PMC-QT:
Private Maternity Care – Quality Toolkit May 2016
The development of this toolkit was supported by funding from MSD, through its MSD for Mothers program. The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD. MSD for Mothers is known as Merck for Mothers in the United States and Canada. This toolkit was produced by Jhpiego, in consultation with the Federation of Obstetrics and Gynaecological Societies of India (FOGSI), Association of Obstetricians and Gynaecologists of Uganda (AOGU), Programme for Accessible health, Communication and Education (PACE), Hindustan Latex Family Planning Promotion Trust (HLFPPT), World Health Partners (WHP), and Pathfinder. Jhpiego is an international, nonprofit health organization affiliated with Johns Hopkins University. For more than 40 years, Jhpiego has empowered frontline health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works to break down barriers to high-quality health care for the world’s most vulnerable populations. Published by: Jhpiego Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA www.jhpiego.org © Jhpiego Corporation, 2016. All rights reserved.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings iii
Table of Contents
Background .................................................................................................................................1
Introduction ..................................................................................................................................8
Section I: Standards of Care .....................................................................................................12
Core Standards for Quality Assurance .....................................................................................19
Comprehensive Standards for Quality Improvement .............................................................23
Section II: Guidance on Quality Measuring and Monitoring .................................................32
Section III: Guidance on Capacity Building of Health Workers .............................................40
Annexures
Annexure 1: Assessment Tool for Use of Core Technical Standards for Supporting the Quality Assurance
Systems (Accreditation, Regulation etc.) ........................................................................................... 54
Annexure 2: Assessment Tool for Use of Comprehensive Set of Technical Standards for Guiding the
Quality Improvement Process ............................................................................................................ 70
Annexure 3: Boxes with Technical Details of Practices Covered Under Key Standards ..................... 108
Annexure 4: Key Resources Referred During Development of Standards of Care* ........................... 116
Annexure 5: S0Ps for using Standards-Based Assessment Tool .......................................................... 119
Annexure 6: Template for Action Planning ....................................................................................... 124
Annexure 7: Client Case Record Template ....................................................................................... 125
Annexure 8: ANC & PNC Card Template .......................................................................................... 142
Annexure 9: Birthing Register Template ............................................................................................ 144
Annexure 10: Monthly Progress Report Format ................................................................................. 145
Annexure 11: Process for development of the toolkit ....................................................................... 147
References ............................................................................................................................... 152
iv A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Abbreviations
AMTSL Active Management of Third Stage of Labor
ANC Antenatal Care
ANCS Antenatal Corticosteroids
APH Antepartum Hemorrhage
ART Anti-Retroviral Therapy
BCC Behavior Change Communication
BEmONC Basic Emergency Obstetric and Neonatal Care
BG Blood glucose
BMW Bio-medical Waste
BP Blood Pressure
BPCR Birth Preparedness and Complication Readiness
CCT Controlled Cord Traction
CEmONC Comprehensive Emergency Obstetric and Neonatal Care
CME Continuing Medical Education
CPD Cephalo-pelvic Disproportion
C-section Cesarean Section
DM Diabetes Mellitus
DVT Deep Vein Thrombosis
EBM Expressed Breast Milk
ENBC Essential New Born Care
ENMR Early Neonatal Mortality Rate
FHR Fetal Heart Rate
FP Family Planning
GA Gestational Age
GDM Gestational Diabetes Mellitus
GoI Government of India
Hb Hemoglobin
HDP Hypertensive Disorders of Pregnancy
HIV Human Immuno-deficiency Virus
HR Human Resource
HTSP Healthy Timing and Spacing of Pregnancy
IUD Intra Uterine Death
IFA Iron and Folic Acid
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings v
IM Intra Muscular
IMR Infant Mortality Rate
IPTp Intermittent Preventive Treatment in Pregnancy
IV Intra Venous
KMC Kangaroo Mother Care
LMP Last Menstrual Period
LSCS Lower Segment C-Section
MDG Millennium Development Goal
MgSO4 Magnesium Sulphate
MMR Maternal Mortality Ratio
MNT Medical Nutrition Therapy
MRP Manual Removal of Placenta
NBCA Newborn Care Area
OGTT Oral Glucose Tolerance Test
OT Operation Theatre
PE/E Pre-Eclampsia/Eclampsia
PIH Pregnancy Induced Hypertension
PNC Post Natal Care
PNMR Perinatal Mortality Rate
POC Point Of Care
PPE Personal Protective Equipment
PPFP Post-Partum Family Planning
PPH Post-Partum Hemorrhage
PPPG Post-Prandial Blood Glucose
PPROM Preterm Premature Rupture of Membrane
PPTCT Prevention of Parent to Child Transmission
PTB Pre-Term Birth
PV Per Vaginum
QA Quality Assurance
QI Quality Improvement
Rh Rhesus
RI Routine Immunization
RMC Respectful Maternity Care
RPR Rapid Plasma Reagin
RTF Return to Fertility
vi A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
SBA Skilled Birth Attendant
SGA Small for Gestational Age
TSB Total Serum Bilirubin
USG Ultra-Sonography
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 1
Background
Achieving the desired reduction in maternal and child mortality remains the unfinished agenda of the Millennium Development Goals (MDGs) 1–4. This task has remained unfinished despite knowing what works for reducing maternal and child mortality in developing country contexts for many years 5,6. As a mission, countries invested heavily in improving access to skilled care at birth and the surrounding period, leading to a global increase in access to skilled attendants at health facilities during childbirth. However, the reduction in maternal and newborn mortality has not been in sync with the high rate of institutional births achieved. Developing countries represent the greatest need for improved strategies for reducing mortality. As per a 2014 progress report on the MDGs, globally, four out of every five deaths of children under-five occur in Sub-Saharan Africa and South East Asia 7. Analysis of child mortality India reveals that while the infant mortality rate (IMR) has shown steady decline, the early neonatal mortality rate (ENMR) has virtually remained static since throughout last decade 8. No change in these indicators of care during childbirth point towards and urgent need for focus on quality of intrapartum care. Globally, it is estimated that better care during labor and birth as well as improved care of newborns immediately after birth could avert up to 1.49 million maternal and newborn deaths and stillbirths, with more than half of this number being newborn deaths 6. There is an urgent need to bridge the gap between evidence and its translation into practice during provision of care, particularly in resource-constrained settings.
Figure 1: Role of private sector in maternity and family planning care
Source: Family planning, antenatal and delivery care: cross-sectional survey evidence on levels of coverage and inequalities by public and private sector in 57 low- and middle-income countries - Campbell - 2016 - Tropical Medicine & International Health
2 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Worldwide, the private sector is an important stakeholder in healthcare services including maternity care. An analysis of DHS data from 57 countries revealed that the private sector provided a substantial proportion of delivery care in low- and middle-income countries. Of those that received services in facilities, the proportion that delivered in the private sector was reported to vary between regions ranging from 9% in Latin America, 20% in Sub-Saharan Africa, 31% in Middle East/Europe, 46% in Asia and 36% overall 10
Moreover, the role of the private sector in maternity services is ever increasing. Another analysis of DHS data from six countries in Asia showed a significant trend towards greater use of private sector delivery care over the last decade 11 It is expected that with rising income levels and improved dispersion of health insurance, the use of private healthcare will further rise. Improvement in quality of care is a felt need across public and private sectors in developing country settings. A systematic review of comparative performance of public and private sectors in lower and middle income countries found that diagnostic accuracy and adherence to medical management standards were worse among private than public sector health facilities. Private practitioners had significantly worse knowledge of correct diagnosis and treatment 12
Specific evidence for quality of maternity services also points towards a need for quality improvement in the private sector. Evidence exists of higher rates of potentially unnecessary procedures, particularly caesarean sections(C-sections), at private than at public settings 11,12. A population-based cluster randomized survey conducted in Delhi found a widespread non-adherence to evidence based maternity care guidelines in both public and private sector facilities 13. A comparative review of quality of Antenatal Care services in Tanzania found technical quality poor in both private and public sectors 14. Moreover, private sector care is poorly regulated in most of developing countries, resulting in a potential compromise in quality of care provision. Around the world, considerable efforts have been made in recent years to improve quality during care provision in antenatal, delivery, and postpartum periods at public sector healthcare facilities. However, despite contributing to care for a significant proportion of institutional deliveries, the private sector has not received similar focus for improving quality of care provision. Standardization of care across the private sector has been difficult. The largely disorganized nature of the private sector has led to non-standardized tools, care protocols, and procedures being used at private sector facilities across the world.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 3
Figure 2: Challenges for quality management in the private sector
What are the challenges in quality management in the private
sector? Quality improvement challenges in the private sector can be categorized as intrinsic and extrinsic influences. Intrinsic factors are the levers of change that lie within the facilities and providers themselves, whereas extrinsic challenges are environmental factors which are external to the facilities and providers but still exert significant influence on the quality of care provision at facilities. Any quality management initiative in the private sector needs to influence both sets of factors in order to foster sustainable improvements in quality of care provision. Intrinsic factors
The success of interventions in the private sector is traditionally measured by the increase in the client base and there are very few incentives to engage with quality improvement processes that may not have an immediate effect on the client inflow into the facilities.
