title: Improving intrapartum fetal monitoring in India: is training the answer?
Creators: name: Lightly, Katie
Publisher: name: University of Liverpool Repository
Year: 2023

description: Introduction: Although intrapartum fetal monitoring is a fundamental aspect of intrapartum care worldwide, research on its use in LMIC is lacking. This thesis uses a multi-methods approach to evaluate an intrapartum FM training and quality improvement package in a government hospital in India, informed by staff and patient perspectives. Methods: This research was conducted in two Government hospitals in central India. The qualitative study involved eight clinician/researcher focus groups and 53 semi-structured interviews with high-risk women before and after labour induction; data was analysed using a framework approach to thematic analysis. A FM training programme was implemented and evaluated using a fixed, parallel, convergent design based on Kirkpatrick’s four-stage evaluation model and reflective diary. The prospective cohort data were analysed to evaluate risk factors, outcomes and FM practices. We then outlined an evidence-based theory of change for FM training, that is adaptable to the local context. Results: The qualitative study developed six themes (in bold). 1. Women preferred vaginal birth as it was "trouble for two hours [rather than] trouble for two months”. 2. Women gained knowledge through experience. 3. FM was part of a positive birthing experience [and women] "felt good by hearing the beats”. 4. Interactions with women, relatives and clinicians were important. 5. Clinicians felt FM as per guidelines was "practically not possible", and 6. FM and risk were linked. "Trying for normal" birth without good FM was considered "too risky”. Clinicians felt that more FM training and equipment would help. Clinicians enjoyed the FM training and gained knowledge and confidence. Post-training, they could quantify and describe how cases were managed differently. Of 84 clinicians, 77 (86%) engaged with one session or more. The interactions between the training, co-interventions, relationships, systems and context were paramount. The pre-and post-intervention groups included 2,272 women (2,319 babies) and 1,881 women (1,920 babies), respectively. The mean fetal heart rate (FHR) documentation count during labour increased significantly from 5 to 7.5 (p=&lt;0.001); the mean time between the last FHR and delivery fell significantly from 60 to 50 minutes (p=&lt;0.001). There were non-significant trends toward increased operative birth rates (42.9% vs 45.5%) and reduced perinatal mortality (4.6% vs 3.7%). Neonatal intensive care unit (NICU) admission rates fell significantly (16.7% vs 10.2%), as did NICU admissions for asphyxia (1.2% vs 0.6%). The CS rate was 42.5% in this very high-risk population. Fetal indications were the most common indication for operative birth (15.4% of all births), and 13.7% were admitted to NICU. Only 3.4% of NICU admissions were for birth asphyxia and 1.2% for meconium aspiration syndrome. The total perinatal mortality rate, using the Indian definition, was 68.7/1000 (459/6682), of whom 58 were possible/confirmed in-facility intrapartum fresh stillbirths (8.9/1000 WHO definition) and 25 neonatal deaths due to asphyxia. Conclusion: Women want a healthy baby and “normal” birth, but clinicians feel vaginal birth is unsafe with inadequate FM, and this drives high operative birth rates. "Hearing the beats" and kind communication promotes a positive birth experience for women. FM training is a complex intervention that can improve FM process indicators and some neonatal outcomes. Clinicians enjoyed the training, gained knowledge and confidence, and changed their practice. However, the interaction between training, co-interventions, context, people and systems is essential. For change to occur, training must be embedded within wider interventions so that barriers to implementation are identified and overcome.