Scaling up quality improvement in intrapartum and newborn care: a process evaluation of the Safe Care Saving Lives programme in India

Background: There is consensus that closing the quality gap in the delivery of an effective package of interventions to reduce neonatal mortality is critical for newborn survival. Yet, very few quality improvement (QI) initiatives have been evaluated through robust designs, and a better understanding of QI processes is needed. Despite progress in access and availability of neonatal care services, neonatal deaths still represent 58% of child deaths in India, which points to major quality of care deficits. The Safe Care, Saving Lives (SCSL) initiative aims to reduce hospital-based neonatal mortality and morbidity by 15% in Telengana and Andhra Pradesh. The initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals included in the Aarogyarsri health insurance network, a government-sponsored health insurance platform in two Indian states, Telangana and Andhra Pradesh. The initiative facilitates the establishment of QI teams in labour and newborn intensive care units, who are supported to implement changes by monthly mentoring from coaches from the implementing organisation, using a structured QI methodology.
Research focus: I aim to analyse the potential to scale up the Safe Care Saving Lives approach to quality improvement in newborn care in Andhra Pradesh and Telangana, India. Informed by the MRC process evaluation framework and inspired by realist evaluation, the research is a mixed methods study nested in the outcome and impact evaluation of the Safe Care Saving Lives programme, led by LSHTM.
The key research questions are: (I) How, for whom, under what circumstances did SCSL improve compliance with evidence-based obstetric and newborn care practices? (ii) To what extent can the quality improvement collaborative approach be scaled-up using a health insurance platform?
Methods: the analysis will use a mixed methods approach. I will describe the programme theory of change, using relevant literature and perspectives of programme designers and implementers, gathered through participatory group sessions. I will assess the intervention's impact on newborn case fatality rates and stillbirths as well as adherence to evidence-based practice using a difference-in-difference analysis comparing 29 intervention and 31 comparison hospitals comprising wave 2 and 3 of the programme. Using qualitative methods in 4 purposely selected case study hospitals at two points in time, I will explore to what extent SCSL was delivered consistently with the envisaged approach, what adaptations were necessary and why, and the mechanisms of change in adherence to evidence-based practices. Analysis of interviews with stakeholders in the health system will allow an assessment of the feasibility of using a government-sponsored health insurance network to scale up quality improvement for newborn care practices, drawing on a scalability framework developed through a literature review. I will also assess the hypothesis that improved adherence to evidence-based practices is associated with organisational readiness for quality improvement, using an appropriate regression analysis model using data from a baseline survey on organisational readiness and outcome data collected through the main outcome evaluation.
MRC theme link: The research fits under the MRC's evaluation of complex interventions theme, and follows the MRC framework for process evaluations.

Key skills gained through this studentship:
1. quantitative skills - throughout my studentship, I will attend training in statistical analysis methods, and principal component analysis.
2. interdisciplinary skills - through training on evaluation of public health interventions, on design and analysis of cluster randomised trials, and on realist evaluation
3. quality improvement - I am attending online training.

Keywords: scale up; quality improvement; newborn care; India;