One of the most common intrinsic factors responsible for sub-optimal quality of care is the overall absence of mechanisms for technical updates for private sector service providers. Though infrequent and irregular, OBGYNs themselves have some access to new information through continuing medical education (CME) courses; however, nurses and paramedics working in the private sector work virtually without any access to skills development courses or continuing education for years. This leads to a continuation of outdated clinical practices that have been proven ineffective or harmful as per recent evidence. The specialized nature of currently available CME courses of OBGYNs, which are mostly sponsored and limited independent knowledge advancement opportunities result in inertia in adopting newer practices or techniques that have been proven to be beneficial.
4 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
There is limited monitoring of quality of care in the private sector due to the lack of incentives for quality improvement, as well as the absence of systems and capacity to measure and monitor quality. There are limited numbers of standardized tools for recording variables of interest, no unified systems for the reporting of quality of care data, and no mechanisms for monitoring the overall quality of care in the private sector.
The private sector is primarily profit driven and in many cases run by individuals or small- to medium-scale entrepreneurs. This often leads to a lack of adequate investment in essential infrastructure and resources that have high costs of establishment but t do not have a direct and immediately apparent impact on the profits of the institutions.
Extrinsic factors:
A major extrinsic factor leading to poor understanding and measurement of quality of services is the absence of normative guidance on inputs required for quality care provision, as well as benchmarks against which to evaluate the quality of their services.
Another important extrinsic factors affecting the quality of care provision in the private sector is regulatory ability of the system. The capacity of governments and/or their regulatory bodies is typically limited in many countries, and therefore, the responsibility of improving quality of care provision falls on private sector providers themselves.
Capacity of the professional associations, that can lead the quality improvement initiatives in absence of government led initiatives, is also highly variable across contexts. Often, the professional associations consider themselves primarily as technical agencies and do not get involved in processes and systems for quality promotion. Professional associations can play an important role in establishing quality mandates, maintaining focus on strategic priorities for interventions, creating systems for capacity building and mentorship, and monitoring the quality of care for private sector health institutions.
Finally, in developing country settings, there is an overall limited focus on the private sector as a stakeholder for healthcare service delivery for maternity services by the national governments, development community, and other players in the global public health fraternity. This causes a non-alignment of quality improvement approaches between public and private sectors, lack of adequate resources allocated to the private sector, and missed opportunities for sharing performance accountability reports with the private sector. The above, in-turn, is responsible for an absence of quality benchmarks suitable to the need and structure of the private sector, which in itself is an important extrinsic factor affecting quality improvement globally.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 5
What is being proposed to address these challenges?
There is no single solution to quality improvement in the private sector due to the complex nature of the challenges faced by it. Quality of care can be defined from many perspectives—system, providers, clients, and communities. Moreover, there can be many dimensions to a quality improvement strategy including leadership, health workforce, financing, technical capacity, measurement systems, and others. Ideally, any comprehensive quality improvement initiative should address all these dimensions of quality. However, considering the vast spectrum of private sector providers in most settings and that they are, in many instances, largely unorganized and/or unregulated, a comprehensive strategy comprising all the dimensions of quality, although ideal, may be prohibitive in terms of resources and scope of implementation in most settings. In light of these considerations, this toolkit proposes a practical quality management process, along with the required tools and aids, which has been developed and customized for use in private sector health facilities in resource-constrained settings. The proposed quality management process focuses on the dimensions of a. Safety (in terms of minimizing any harm to pregnant women, mothers and their
newborns); b. Effectiveness (in terms of reducing mortality and morbidity); and c. Client centric care (in terms of respectful and dignified care-provision). These components will serve as an important step toward quality improvement for improving health outcomes in the private sector.
Quality Management
Quality Management is a set of processes by which a
desired level of excellence is maintained for a product or
services by an organization. In this context, quality
management is defined as a set of activities to ensure
that the health facility achieves desired level of
excellence, and maintains it with or without external
facilitation.
Quality Management is defined in the toolkit, includes
Quality Assurance (QA) and Quality Improvement (QI).
Quality Assurance
Quality Assurance means the maintenance of a desired
level of quality in service or product. In this context, QA
is being defined as a set of activities to ensure that the
quality of services provided by a health facility is
externally monitored and certified using a set of
essential quality standards.
It is presumed that, by implementing QA, the facilities
will sustainably maintain the quality of services.
Quality Improvement
Quality Improvement is a systematic approach for
analyzing performance and implementing targeted
solutions to improve it. In this context, QI is being
defined as self-performed or externally facilitated
cyclical set of activities to review performance against
desirable standards of care, implement specific activities
to address identified gaps, and periodic monitoring of
adherence to standards.
6 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
This practical toolkit proposes a two-step process for quality management in the private sector:
1. The first step of this process is implementing changes that will foster improved quality standards in the health facilities in order to reach to a level which is benchmarked for safety and effectiveness in the respective context. Once a facility reaches a minimum level of normative quality standards, the second step of the process, to sustain the quality of care provision, is initiated. The first step of implementing the toolkit process is largely an internal process, but may require some initial external promotion and facilitation.
2. The second step of the, process, however is largely dependent on the environment in which the health facility is situated. Therefore, the sustenance of the quality in the private health facilities will be a function of the extrinsic factors including the presence of a regulatory, accreditation, and/or other recognition mechanisms and systems, which incentivize the engagement of the private sector to maintain their quality in the intermediate and long term. This proposed quality management cycle uses a specially designed toolkit as the framework for action.
Figure 3: The Two-Step Cycle for Quality Management Process
QI Process
The quality improvement (QI) process proposed in this toolkit is based on a simple quality improvement cycle which uses normative standards to assess gaps in the facilities for developing action plans for improvement, planning and implementation of action plans, and periodically measuring progress. The first step in this process is to engage a facility in the QI cycle. Engagement will include leaders and facility level health workers’ orientation of the QI process. This can be externally initiated and/or facilitated among private sector providers by a QI organization or a professional association. Subsequently, the facility will use the various aids given in this toolkit to run the QI cycle—conducting assessments using standards to identify gaps, addressing gaps through action planning and focused trainings, intervention and measurements on selected metrics to ensure efficient efforts towards progress.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 7
Figure 4: The Quality Improvement Cycle
QA Process Once the facility achieves the desired improvements in quality standards, the facility can be engaged in a continuous, self-sustaining quality assurance (QA) process through various mechanisms like accreditation or regulation. The accreditation process or the regulatory framework can also use the standards of care described in this toolkit as the necessary basic requirement. The QA process will have the potential for linkages with financing schemes, insurance providers, and other funders to ensure sustainable engagement of private providers. While the QI process can be initiated and self-propelled, the QA system may need to be assisted by external facilitators such as the governments, development organizations, or professional associations.
This toolkit contains two sets of standards, one each for QA and QI process.
The set of standards for QA mechanism comprises of 15 core standards which can be used by the governments or accreditation institutions or professional agencies for recognizing/accrediting or regulatory purposes.
The other set of standards is a comprehensive version which can be used for the QI process by the individual facilities or external facilitators, to improve the quality of care process at the private health facilities.
8 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Introduction
This toolkit functions as the set of resources, know-how, and aids to implement the proposed quality management process to improve and sustain the quality of care in private sector institutions. The toolkit can be used in the following ways:
1. The standards, tools, and resources in the toolkit can be self-use by facilities independently to improve their own quality of care.
2. The toolkit can also be used by external facilitators, such as professional associations or government agencies for helping a group of facilities improve their quality in a structured manner.
3. As a part of the quality management cycle, the toolkit can be used by external stakeholders for benchmarking facility-based care against normative standards and establishing continuing quality assurance requirements as a part of an accreditation or regulatory process. The toolkit can also be used by professional associations or similar entities for peer recognition, as well as forging linkages with financing schemes. Such linkages of the quality management cycle to the regulatory, accreditation, or financing schemes will be critical in ensuring sustainable quality assurance in the private sector health facilities.
The proposed toolkit has three components— A. Standards of care, B. Guidance for quality measurement and monitoring, and C. Guidance for capacity building.
Each component of the toolkit is supported by a set of tools for its effective use.
Figure 5: Standards of care as the key component of the toolkit
Figure 6: Description of Core and Comprehensive Standards
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 9
A. Standards of care
Standards of care form the key components of the toolkit. The other two components are linked to the standards. Standards are divided into three sections—antenatal care (ANC), intra- and immediate postpartum care, and postnatal care (PNC). As mentioned earlier, this toolkit contains two sets of standards, one each for the QA mechanism and the QI process. For QA system
For the quality assurance system, a set of 15 core standards is proposed (pages 16-24), which can be used by the external agencies to accredit/recognize/empanel or regulate the quality of care at the private health facilities. For QI system
There is a set of 37 comprehensive standards (pages 25-40) which can be used by the facility or external facilitator for undertaking the quality improvement process before engaging in the QA system of accreditation or regulation. This set also includes three standards related to inputs that offer guidance on the availability of essential infrastructural and human resources. There are two tools linked with this component of the toolkit—a standards-based assessment tool (page 65) and a tool for preparing action plans based upon the findings of the assessment. B. Guidance for quality measurement and monitoring
Guidance for quality measurement and monitoring forms the second component group of the toolkit. These metrics are intended to enable the facility clinical and administrative leaders for measuring progress towards compliance to the standards and resultant improved outcomes. There are two types of metrics recommended in the toolkit.
i. Dashboard indicators: A list of ten high-level indicators which have been identified based on their effectiveness in reducing morbidity and mortality, as well as collectability through the system itself (without the need of external surveys). These indicators are global in nature and will serve to provide a dipstick in the facility to understand overall care quality.
ii. Performance indicators: A list of indicators that are directly linked to various standards of care. The facilities, based on their need, can select some of these
10 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
indicators to monitor progress on the standards to which they are non-compliant. The facilities will need to collect data on these indicators on a quarterly basis. Tools such as a standardized case sheet template, labor room register, and an antenatal card template to enable the facility to record data required for the indicators in a standardized manner are linked with this component of the toolkit.
