What is it about?

Good quality of care around childbirth and care of newborns is critical for reducing maternal and neonatal mortality. It is more important in resource-poor settings. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the quality of care for pregnancy, delivery, and newborn care at nine busy public hospitals in three districts. This study followed pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. The implementation was done through six quarterly plan-do-study-act cycles. The activities were led by the facility and district quality improvement teams facilitated, supported and monitored by the research team. The teams reviewed the status, structures, procedures, manpower and capacity for service delivery. Following the gap identification, solution planning and implementation were done address the identified gaps. Data were collected on various indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider’s knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact. The interventions closed 50% of the gaps identified in different domains. During the study period, a rise in the number of deliveries, improved care of pregnant women in labour with high-risk factors and/or complications, and improve essential newborn care services at birth were observed. During pregnancy, the identification of high-risk pregnancies increased by over two times and the waiting time for antenatal checkups at these facilities was reduced and client satisfaction improved. The infection control and prevention practices improved significantly. The documentation and completeness of case records completeness improved. The overall patient satisfaction scores improved to over 95.5%. While significant improvements were observed across multiple domains and services, the key challenges like manpower shortage, staff transfers, leadership change and limited orientation for QoC, were experienced, which influenced the implemented.

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Why is it important?

While targeting maternal and child mortality reduction, quality of care emerges as an important issue for accelerating the decline and sustaining the trend. While most of the interventions and efforts usually target the treatment aspect with limited attention to the quality of care aspect. The documentation on level of quality of care, the challenges, modalities to improve these and the impact on various short-term, medium-term and longer-term outcomes are limited in public health settings.


This project with a multipronged quality improvement strategy improved maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up in other developing country contexts.

Manoja Kumar Das
The INCLEN Trust International

Read the Original

This page is a summary of: Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study, PLoS ONE, July 2021, PLOS, DOI: 10.1371/journal.pone.0254781.
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