A comprehensive approach to improving the quality of health services in private maternity facilities in India.
By Indrani Kashyap
Pune, Ranchi and Lucknow, India. September 2018
In India, a third of women give birth in private facilities. Manyata, a first of its kind program, offers standards-based and mother-centered care to help save lives in those private facilities. Manyata is under way in more than 300 health facilities across three states — Uttar Pradesh, Jharkhand and Maharashtra thanks to MSD for Mothers — MSD’s landmark initiative to help create a world where no woman dies giving life.
Manyata aims to create a robust quality improvement environment by helping private maternity care providers strengthen their services and recognizing the health facilities that consistently deliver high quality care to the women they serve. The program is carried out in partnership with the Federation of Obstetrics and Gynaecological Societies of India (FOGSI) and Jhpiego, a global health nonprofit and Johns Hopkins University affiliate.
Responding to a need to address quality in the private sector
Launched in 2013, Manyata responded to a glaring need: Although the private sector accounts for 34% of all institutional deliveries in India and is as high as 48% in urban settings, no national system exists to ensure quality among private providers. Consequently, private maternity facilities suffer from inconsistent and unclear quality standards.
Including private maternity care facilities in efforts to improve quality care during childbirth is critical to decreasing India’s maternal mortality rate from 130 deaths per 100,000 live births to 70 per 100,000 by 2030, achieving the country’s Sustainable Development Goal target. The government of India recognizes the need for quality improvement in the private sector and supports initiatives like Manyata.
Manyata: Improving and assuring quality at maternity facilities
Currently in its second phase, the Manyata program has certified 225 facilities, a formal designation granted by FOGSI. Facilities receive certification after an independent evaluation that consists of provider interactions, facility assessments, physical verification of records and observation of practices. The data collected from these facilities reveal monumental improvements in all standards.
Transforming the birthing experience through quality
Thirty-year-old Rujuta Rohit Karandikar, a first-time mother, delivered her baby girl at the Manyata-certified Colony Nursing Home in Pune, India.
“The whole experience was so good and memorable for me. It felt very special to see my baby come into this world and then immediately coming to me for breastfeeding,” she said, referring to a “breast crawl,” a traditional process in which a newborn, when placed on the mother’s abdomen, finds the mother’s breast on its own for a first breastfeeding experience. While breast crawl has been practiced for years, Manyata’s mother-centered approach reinforces the practice among providers.
“The way the hospital staff handled me during the entire delivery was remarkable. They communicated with me throughout. They were trying to make me forget my pain and enjoy the process,” said the new mother as she cradled her baby close to her chest.
The staff at Colony Nursing Home received the Manyata certification after undergoing robust training and mentorship, and ably demonstrating lifesaving practices during childbirth, evidence-based protocols for safe delivery, and respectful and supportive care to clients like Karandikar.
Nurses and support staff at private facilities feel a new sense of power and confidence due to their strengthened skills.
“Apart from learning the importance of respectful care and the necessity of taking vitals, plotting partographs, following infection prevention protocols and disposing of the waste judiciously, one of my favorite parts of the training was management of complications,” nurse Champa Tigga said, after a recent success resuscitating a newborn. “It infused me with confidence that even I can save mothers and newborns, just like the doctors that I have watched for the past 12 years of my service.”
A small maternity care facility’s quality journey with Manyata
Kamla Devi Hospital, an independent maternity facility in Lucknow, Uttar Pradesh, is another apt example of transformative change. Namita Chandra, an ob-gyn, owns and directs the hospital.
“I came out of medical college and started practicing in 1997. Since then, no one had held my hand to show me how I can improve my hospital,” she said candidly, thanking the Manyata program for its support over the past 3 years.
In the fall of 2016, she attended her first Jhpiego training on clinical skills and knowledge standardization around normal vaginal delivery.
“I did not expect much because I thought I knew everything about conducting deliveries and managing complications, and there wasn’t much for me to learn,” said Chandra. “But the training methods, the updates on the latest protocols and practices, the lifelike anatomic models that were used … it amazed us. That, I think, was the real eye opener,” she said.
Following the training, Chandra’s hospital team worked closely with Jhpiego to understand up-to-date protocols, practice scenario-based drills, institute infection prevention practices, and learn respectful and client-centric care.
“My staff and I got to know the procedures and practices as per the latest guidelines. Now the older staff teaches the new staff, so the atmosphere is of teaching and learning,” Chandra said.
Kamla Devi Hospital received the Manyata certification in the fall of 2017, but Chandra’s efforts did not stop. The facility then developed several standard operating procedures and new consent forms, and installed a hospital information management software to generate unique client record numbers. It established a central sterilization storage department, took measures to ensure fire safety in the facility, set up committees with mandated protocols for continuous quality improvement and strengthened the documentation of practices.
“We are also now taking feedback from every patient, which we were not doing earlier,” Chandra said. It was through this feedback that she realized that her clients were facing difficulty in procuring necessary drugs. To resolve that, Chandra set up an in-house pharmacy.
Client satisfaction is among the benefits. “Our patients notice the difference and complement us on the improvements,” she said.
Continuous quality improvement is also good for business. “I want to ensure that we follow all protocols, so in the event that an adverse event happens, I am confident that all mandated procedures have been properly followed,” she said.
The next steps for Manyata
Moving forward, Manyata aims to expand in current and new implementing states, with the goal of reaching 3,000 facilities. The program will have a strengthened sustainability aspect by developing a leaner quality improvement support model complemented by a digital platform for process management, helping the program reach greater scale, a vital step for success in one of the world’s most populous countries.
What’s next for Chandra and Kamla Devi Hospital?
“I think quality is a personal and institutional goal that we have set for this hospital,” she said. “I would like to continue on this quality journey into the future.”
Parvez Memon, Shivani Singh, Parag Bhamare, Tapas Nair and Anam Khan contributed to the reporting of this story.
Photos are courtesy of Mansi Midha/MSD for Mothers, and other Jhpiego staff and friends.