C. Guidance for capacity building
Guidance for capacity building of health workers in a structured manner constitutes the third component of the toolkit. This includes course outlines that are fully aligned with the standards of care and focus on care processes included in the standards. A learning resource package including power point presentations, job-aids, and various checklists for self-learning and use by health workers have been included as a set of tools linked to this component of the toolkit.
Use for Quality Improvement
The comprehensive set of 37 standards (pages 25-40) form the technical basis for other toolkit components to complete the facility-intrinsic quality improvement cycle described earlier. The first step in this is facility assessment is using a standards-based assessment tool (page 65) to evaluate areas of non-compliance to the normative standards of care. Non-compliance to the standards can be due to the lack of technical updates or skills among health workers, non-availability of essential supplies, or lack of an enabling environment in the facility. A planning tool is included in the toolkit for preparation of gap-based action plans. Based upon the action-planning tool, the quality improvement process can be facilitated. Typically, the action plans will include plans for clinical updates and skill development of health workers, actions to ensure resource availability, or plans for change in practices and protocols of the facility. While resource availability and changes in protocols will be gap-driven, in order to ensure comprehensiveness, the process for clinical updates and skill development of health workers can be standardized. Progress on quality improvement can be measured using the indicators. Scores on dashboard of indicators can o be compared across facilities in the case of externally facilitated quality improvement programs. The facility will need to collate data on a monthly basis for monitoring dashboard of indicators. Additionally, more in-depth monitoring of quality improvement can be done using the performance monitoring indicators. The facilities will need to collect data on these indicators on a quarterly basis. Tools such as a standardized case sheet template, labor room register, and an antenatal card template can be used to enable the facility to record data required for the indicators in a standardized manner
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 11
Use for Quality Assurance
Relevant authorities can use the set of 15 core standards (pages 16-24) in the toolkit as normative benchmarks for regulatory purposes. Professional organizations (like the association of midwives, association of obstetricians) could adapt standards from the toolkit and release them to private healthcare system practitioners to self-regulate in achieving high-quality care and performance. Regulatory authorities could also use the toolkit to standardize care across the region and thus ensure quality of care. These 15 core standards could also be used in an active regulatory system to register, provide licensing or accredit maternity health facilities. Most accreditation systems mandate that institutions follow standard operating procedures and protocols; the standards described in the toolkit can be adapted and contextualized to be used as a part of the accreditation system for maternity healthcare systems. Similarly, the metrics described in the toolkit could also be adapted and used by regulators as part of their management information systems in tracking essential practices amongst private sector providers.
12 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Section I: Standards of Care
Standards of Care form the key component of the toolkit and depict safe care practices to be adhered to at the target health facilities. The standards included in this toolkit cover the full spectrum of care for various times during and after delivery including screening and early diagnosis of conditions, normal care processes, and early and comprehensive management of complications. The standards have the following properties:
Structure of the standards
Each standard consists of two important components—a standard statement and a set of essential elements. The standard statement is a statement related to a normative clinical practice in support of routine care or identification or management of complications. Each essential element describes a component of care/clinical practice under that standard. Essential elements are objective statements, and compliance to them can be assessed by the means of one or more verification criteria included in the standards-based assessment tool.
Clinical Standards
The core standards in this toolkit are broadly classified into three sections—ANC, intra- and immediate postpartum, and PNC. Additionally, three basic standards related to inputs are also included in the toolkit. The standards and essential elements do not include details of an activity or clinical practice. Wherever necessary, references are given to boxes that include details of such processes. These boxes have been included under the technical details of the standards in the last chapter.
Figure 7: Organization of the core standards of care*
* Comprehensive set includes 37 standards of care
Apart from these there are 3 standards related to inputs
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 13
Standards related to inputs
There are three standards related to inputs focusing on availability of basic minimum resources which are required for compliance to normative care standards. These include standards related to infrastructural and human resources for normal delivery and caesarean section.
Measuring compliance to the standards
Compliance to the standards can be assessed using the standards-based assessment tool (included under technical details of the standards in last chapter). For a facility to be determined compliant to a standard, it should be found compliant to all the essential elements associated with that standard. In the case that even one essential element is found to be missing, the facility will be determined non-compliant to the respective standard.
Scope of the standards
The standards have progressive levels to cover services provided by various levels of facilities. For the purpose of this toolkit, the standards cover three progressive levels of care facilities:
Facilities providing ANC services only: basic ANC services including routine care, screening of conditions, and pre-referral care for complicated cases. Other sets of standards are not applicable to these facilities.
Facilities providing Basic Emergency Obstetric and Newborn Care (BEmONC): full spectrum of ANC services including screening and basic management of complications; routine care during the intrapartum period and basic management of maternal and newborn complications; full spectrum of PNC services. Some ANC, intra- and immediate postpartum and PNC standards do not apply to these facilities.
Facilities providing Comprehensive Emergency Obstetric and Newborn Care (CEmONC): full spectrum of ANC, intra- and immediate postpartum care, and PNC services. All standards apply to these facilities
Who can use the standards? The standards can be used by:
External agencies for accrediting/rewarding/recognizing, and/or regulating quality of care among private facilities in various settings (QA process). For this purpose, a set of 15 standards has been included in this toolkit (pages 16-24), which can be used by relevant stakeholder(s) for assessing quality among private sector facilities for the purposes of regulation/accreditation/recognition.
Technical focus of the standards The standards focus on normative care and critical clinical practices to ensure safe delivery and
prevention, early detection, and management of major complications amongst mothers and
newborns during pregnancy and childbirth.
14 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Private health facilities to improve their own quality of care or by external facilitators such as development organizations or professional associations to improve the quality of care of a group of private sector facilities (QI). For this purpose, a set of 37 standards has been included in this toolkit (pages 25-40) to move forward for engaging in the regulation/accreditation system.
How to use the standards?
Use of Standards for Quality Improvement
Use of standards for QI by individual health facilities
Individual health facilities can use the standards in a structured manner to develop focused plans for quality improvement. This quality improvement process will have the following steps:
Formal adoption of standards and staff orientation
The facility should conduct an all-staff meeting to formally adopt the standards, express commitment to compliance, and develop immediate plans for following the standards. This meeting can be used to orient all the health workers involved in the process of care during pregnancy and childbirth on the toolkit components. Nodal persons can be identified from within the facility to ensure compliance to various sections of the standards.
Assessment of facility’s compliance to the standards
Immediately following the staff orientation, key care providers from the facility should conduct a baseline assessment of its status of compliance to the standards. This should be conducted using the standards-based assessment tool (page 65) for the applicable standards or essential elements.
Action planning based on gaps
Facility leaders, during the process of assessment of facility compliance, should clearly identify unmet criteria for each essential element or standard. Root cause analysis should be undertaken to identify the underlying reasons behind the non-compliance. An action plan should be prepared to address underlying reasons behind each unmet essential element. Action plans should have clearly assigned responsibilities and timelines for completion of actions.
Implementation of action plan
Implementation of the action plan may include ensuring prioritized availability of resources necessary for compliance to the standards and knowledge and skill building of health workers. This can be led internally by the facility in-charge him/herself. Implementation of the action plan includes prioritizing the availability of missing resources essential for practices included in the standards that were found to be the reasons for non-compliance during assessments. The next step is the skill building of health workers in key practices included in the standards. Traditionally, in-service training programs in the country were long and of foundational nature rather than focusing on key skills. Since major causes of maternal and newborn mortality are widely known, focusing on developing the skills of health workers in practices addressing major
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 15
causes of mortality is considered a time and resource efficient intervention that helps rapidly equip institutions with a workforce that is skilled in responding to a major causes of mortality.
Progress assessments
The facilities should monitor their progress based on adherence to the standards using the standards-based assessment tool at six-month intervals. The assessment methodology for the periodic assessments should remain the same as the baseline assessment, and ideally the same person should conduct successive assessments. Action plans based upon the identified gaps should be prepared during each assessment.
Displays to show commitment to quality
The facilities can display the standards summary prominently within the facilities as commitments statements to high-quality service delivery.
16 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Figure 8: Methodology for using standards for quality improvement
Use of standards for QI supported by external facilitators
External facilitators using the toolkit can facilitate the quality improvement process at a larger scale. However, since in this case the facilities themselves are not taking the initiative, the process of using the standards must be approved by a group consensus on the standards before initiating in-facility quality improvement activities. External facilitators should undertake the following steps for using the standards in a target group of facilities:
Collaborative meeting to adapt, prioritize, and adopt the standards
The external facilitator should organize local group meetings of partnering facility clinical leaders to develop a group consensus on the standards. Since the scale of implementation will be larger, the group can review the standards to modify essential elements to align them (if needed) with the local guidelines. The groups can also prioritize collections of standards or individual standards within each group for immediate and intermediate term implementation. The groups should form a local consensus on the frequency of externally facilitated assessments and roles and responsibilities for implementation.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 17
Baseline assessments with external presence
The external facilitators should help facilities plan and conduct their baseline assessments in a way that there is an external presence (representative of an external facilitator or a peer assessor) at the time of assessment to ensure objectivity.
