Implementation of Delayed Cord Clamping in public health facilities: a case study from India

Delayed umbilical cord clamping (DCC) is an essential component of labour management and immediate newborn care. The World Health Organization (WHO) recommends DCC (not earlier than 1 min) after birth to improve maternal and infant health and nutrition outcomes [1]. However, DCC is slow to be adopted into practice despite a substantial body of evidence on its benefits, including helping to ensure adequate infant iron stores in the first months of life, as well as the existence of global and country recommendations. The feasibility of its implementation in routine care has been reported by a few studies from high-income countries [2‐5]. These studies primarily assessed the effectiveness of DCC and reiterated that implementation is feasible in tertiary care units. Adoption of this practice requires multidisciplinary approach [6]. Understanding the obstacles to implementation informs strategies to improve coverage of the practice worldwide. However, there remains limited documentation of program experiences that could inform practical guidance in this area, especially in low-and- middle income countries.

The India Newborn Action Plan (INAP) is India’s commitment to the Global Every Newborn Action Plan (ENAP), launched in 2014 at the 67th World Health Assembly, to advance the Global Strategy for Women’s and Children’s Health [7]. The ENAP envisions the elimination of preventable newborn deaths and stillbirths by 2030. INAP lays out a plan for India to end preventable newborn deaths, accelerate progress, and scale up high-impact, cost-effective interventions. Nutrition International (NI) has been supporting the state governments of Gujarat and Uttar Pradesh (UP) to implement the INAP since 2015 under its Right Start Project (2015-2020), funded by the Government of Canada. These two states were selected for their willingness and readiness to work on implementing the INAP.

NI has focused on improving maternal and newborn care services at health facilities and in the community. This includes the entire package of care under the INAP, with specific emphasis on neonatal resuscitation, timely initiation of breastfeeding (TIBF), prevention of hypothermia, vitamin K supplementation, kangaroo mother care (KMC) and DCC. INAP implementation had just begun when NI initiated this project in late 2015, and sensitization in UP and Gujarat had only started. NI’s main role was to provide technical support and assist the health systems to implement INAP.

NI commissioned this case study to an external, independent evaluator, to confirm these early findings, document the learnings and recommendations from its collaboration with the state governments and understand the health system factors that affected operationalization of DCC in UP and Gujarat.

The findings are structured in the context of the WHO health systems building blocks. The findings under the sections of Leadership and Governance, health system financing, health information system and health workforce emerged from the interviews of the key informants. For service delivery component, results from the quantitative assessment and in-depth interviews were used to synthesize the findings.

This case study on implementation of DCC through the public health facilities in UP and Gujarat demonstrates strong political commitment and governance at all levels of the health system. The coverage of implementation was 95% as per the review of labour room records. It was less likely to be followed in babies with Caesarean section, birthweight < 2000 g, multiple pregnancies, birth asphyxia requiring resuscitation, or those delivered during day shift, owing to work load or institutional differences between shifts. The approach for collating information was pragmatic in nature that lends itself as a strength to the case study. Most of the information was obtained from existing records and documents. The use of multiple sources supported triangulation of the information. Although this approach decreases the risk of bias that may have occurred with the prospective collection of data as part of this exercise, it is not completely devoid of gaps. Purposive selection of key informants depending on their availability on the day of the interview could have introduced some selection bias. Secondary data have usual challenges of reporting and recording errors and missing values; however, these can be minimized with repeated monitoring and supervision. Information obtained from direct observation of deliveries helped us triangulate the information better. The data are obtained from select facilities of two states. Although the findings may be representative of the states owing to similar practices, these may not be generalizable to other states of the country.

Research from Nepal has highlighted the importance of authorized protocols for successful implementation of any intervention [10, 11]. Despite the availability of evidence on the benefits of DCC, even in well-resourced settings, the implementation in clinical practice was reported as a challenge [12, 13]. In India, inclusion of DCC in national guidelines supported consistent information and coherence within the public health system. This was likely to be a main driver behind achieving a high coverage.

Different Quality Improvement (QI) projects have aimed at improving DCC practices [5, 14, 15]. One such QI model helped a not-for-profit community hospital in the United States of America to increase the coverage from 19.5% in 2013 to 85% in 2017 [14]. This is in contrast to the reported prevalence of 52% among non profit hospitals, 44% among government and 43% among private hospitals in US [16]. In another centre, within a year of implementation, the coverage was reported to be 73% among very LBW babies and 93.7% in all infants less than 37 weeks of gestation [15]. This was achieved by regular engagement, feedback and education with key stakeholders including doctors and nurses. It was felt that a mechanism for routine monitoring was needed to embed DCC in the health system. Notwithstanding the good coverage that DCC has in primary and secondary care health facilities, there are challenges with respect to monitoring and supervision. Supervisory visits do happen but the importance of crosschecking data reported with real time records is yet to be strengthened. There are certain aspects which if validated and implemented can improve the coverage further especially in caesarean sections. For instance, the babies could be kept on the anterior thighs of the mothers as was documented in a recent systematic review [17].

There is some evidence in the literature on the types of health system factors that influence the practice of DCC. Barriers include lack of awareness among staff, professional resistance to change, caesarean section, need for resuscitation, risk of jaundice, polycythemia besides logistical difficulties [6]. Besides, hospital characteristics such as level of facility, number of beds and type of hospital ownership also influence practice. For instance, higher facilities (teaching, non-profit hospitals) were less likely to implement DCC in USA [5, 16]. Similarly, in this case study we found that L-3 facilities equipped to deliver more specialized services had lower coverage of DCC. This could be due to more caesarean sections in these facilities. High risk cases may be a deterrent but there is little evidence to support this theory [10]. The literature suggests that the probability of implementing DCC is higher during night shifts, similar to findings in this case study [10]. The differences could be either because of greater work load due to competing priorities or differences in the institutional systems between shifts. For babies requiring resuscitation, DCC was less likely to be followed. This could be due to more aggressive and prompt measures required for managing a case of birth asphyxia. Caesarean section is a negative factor for predicting DCC as reported [5, 6]. In our case study too, we found similar results. This seems to be more of a feasibility issue rather than technical. Placing the baby on mother’s thighs may overcome this barrier [17]. This, however, should be assessed for inclusion in the current global operational guidelines for standardization. Role of private sector is particularly important when wider coverage is aimed for. Innovative approaches should be devised to increase their involvement in programs.

While it is widely recognized that DCC is more beneficial than Early Cord Clamping (within the first 60 s of birth), the optimal timing of cord clamping continues to be a grey area [1, 17, 18]. A recent study from India recommends delaying clamping until delivery of the placenta [19]. Feasibility of DCC in caesarean deliveries, or in asphyxiated babies needs further exploration. A rational choice between providing immediate neonatal care such as resuscitation with cord intact or after cord clamping should be guided by robust clinical effectiveness studies in low and middle-income countries [17, 20].