinical quality index
Coefficient	2.81	−2.15	3.10
95% CI	1.91, 3.72	−2.94, −1.36	1.96, 4.24
p-Value	.000	.000	.000
Delivery problems
aOR	2.90	1.74	0.15
95% CI	1.26, 6.67	0.80, 3.80	0.05, 0.42
p-Value	.012	.166	.000
Frequency of doctor visits (per day)
Coefficient	−0.41	−0.61	0.74
95% CI	−0.54, −0.28	−0.75, −0.48	0.56, 0.92
p-Value	.000	.000	.000
Frequency of nurse visits (per day)
Coefficient	0.16	−1.49	1.84
95% CI	−0.09, 0.40	−1.73, −1.24	1.52, 2.15
p-Value	.206	.000	.000

Note:  All estimates adjusted for age, parity, education, religion, wealth, caste, facility type, delivery provider, ANC visits, and pregnancy complications. Robust standard errors were used.

Data availability statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.