Action planning based on gaps
Based upon the gaps identified through the baseline assessments using the standards-based assessment tool, the facilities should prepare their own action plans. However, since many of the gaps may be common across the group of facilities involved in the process, the external facilitator can support in planning standardized sets of activities such as trainings, procurement of resources, and development of protocols to be implemented in the groups.
Implementation of action plans
External facilitators should periodically follow-up (can be done remotely but through facility visits wherever possible) with the facilities to track the progress of implementation of action plans based upon the standards.
Group trainings for facility staff
External facilitators, wherever possible, can facilitate group trainings for facility staff to improve efficiency, enable cross-learning among participants, and effective skill development. These group trainings can involve key staff trained in a facility setting using the standard course outlines described in the next session.
Periodic assessment
While the facilities are expected to conduct their own periodic assessments at least once every six months, the external facilitators should decide upon an appropriate frequency (once every year) to have a presence in the facilities at the time of periodic assessments using the standards.
Recognition of facilities achieving desired scores
The recommended score to be achieved on standards is 70%. The external facilitator should track the facilities’ achievements on standards as observed during external presence during assessments. The facilities achieving desired scores on the standards should be recognized at peer or public forums. This can be done in the form of an achievement seal or plaque designed locally.
Use of Standards for Quality Assurance through Accreditation/Recognition/
Regulation
Linkages with accreditation or regulatory mechanisms
As mentioned earlier, there is a limited capacity in most of the developing countries to ensure provision of standardized quality of care in the private sector. This is mostly due to the sub-optimal regulatory capacity of the government and/or the professional associations to promote quality, absence of accreditation systems, and non-availability of standardized tools for quality assurance. This toolkit attempts to address some of these gaps by including a simplified set of 15 core standards (pages 16-24), which can be
18 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
used by governments and/or accreditation institutions or professional agencies and associations to recognize/accredit private healthcare facilities for regulation of the quality of care. This is critical to ensure mechanisms for provision of sustained standardized care in the private sector. Efforts should be made to incentivize the engagement of private sector facilities in such quality assurance mechanisms through linkages of QA systems like accreditation to health financing schemes of the government, health insurance sector, and/or peer recognition processes for developing a robust regulatory mechanism. This QA system will need to be facilitated by external agencies like national governments, professional associations or accreditation boards. If private healthcare facilities are unable to achieve the desired QA related standards, they can undertake the process of quality improvement (described earlier in the section), to institutionalize and strengthen their quality care process, and then re-engage to develop self-sustaining quality assurance systems. The standards of care form the cornerstone of the quality improvement process by providing a framework planning and implementing actions based upon the needs of health facilities. Prioritization of standards into core standards for quality improvement will enable the external facilitators to easily benchmark the quality of facilities for quality assurance purposes. Core and comprehensive standards with respective essential elements are given in the next section.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 19
Core Standards for Quality Assurance
ANC Standards
Standard 1
Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman
and fetus in all ANC visits
A Establishes gestational age
B Takes appropriate history (medical, surgical, obstetric and personal) and performs general
and systemic examination (Box 1)*
C Records weight of pregnant woman during all ANC visits
D Conducts abdominal examination
E Records fetal heart rate (FHR)
F Performs PV examination during 4th ANC visit (37weeks or more) to check for pelvic
adequacy (Box 2)
Standard 2
Provider screens for key clinical conditions that may lead to complications during pregnancy
A Laboratory facilities/linkage to laboratory facilities are available
B Screens for anemia
C Screens for hypertensive disorders of pregnancy
D Screens for DM (as per relevant national guidelines)
E Screens for HIV
F Screens for hepatitis B (if applicable, as per national guidelines)
G Screens for syphilis
H Screens for malaria
I Establishes blood group and Rh type during first ANC visit
Standard 3
Provider ensures adequate preventive care for key clinical conditions which can lead to complications
in pregnancy
A Ensures adequate preventive care for anemia
B Ensures adequate preventive care for neonatal tetanus by tetanus toxoid vaccination
C Ensures adequate preventive care for pre-eclampsia/eclampsia by calcium
supplementation
D Ensures adequate preventive care for malaria (if applicable, through IPTp in moderate to
high transmission areas of Africa or as per relevant national guidelines)
*Boxes are given on page 109-116
20 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Intra- and Immediate Postpartum Care Standards
Standard 1
Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman
and fetus at the time of admission
A Elicits comprehensive obstetric, medical and surgical history and conducts examination
(Box 1)
B Assesses gestational age correctly
C Records fetal heart rate
D Records mother’s blood pressure
E Records mother’s temperature
Standard 2
Provider ensures respectful and supportive care for the pregnant woman coming in for delivery
A Treats pregnant woman and her companion cordially and respectfully (RMC), ensures
privacy and confidentiality for pregnant woman during her stay
B Encourages the presence of birth companion during labor
C Explains danger signs and important care activities to pregnant woman and her companion
during the stay (for the woman and her newborn)
Standard 3
Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly
A Monitors progress of labor regularly on various parameters (Box 9)
B Interprets partograph correctly and adjusts the care according to findings
Standard 4
Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried
immediately)
A Delivers the baby and places on mother’s abdomen to conduct immediate newborn care -
drying and assessment of baby’s breathing
B Performs delayed clamping of cord
C Assesses the newborn for any congenital anomalies
D Ensures early initiation of breastfeeding
E Weighs the baby and administers Vitamin K
Standard 5
Provider performs newborn resuscitation if baby does not cry immediately after birth
A Performs recommended initial steps for resuscitation within first 30 seconds
B Initiates bag and mask ventilation for 30 seconds if the baby is still not breathing
C Takes appropriate action if baby doesn’t respond to ambu bag ventilation after golden
minute
D
Performs next level of resuscitation in babies not responding to initial resuscitation- when chest
rise is seen after bag and mask but heart rate continues to be < 60/pm (only at facilities
where specialist care for newborn or SNCU is available)
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 21
Standard 6
Provider performs Active Management of Third Stage of Labor (AMTSL)
A Performs AMTSL and examines the placenta thoroughly
Standard 7
The facility adheres to universal infection prevention protocols
A Instruments and re-usable items are adequately and appropriately processed after each use
B Biomedical waste is segregated and disposed of as per the guidelines
C Performs hand hygiene before and after each procedure, and sterile gloves are worn during
delivery and internal examination
Standard 8
Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)
A Identifies mothers with severe PE/E
B Gives correct first dose of MgSO4 and refers to higher center or manages appropriately (Box 4)
C Facilitates prescription of anti-hypertensives (Box 5)
D Ensures specialist attention for care of mother and newborn
Standard 9
Provider identifies and manages Postpartum Hemorrhage (PPH)
A Assesses uterine tone and bleeding per vaginum regularly after delivery
B Performs initial steps of management as per the protocol in case of PPH
C Manages atonic PPH
D Manages PPH due to retained placenta/placental bits
Standard 10
Provider ensures appropriate care of newborn with small size at birth
A Facilitate specialist care in newborn weighing <1800 gm
B Facilitates assisted feeding whenever required
C Facilitates thermal management including kangaroo mother care (KMC)
(Caesarean Section)
Standard 11
Provider reviews clinical practice related to C-section at regular intervals
A Ensures classification as per Robson’s criteria and reviews indications and complications of C-
section at regular intervals
22 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Postpartum Care Standards
Standard 1
Provider ensures adequate postpartum care package is offered to the mother and newborn
A Ensures at least 4 postpartum visits for the mother
B Conducts proper physical examination of the mother and newborn
C Identifies and appropriately manages maternal and neonatal sepsis
D Identifies and appropriately manages postpartum maternal depression
E Ensures to offer the FP services
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 23
Comprehensive Standards for Quality Improvement
ANC Standards
Standard 1
Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman
and fetus in all ANC visits
A Establishes gestational age
B Takes appropriate history (medical, surgical, obstetric and personal) and performs general
and systemic examination (Box 1)
C Records weight of pregnant woman during all ANC visits
D Conducts abdominal examination
E Records fetal heart rate (FHR)
F Performs PV examination during 4th ANC visit (37weeks or more) to check for pelvic
adequacy (Box 2)
Standard 2
Provider screens for key clinical conditions that may lead to complications during pregnancy
A Laboratory facilities/linkage to laboratory facilities are available
B Screens for anemia
C Screens for hypertensive disorders of pregnancy
D Screens for DM (as per relevant national guidelines)
E Screens for HIV
F Screens for hepatitis B (if applicable, as per national guidelines)
G Screens for syphilis
H Screens for malaria
I Establishes blood group and Rh type during first ANC visit
Standard 3
Provider ensures adequate preventive care for key clinical conditions which can lead to complications
in pregnancy
A Ensures adequate preventive care for anemia
B Ensures adequate preventive care for neonatal tetanus by tetanus toxoid vaccination
C Ensures adequate preventive care for pre-eclampsia/eclampsia by calcium
supplementation
D Ensures adequate preventive care for malaria (if applicable, through IPTp in moderate to
high transmission areas of Africa or as per relevant national guidelines)
Standard 4
Provider performs adequate management of anemia
A Performs adequate management of anemia (Box 3)
24 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Standard 5
Provider performs adequate management of hypertensive disorders of pregnancy
A Confirms hypertension and identifies pregnant woman with severe PE/E
B Manages hypertension using recommended anti-hypertensives (Box 5)
C In case of severe PE/E, gives correct first dose of MgSO4 and refers to higher center for further
management (Box 4)
Standard 6
Provider performs adequate management of Gestational Diabetes Mellitus (GDM)
A Initiates MNT in all diagnosed GDM cases
B Initiates insulin therapy if required
C Initiates fetal surveillance
D Ensures specialist attention for care of pregnant woman and newborn during labor
Standard 7
Provider performs adequate management of communicable conditions in pregnant woman- HIV,
Malaria and Syphilis
A Appropriately manages HIV seropositive cases (If ART center) (Box 13) or refers to an ART
center (If not ART center)
B Appropriately manages syphilis in pregnant woman and spouse/partner
C Appropriately manages malaria in pregnancy
Standard 8
Provider manages threatened preterm labor
A Identifies threatened PTB
B Essential medicines for managing PTB are available
C Appropriately manages conditions leading to PTB (For GA 24 - 37 weeks)
D Ensures interventions to facilitate fetal maturity and protection if GA is <34 weeks (Box 8)
E Ensures heightened monitoring and care (GA between 34 - 37 weeks)
F Prepares for specialist care for newborn
Standard 9
Provider counsels pregnant woman on care during pregnancy
A Shares a written schedule of ANC visits with the pregnant woman
B Counsels pregnant woman and her husband/partner/companion on BPCR at least during last
trimester
C Counsels pregnant woman and her husband/partner/companion on importance of lifestyle
modification at least during first trimester
D Counsels pregnant woman and her husband/partner/companion on importance of optimal
newborn care at least during last trimester
E Counsels pregnant woman and her husband/partner/companion on postpartum family
planning in all ANC visits
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 25
Standard 10
The facility adheres to universal infection prevention protocols
A Instruments and re-usable items are adequately and appropriately processed after each use
B Biomedical waste is segregated and disposed of as per the guidelines
C Performs hand hygiene before and after each procedure, and sterile gloves are worn during
delivery and internal examination
INTRA- AND IMMEDIATE
POSTPATUM CARE STANDARDS
& IPP CARE STANDARDS
26 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Intra- and Immediate Postpartum Care Standards
Standard 1
Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman
and fetus at the time of admission
A Elicits comprehensive obstetric, medical and surgical history and conducts examination
(Box 1)
B Assesses gestational age correctly
C Records fetal heart rate
D Records mother’s blood pressure
E Records mother’s temperature
Standard 2
Provider ensures respectful and supportive care for the pregnant woman coming in for delivery
A Treats pregnant woman and her companion cordially and respectfully (RMC), ensures
privacy and confidentiality for pregnant woman during her stay
B Encourages the presence of birth companion during labor
C Explains danger signs and important care activities to pregnant woman and her companion
during the stay (for the woman and her newborn)
Standard 3
Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly
A Monitors progress of labor regularly on various parameters (Box 9)
B Interprets partograph correctly and adjusts the care according to findings
Standard 4
Provider assists the pregnant woman to have a safe and clean birth
A Conducts PV examination at admission, and every four hours in active labor or as per the
clinical indication
B Performs PV examination in a safe and clean manner (Box 2)
C Allows spontaneous delivery of head by maintaining flexion and giving perineal support;
manages cord round the neck; assists in delivery of shoulders and body
D Performs an episiotomy only if indicated (Box 11)
Standard 5
Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried
immediately)
A Delivers the baby and places on mother’s abdomen to conduct immediate newborn care -
drying and assessment of baby’s breathing
B Performs delayed clamping of cord
C Assesses the newborn for any congenital anomalies
D Ensures early initiation of breastfeeding
E Weighs the baby and administers Vitamin K
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 27
Standard 6
Provider performs newborn resuscitation if baby does not cry immediately after birth
A Performs recommended initial steps for resuscitation within first 30 seconds
B Initiates bag and mask ventilation for 30 seconds if the baby is still not breathing
C Takes appropriate action if baby doesn’t respond to ambu bag ventilation after golden
minute
D
Performs next level of resuscitation in babies not responding to initial resuscitation- when
chest rise is seen after bag and mask but heart rate continues to be < 60/pm (only at facilities
where specialist care for newborn or SNCU is available)
Standard 7
Provider performs Active Management of Third Stage of Labor (AMTSL)
A Performs AMTSL and examines the placenta thoroughly
Standard 8
Provider assesses condition of mother and baby before shifting them from labor room
A Looks for signs of infection in baby
B Looks for signs of hypothermia in baby
C Looks for signs of infection in mother
D Records blood pressure of mother
Standard 9
The facility adheres to universal infection prevention protocols
A Instruments and re-usable items are adequately and appropriately processed after each use
B Biomedical waste is segregated and disposed of as per the guidelines
C Performs hand hygiene before and after each procedure, and sterile gloves are worn during
delivery and internal examination
Standard 10
Provider induces labor only when indicated (based on history and findings of examination)
A Induces labor only when indicated (Box 12)
B Uses only recommended technique for induction of labor
C Monitors the progress of labor
D Appropriately manages the hyperstimulation of uterus due to use of uterotonics
Standard 11 (applicable only for CEmONC facility)
Provider augments labor only when indicated (based on history and findings of examination)
A Augments labor only when indicated
B Carefully assesses the condition of pregnant woman before considering augmentation of
labor
C Ensures appropriate supportive care to pregnant woman
D Uses correct technique for augmentation of labor
E Monitors maternal and fetal well-being continuously
28 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Standard 12
Provider identifies and manages HIV in pregnant woman and newborn
A Checks for test results or recommends testing if not done
B Appropriately manages HIV seropositive cases (if ART center) (Box 13) and refers to ART
center (If not ART center)
C Appropriately manages newborn of HIV seropositive mother
Standard 13
Provider identifies and manages severe Pre-eclampsia/Eclampsia
A Identifies mothers with severe PE/E
B Gives correct first dose of MgSO4 and refers to higher center or manages appropriately
(Box 4)
C Facilitates prescription of anti-hypertensives (Box 5)
D Ensures specialist attention for care of mother and newborn
Standard 14
The facility has services available for conducting assisted vaginal delivery as clinically appropriate
A Reviews the pregnant women for suitability for vacuum extraction
B Performs vacuum extraction using recommended procedures
C Identifies failure of vacuum extraction
Standard 15
Provider effectively manages special obstetric conditions- shoulder dystocia and mal-presentations
A Identifies and effectively manages shoulder dystocia
B Effectively manages breech delivery
C Effectively manages other mal-presentations
Standard 16
Provider identifies and manages Postpartum Hemorrhage
A Assesses uterine tone and bleeding per vaginum regularly after delivery
B Performs initial steps of management as per the protocol in case of PPH
C Manages atonic PPH
D Manages PPH due to retained placenta/placental bits
Standard 17
Provider ensures appropriate care of newborn with small size at birth
A Facilitate specialist care in newborn weighing <1800 gm
B Facilitates assisted feeding whenever required
C Facilitates thermal management including kangaroo mother care (KMC)
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 29
Standard 18
Provider performs appropriate management of hypoglycemia in newborn
A Identifies neonatal hypoglycaemia
B Manages neonatal hypoglycemia (only at facilities where specialist care for newborn or
SNCU is available)
Standard 19
Provider performs appropriate management of hyperbilirubinemia in newborn
A Identifies neonatal hyperbilirubinemia
B Manages neonatal hyperbilirubinemia (only at facilities where specialist care for newborn or
SNCU is available)
(Caesarean Section)
Standard 20
Provider makes proper preparation and adheres to standard procedure and technique of C‐Section
A Makes correct indication and ensures general preparation for C‐Section
B Adheres to standard procedure and protocols for conducting C-section
Standard 21
Provider ensures appropriate postoperative monitoring course and postnatal care for the mother
A Correctly monitors postoperative course and ensures postnatal care for the mother
Standard 22
Provider reviews clinical practice related to C-section at regular intervals
A Ensures classification as per Robson’s criteria and reviews indications and complications of C-
section at regular intervals
30 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Post Natal Care Standards
Standard 1
Provider ensures adequate postpartum care package is offered to the mother and newborn
A Ensures at least 4 postpartum visits for the mother
B Conducts proper physical examination of the mother and newborn
C Identifies and appropriately manages maternal and neonatal sepsis
D Identifies and appropriately manages postpartum maternal depression
E Ensures to offer the FP services (PPIUCD, PPS)
Standard 2
Provider counsels the mother on care for herself and her newborn
A Counsels mother on routine care for herself and her baby
B Counsels on RTF, HTSP and PPFP
C Counsels on immunization for the newborn
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 31
Standards Related to Inputs
Standard 1
Adequately resourced and properly organized labor room is available
A
Adequate number of labor tables are available in labor room (as per the delivery load: 1 for
< 20, 2 for 20-99, 4 for 100-199, 6 for 200-499, use formula for calculation* for > 500 deliveries
per month)
B
Adequate space is available in labor room for placement of required labor tables (labor
tables have a distance of at least 3’ from the side wall, at least 2’ from head end wall, and at
least 6’ in between two tables)
C Adequate privacy is maintained in labor room through use of partition/curtains
D Adequate facility (chair/stool) for birth companions is available
E Adequate number of sterilized delivery trays as per the delivery load are available (at least 2
sets per labor table)
F Functional NBCA is available in labor room (Box 14)
G
NBCA is in the labor room with easy accessibility from the labor tables (if required, can be
accessed from labor tables within 5 seconds) and is open on three sides for ease of
movement
H Labor room has adequate availability of all the necessary supplies (Box 15)
I Functional toilet and washing area with 24-hour running water supply is available
J Labor room has adequate lighting, ventilation and temperature control
*Formula for calculation = {(Projected labor events in a year)*(Average length of stay)}/ {(365)*(Occupancy rate)}
Standard 2
Adequately trained human resources are available in appropriate number
A
Adequate SBA trained staff is available for conducting normal vaginal deliveries (as per
delivery load: 2 nurses for < 100, 4 for 100-200, 8 for 200-500 and 10 for > 500 deliveries per
month)
B Appropriately trained personnel is available for conducing assisted vaginal deliveries
C ObGyn/Specialist is available for complication management
D ObGyn/Appropriately trained staff is available for conducting C-section
E Anesthetist is available for performing C-sections
F Adequately trained support staff is available as per the delivery load
Standard 3 (applicable only for CEmONC facility)
Operation theatre is adequately equipped for conducting C-Section
A Number of OT tables in the OT is appropriate as per the C-section rate
B Adequate supplies and equipment are available in the OT for C-section
C Anesthesia tray with functional Boyle's apparatus is available
D OT has adequate lighting, ventilation and temperature control
E OT complex has provision for separate washing area with 24-hour running water supply
F OT complex has functional toilet and staff resting/changing area
G Functional NBCA is available in the OT (Box 14)
H Adequate supplies and equipment are available for conducting advanced adult and basic
newborn resuscitation
32 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Section II: Guidance on Quality Measuring and
Monitoring
Quality Measurement and Monitoring
Monitoring of the quality in the facilities and the use of data for decision making is an essential element of the proposed quality management cycle. One of the major challenges in measuring the quality of maternity care is the inability of the health system to generate data on indicators related to quality. Therefore there is a dependence on externally conducted surveys to provide feedback on the quality of care. This toolkit proposes to address this gap by proposing a set of simple processes and outcome related indicators, which are not only valid and reliable for measuring quality, but most importantly, data on these indicators can be collected by the system itself for a more internally-led quality management system. Additionally, the toolkit also includes tools to enable facilities to capture data themselves, such as a standardized set of case sheets, labor room registers, and the reporting format.
Metrics
Metrics have been included in the toolkit to help facilities improve efficiency in monitoring change in quality of care to ensure comparability among toolkit user groups. The metrics are divided into two main groups of indicators—universal dashboard indicators consisting of seven process indicators and three outcome indicators, which make a total of 10 dashboard indicators, and an optional set of performance monitoring indicators linked to major standards of care. While the universal dashboard indicators give a guiding framework to all facilities to measure and manage quality, the optional set of performance indicators gives a much more exhaustive list of indicators, which can be used by the facilities to measure quality in specific areas based on their need, epidemiology, and priorities in quality.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 33
Figure 8: Measurement Metrics for Monitoring Quality of Care
Dashboard indicators
Ten dashboard indicators have been proposed as a part of the toolkit. These indicators are included as a broad guidance for regular quality improvement process among the toolkit user groups. The dashboard indicators focus on critical aspects of key evidence-based practices to be performed universally to prevent complications and mortality during childbirth. Thus data on these indicators should be collected and collated on a monthly basis in all the user facilities. These indicators can be used to compare status of change in quality of care during childbirth across a group of facilities.
Performance monitoring indicators
Performance monitoring indicators are more comprehensive in nature than the dashboard indicators and focus on key aspects of the major standards of care. Due to the exhaustive nature of data requirement of these standards, they are kept optional for the facilities. However, monitoring these indicators will give a more in-depth picture of the status of adherence to evidence-based practices. These indicators are primarily meant for individual facilities or smaller groups of facilities to track their own progress on quality improvement and have a limited value for comparison across large groups of facilities. Overall, 26 performance monitoring indicators have been included in the toolkit for the facilities to choose from. It is recommended that the facilities select a set of performance indicators from this list based upon their quality gaps and the compliance status on related standards of care. These indicators can be monitored until the time compliance is achieved on the related standard of care. Facilities then can switch to other sets of indicators.
34 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Structure of the indicators
For the purpose of this toolkit, the indicators have been presented in a tabular manner. The structure of this table includes a statement of indicator itself, a definition of the indicator focusing on the relevance and importance of the indicator, descriptions of numerators and denominators of the indicator, and proposed sources of data.
How to use the indicators
The indicators can be used by both individual facilities and groups of external facilitators. The process of use by different users is being described below.
Individual Facility
Individual facilities can use indicators to monitor change in quality of care using the following process:
Adoption of indicators and standardization of data recording tools
Facility leaders should formally decide to adopt the standards (all dashboard and select performance monitoring indicators) as a commitment to improve quality of care. In order to be able to collect the data required for monitoring these indicators, they should review their data collection tools to understand the feasibility of collection relevant data. If their tools have missing data elements, they should use their tools for inclusion of these elements. Frequency of data reporting should also be decided at the same time. A nodal person should also be identified for the purpose of collating the data and reporting the indicators.
Implementation of revised data tools
The facility should formally start implementing the revised data tools for the purpose of collecting data for the selected indicators.
Data collation
The person responsible for data collation should compile the data from relevant sources on a monthly basis and generate reports on selected indicators.
Review of data
Key stakeholders should periodically review performance on the indicators and decide upon a course of action for improvement.
Data display Wherever feasible, the status of performance on the indicators should be prominently displayed in the facilities in staff areas to keep them aware of the status of performance on key indicators.
Data Collection Tools
A set of tools for data recording and collation has been developed along with the toolkit. This includes
a standardized version of a Client Case Record, a template for a Standard Birthing Register, a template
for a Standard Antenatal Care Card, and a Standard Reporting Form are included as Annexures linked
to this component of the toolkit. (Annexures III-VI)
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 35
Dashboard Indicators
S.No. Indicator Definition Numerator Denominator Data
Source
Process indicators
1 Proportion of
pregnant women
whose blood
pressure was
recorded at the
time of admission
This reflects the
practice of
recording BP of
pregnant
women by the
service provider
at the time of
admission
(targeted to
identify cases of
pregnancy
induced
hypertension)
Number of pregnant
women admitted in
the targeted facilities
whose BP was
recorded at the time
of admission during
specified period
Total number of
pregnant
women
admitted in the
targeted
facilities for
delivery during
same period
Case
sheets/
Labor
room
register
2 Proportion of
pregnant women
where FHR was
recorded at the
time of admission
This reflects the
practice of
recording FHR
by the service
provider at the
time of
admission of
pregnant
women to the
facility
(targeted to
monitor the fetal
wellbeing)
Number of pregnant
women admitted in
the targeted facilities
where FHR was
measured at the time
of admission during
specified period
Total number of
pregnant
women
admitted in the
targeted
facilities for
delivery during
same period
Case
sheets/
Labor
room
register
3 Proportion of
mothers who were
administered
Uterotonics
(Oxytocin/Misoprost
ol) immediately
after delivery for
active
management of
third stage of labor
(AMTSL)
This reflects on
the practice of
oxytocin
administration
as a part of
AMTSL
Number of deliveries
where administered
to women within 5
minutes of delivery
Total number of
deliveries in the
same period
Case
sheets/
Labor
room
register
4 Proportion of
mothers whose
body temperature
was recorded at the
time of discharge
This reflects on
the practice of
recording
temperature of
mothers by the
service provider
at the time of
discharge
(targeted to
identify cases of
maternal sepsis)
Number of pregnant
women admitted in
the targeted facilities
whose body
temperature was
recorded at the time
of discharge
Total number of
pregnant
women
discharged in
the targeted
facilities after
delivery
Case
sheets/
Labor
room
register
36 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Dashboard Indicators
S.No. Indicator Definition Numerator Denominator Data
Source
5 Proportion of
deliveries where
newborn
temperature was
recorded before
discharge
This reflects on
the practice of
recording
newborn
temperature by
the service
provider at the
time of
(targeted to
identify cases of
neonatal sepsis)
Number of deliveries
where newborn
temperature was
recorded before
discharge
Total number of
deliveries in the
targeted
facilities
(excluding
deliveries
resulting in IUD
or still birth)
Case
sheets/
Labor
room
register
6 Proportion of
Deliveries for which
Partograph were
used to monitor
progress of labor
This reflects the
use of
Partograph to
monitor progress
of labor
Number of deliveries
for which Partograph
was used
Total number of
deliver
(excluding
elective
caesarean
sections)
Case
sheets/
Labor
room
register
7 Proportion of
preterm births (<34
wks) where
antenatal
corticosteroids were
administered
This reflects the
practice of
identification
and
administration
of ANCS for PTB
at facility
Number of preterm
deliveries where
antenatal
corticosteroids was
administered
Total number of
preterm
deliveries at
facility
Case
sheets/
Labor
room
register
Outcome Indicators
1 Proportion of
deliveries with
severe
complications in the
targeted facilities
(segregated by
type of
complication: PPH
or severe PE/E or
prolonged labor or
obstructed labor
Reflects the
occurrence of
severe
complications
such as PPH/
severe PE/E/
prolonged
labor/
obstructed
labor
Number of
complications (like
PPH/severe PE/E/
prolonged
labor/obstructed
labor) occurring at
facility during a
specified period
Total number of
deliveries in the
same period
Labor
room
register
2 Proportion of live
births with neonatal
asphyxia
Reflects the
occurrence of
neonatal
asphyxia
among all live
births at facility
Number of new born
with neonatal
asphyxia
Total number of
live births at
facility
Labor
room
register
3 Still birth rate at
facility
Reflects the still
birth rate at
facility
Number of still births
at facility
Total number of
live births at
facility
Labor
room
register
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 37
Illustrative set of performance monitoring indicators
(Facilities can identify indicators from the list based on their priorities, for inclusion in their regular quality
monitoring)
S.No Indicator Definition Numerator Denominator Data
Source
ANC Indicators
1 Proportion of
booked deliveries in
which at least 4
ANC visits have
been completed
This reflects if the
required number of
ANCs have been
completed
Number of booked
deliveries in a month
who had all 4 ANCs
completed
Total number of
booked
deliveries in
same month
ANC
card
2 Proportion of cases
where gestational
age was established
during first ANC visit
This reflects the
practice of
gestational age
estimation at first
ANC at facility
Number of cases
where Gestational
age was established
at first ANC in a
month
Total number of
cases at first
ANC in same
month
ANC
card
3 Proportion of cases
in which BP was
recorded during all
ANC visits
This reflects the
practice of
recording Blood
pressure during ANC
at facility
Number of all ANC
cases where Blood
pressure was
recorded in a
month
Total number of
all ANC cases in
month
ANC
card
4 Proportion of cases
in which FHR was
recorded at least
during last trimester
This reflects the
practice of
recording FHR
during last ANC visit
at facility
Number of all cases
at last ANC visit
where FHR was
recorded in a
month
Total number of
ANC cases in
month
ANC
card
5 Proportion of cases
in which Hb
estimation was
done in all ANC visits
This reflects the
practice of Hb
estimation during
ANC at facility
Number of all cases
at all ANC visit
where Hb estimation
was performed in a
month
Total number of
all ANC cases in
month
ANC
card
6 Proportion of cases
in which screening
for Gestational
Diabetes Mellitus
was done
This reflects the
practice of GDM
screening at ANC
Number of ANC
cases where GDM
screening was done
in a month
Total number of
ANC cases in
month
ANC
card
7 Proportion of cases
in which Ca
supplementation
was prescribed for
prevention of PE/E
This reflects practice
of prescribing Ca
supplementation for
prevention of PE/E
during ANC
Number of ANC
cases in a month
where Ca
supplementation
was prescribed for
prevention of PE/E in
a month
Total number of
ANC cases in
month
ANC
card
Intrapartum Care Indicators
8 Proportion of cases
in which gestational
age was established
at the time of
admission
This reflects the
practice of
gestational age
estimation during
admission at facility
Number of deliveries
where gestation
age was estimated
at admission
Total number of
deliveries in a
month
Labor
room
register
9 Proportion of cases
in which mothers
temperature was
recorded at the
time of admission
This reflects the
practice of
recording mothers
temperature during
admission at facility
Number of deliveries
where mothers
temperature was
recorded at
admission
Total number of
deliveries in a
month
Labor
room
register
38 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Illustrative set of performance monitoring indicators
(Facilities can identify indicators from the list based on their priorities, for inclusion in their regular quality
monitoring)
S.No Indicator Definition Numerator Denominator Data
Source
10 Proportion of
deliveries in which
birth companion
was allowed to stay
with pregnant
woman inside labor
room during delivery
This reflects the
practice of
encouraging the
presence of birth
companion during
delivery
Number of deliveries
where birth
companion/s were
allowed to stay with
women during
delivery inside the
labor room
Total number of
deliveries in a
month
Labor
room
register
11 Proportion of cases
in which Vitamin K is
administered to
newborns
This reflects the
practice of
administration of
Vitamin K to
newborns
Number of deliveries
in which Vitamin K
was administered
Total number of
live births in a
month
Labor
room
register
12 Proportion of cases
of PPH that were
managed through
the use of oxytocin/
appropriate
uterotonic
This reflects the
practice of
management of
PPH through use of
oxytocin/
appropriate
uterotonic
Number of PPH
cases where
oxytocin/
appropriate
uterotonic was used
for management
Total number of
PPH cases in
month
Labor
room
register
13 Proportion of cases
with severe PE/E
which were
managed using
MgSO4 within the
facility
This reflects the
practice of
management of
Pre-
eclampsia/Eclampsi
a using MgSO4 at
facility
Number of Pre-
eclampsia/eclampsi
a which were
managed using
MgSO4
Total number of
deliveries with
Pre-
eclampsia/ecla
mpsia
Labor
room
register
14 Proportion of babies
with small size at
birth in which KMC
was performed
This reflects the
practice of KMC
being given to small
size babies at facility
Number of small
sized babies where
KMC is given
Total number of
small sized
babies in a
month
PNC
card
15 Proportion of
deliveries where
new-born/s breast
fed within one hour
of delivery
This reflects the
practice of initiation
of breast feeding in
newborn within one
hour of delivery
Number of
newborns who were
breast fed within
one hour of delivery
Total number of
live births in a
month
Labor
room
register
16 Proportion of
women counselled
on family planning
in post-partum
period
This reflects the
practice of post-
partum family
planning counselling
at family
Number of mothers
counselled on post-
partum family
planning counselling
Total number of
deliveries in a
month
Labor
room
register
17 Proportion of
asphyxiated
newborns who were
resuscitated in the
labor room
This reflects the
practice of new
born resuscitation in
asphyxiated
newborns
Number of
asphyxiated
newborns who were
resuscitated
Total number of
asphyxiated
babies
Labor
room
register
18 Proportions of
deliveries with
known HIV status
This reflects the
practice of
checking for HIV
status of women
during deliveries
Number of deliveries
with known HIV
status
Total number of
deliveries in a
month
Labor
room
register
19 Proportion of This reflects the Number of Total number of Labor
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 39
Illustrative set of performance monitoring indicators
(Facilities can identify indicators from the list based on their priorities, for inclusion in their regular quality
monitoring)
S.No Indicator Definition Numerator Denominator Data
Source
caesarean
deliveries at facility
caesarean delivery
rate at facility
caesarean sections
performed
deliveries in a
month at facility
room
register
20 Proportion of LSCS
cases where
prophylactic
antibiotics were
administered
This reflects the
practice of
prophylactic
administration of
antibiotics in LSCS
cases
Number of LSCS
cases where
prophylactic
antibiotics were
administered
Total number of
LSCS cases in a
month
Labor
room
register
21 Proportion of LSCS
cases classified
using Modified
Robson's criteria
This reflects
appropriateness of
performing
caesarean sections
Number of LSCS
cases which were
classified using
modified Robson’s
criteria
Total number of
LSCS cases in a
month
Labor
room
register
22 Proportion of
mothers referred out
of the facility
This reflects referral
rate of mothers at
facility.
Number of mothers
referred out to
higher facilities
Total number of
admission of
women at
facilities for
delivery care
Labor
room
register
23 Proportion of new
born referred out of
the facility
This reflects referral
rate of new-borns at
facility.
Number of new-
borns referred out to
higher facilities
Total number of
live births in a
month
Labor
room
register
PNC Indicators
24 Proportion of cases
in which at least 4
PNC visits were
ensured
This reflects the
coverage of post-
natal visits at facility
Number of deliveries
in which at least four
PNC cases were
ensured
Total number of
deliveries
tracked till six
months of
postpartum
period
PNC
card
25 Proportion of post-
partum cases of
infection that were
managed using
antibiotics
This reflects practice
of management of
infection in post-
partum cases
Number of post-
partum cases of
infection which
were managed
using antibiotics
Total number of
post-partum
cases of
infection
PNC
card
26 Proportion of cases
in which newborn
temperature was
taken during
postpartum visits
This reflects the
practice of
recording newborns
temperature during
post-partum visit
Number of
newborns visit during
post-partum visit in
which the
temperature was
recorded
Total number of
newborns seen
during post-
partum visit at
facility
Labor
room
register
40 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Section III: Guidance on Capacity Building of
Health Workers
The third main component of the proposed toolkit is guidance for training of facility-based health workers on life-saving evidence-based practices to improve facility-based health outcomes. This includes course outlines for designing trainings of health workers and a learning resource package including tools linked to the course outlines. The course outlines have been designed keeping in mind alignment with the essential elements of the standards, and these can be adapted or customized based on facilities’ compliance to the standards. Key features of the course outlines are as follows:
Structure of the course outlines
The course outline has been divided into four main areas:
Topic: Defines the broad area of focus for the session.
Content: This part guides the facilitator on the key items to be covered under any given topic and is linked to the objectives of the session.
Methodology: This area proposes the appropriate training methodology for effectively delivering the content for each topic. The methodology varies according to the content of the topic and level of engagement requirement from the participants. Methodology includes a mix of methods such as interactive presentations, role-play by participants, skill demonstration, group discussions, and use of AV aid to ensure that the content is adequately delivered and participants are engaged throughout.
Resources: The area guides on the possible resources required for the proposed training methodology and for effective delivery and content for the participants.
Duration: This area is to be used to assign the time slot for each topic.
Technical focus of the course outlines The course outlines follow the group pattern of the standards of care and focus on key practices during the ANC, intra- and immediate postpartum, and PNC period. Since Caesarean section and related anaesthesia skills are meant to be developed in formal academic environments, the course outlines do not focus on these areas. The course outlines are designed in a way that the flow of the training follows the routine care provision pathway for any client.
Scope of the course outlines To ensure comprehensive coverage of all important areas, the course outlines have been designed keeping in mind the requirements of health workers of CEmONC facilities. Lower level facilities can choose topics based upon the standards applicable to their facilities.
How to use the training course outlines
The course outlines can be used both by individual health facilities to improve knowledge and skills of
their own health workers and also by external facilitators to support a group of facilities.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 41
Individual health facilities
The course outlines are intended to be used as a part of the strategic skill building under the implementation of action plan activity. Once the facility has completed its baseline assessment using the clinical standards, developed an action plan for addressing the gaps, and ensured essential resources as identified through gap analysis, the facility clinical leader should plan a training pathway for the training of all the health workers in the facilities. This pathway can include two approaches:
Group trainings of health workers over two days: All the relevant health workers can be trained over two to three consecutive days to ensure that the facility is saturated with trained providers in a short span. However, this methodology will require frequent post-training follow-up and support to the health workers while they are on the job.
On-the-job training of health workers using the guidance in the course outlines: The course outlines can be broken down into short modules based upon the time availability with the key participants and trainers. These modules can be covered over an extended duration to ensure that the participants are trained on one to two skills at a time and get adequate time to internalize the key messages.
External facilitators
In order to improve time efficiency and contact with better trainers, external facilitators can prefer to use the centralized training methodology, wherein participants from a group of facilities are invited for training at a health facility with adequate delivery loads. The facilitators can then use the course outlines to conduct training of health workers and simultaneously can demonstrate important practices on clients wherever feasible. Key facility staff can be identified as facility-based champions who can take forward the post-training and offer onsite support to the health workers for effective translation of skills into practice.
Learning resource package
A learning resource package has been developed based upon the proposed course outline as a set of
tools linked to this component of the toolkit. This resource package includes specific folders for each
topic on the course outline. Each folder includes power point presentations wherever applicable, job
aids, including self-learning checklists, and videos. Some of these have been sourced from the existing
training programs being implemented by the Government of India and other stakeholders. The learning
resource package has not been included in this document due to its large size and can be accessed
at the following link:
https://www.dropbox.com/sh/5agy7mj4t3w1kfs/AABxUuYy38eZvZZwPS_i5qqNa?dl=0
42 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Course Outline for ANC
(This includes indicative durations of various sessions. The facilities may want to implement these trainings in a modular manner, based on the availability of providers.)
S.
No. Topic
Duration
(in minutes) Contents Methodology Resources
1 Identification
and
confirmation
of pregnancy
and
registration
15 Brief Introduction - early
signs and symptoms
UPT
Interactive
presentation
Demonstration of
UPT
Video of UPT
Flip charts
Markers
Demonstration
station
UPT video
PPT
2 Focused ANC 30 Timing of focussed ANC:
4 ANC visits
Content:
Surveillance &
screening of
normal conditions
& complications
Preventive care
Management of
conditions
Counselling for
ANC care
Interactive
presentation
Flip charts
Markers
PPT
3
Assessment of
pregnant
woman
15 ANC history taking:
Relevant menstrual
history LMP/EDD
Relevant obstetric
history & Medical &
surgical history
Personal history
ANC Card/MCP card
Interactive
presentations
Video
Role Play
Group exercises
on calculation of
EDD and filling of
ANC card
Flip charts
Markers
PPT
Role play
scenario
ANC card /
MCP card
Case
scenarios
EDD
calculation
exercises
45 ANC examination:
General – Height,
weight , BP, TPR ,
Pallor
P/A – Fundal
height, 4 obstetric
grips (fundal,
lateral, pelvic), FHR
Breast exam
PV examination
Interactive
presentations
Demonstration
and practice
Flip chart ,
Markers
PPT
Demonstration
Station for BP,
PA
Checklists and
job-aids
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 43
S.
No. Topic
Duration
(in minutes) Contents Methodology Resources
4 ANC Lab tests 20 List of Blood tests &
importance
ABO + Rh
Hb gm %
VDRL
HIV
OGTT
Malaria (RDT)
HBSAg
Urine – routine, protein ,
sugar
Demonstration
(optional)
Interactive
presentation
Videos
Demonstration
station for
Sahli’s, urine
protein and
sugar by
dipsticks,
OGTT, malaria
RDT
Videos,
checklists and
job-aids
PPT
5 ANC-
Preventive
care
20 Prevention for:
Anemia
Neonatal tetanus
PE/E
Helminthic infection
Malaria
Infection prevention
Interactive
presentation PPT
6 Minor
disorders in
pregnancy
and their
management
15 Vomiting, Fever, Diarrhoea,
Urinary problems
Interactive
presentation
Flip chart
Marker
PPT
7 Identification
&
Management
of Anaemia
20 Definition of Anemia
Causes
Management of
Anemia
Interactive
presentation
PPT
8 Management
of Gestational
Diabetes
Mellitus
20 Definitions of DM
Management of GDM
Interactive
presentation
PPT
Flip chart
White board
Marker
9 Identification
and
management
of
hypertensive
disorders in
pregnancy
(HDP)
30 Definitions in HDP
Management of severe
PE/E
MgSO4 regime
Interactive
presentation
Demonstrations
on knee jerk and
preparation of
MgSO4
PPT
Demonstration
station
Checklists, job-
aids and video
10 Identification
&
Management
of HIV
15 Management of HIV
HIV testing and
treatment of
spouse/partner
Counselling for lifelong
ART
Interactive
presentation
PPT
44 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S.
No. Topic
Duration
(in minutes) Contents Methodology Resources
11 Management
of Syphilis
10 Management of Syphilis
Syphilis testing and
treatment of
spouse/partner
Interactive
presentation
PPT
12 Identification
and
Management
of Malaria
15 Identification of Malaria
Management of
Malaria
Interactive
presentation
PPT
13 Identification
and
management
of bleeding
during
pregnancy
30 Identification of
Bleeding in early and
late pregnancy
Management
Interactive
presentation
Case studies
PPT
Case studies
14 ANC
Counselling
15 ANC Counselling- General:
Nutrition – balanced
diet
Rest & general care
Hygiene – Bathing
Exercise /yoga
Work
Sexual activity
Breast care
2 doses of TT
IFA
Importance of health
check-ups /Follow-up
Optimal newborn care
Relationship between
family members &
bonding
Men’s role in care of
pregnant woman
Interactive
presentation
Role plays
PPT on ANC
care
Role play
scenarios
15 ANC counselling BPCR
List of danger signs
Importance of early
identification & taking
timely action
Appropriate referral
centre
Place of delivery,
transport, money,
clothes
Birth companion
Blood donor
Interactive
presentation
Role play
PPT
Role play
scenario
20 ANC counselling –PPFP
HTSP, RTF, FP methods,
counselling approach
and strategy
Interactive
presentation
Role play
PPT
Role play
scenario
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 45
S.
No. Topic
Duration
(in minutes) Contents Methodology Resources
15 Do’s and
Don’ts
15 Game on good and
harmful practices
Discuss how the harmful
practices can be
converted into good
one
Game on good
and harmful
practices
Do’s and
Don’ts written
chits
Bowl
16 Recording
and reporting
20 ANC/MCP card
Registers
Monthly reporting
format and other
relevant documents
Referral protocol
Discussion with
handouts
Handouts
46 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Course Outline for Intrapartum and Immediate
Postpartum Care
(This includes indicative durations of various sessions. The facilities may want to implement these trainings in a modular manner, based on the availability of providers.)
S.N Topic Duration Contents Methodology Resources
1. Respectful
Maternity Care
15 RMC
Client rights &
responsibilities
Interactive
presentation
using job-aids
Role play
Brainstorming
& discussion
Job-aid on
clients’ rights
Role play
scenario
Video
2. Assessment at
the time of
admission and
decision
making
A. Triaging
Assessment at
the time of
admission and
decision
making
B. Admission/
Referral
60 History taking
Relevant
menstrual history
LMP/EDD
Relevant obstetric
history & Medical
& surgical history
Personal history
Brainstorming
Interactive
presentation &
discussion
Role play
Video
GoI SBA video
mod 1 PPT on
history taking
Role play
scenario
General physical
examination including
importance of vitals
Interactive
presentation
Demonstration of
BP (vitals) check-
up
PPT
Job-aid on
BP
GoI video on
BP (vitals)
Skill CL on BP
Demonstratio
n station
PA examination
Inspection
Palpation
Estimation of GA
by Fundal height
& imaginary
divisions of
abdomen
Grips
Uterine
contractions
Localization of
FHS &
Auscultation of
FHR
Demonstration Demonstration
station
PV examination
Wearing & removal of
gloves
Demonstration
Interactive
presentation
on assessment
of progress of
labor and
Demonstration
station
PPT
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 47
S.N Topic Duration Contents Methodology Resources
pelvic
adequacy
through PV
examination
Admission protocol
Referral protocol
Maternity case sheet
Interactive
presentation
on both
protocols
Reading of
maternity
case
sheet/group
exercise
Admission
protocol
Referral
protocol
Maternity
case sheet
3. Prevention,
identification
and
management
of PE/E
30 Prevention of PE/E
Identification of
various conditions
under HDP
Management of
severe PE/E
Interactive
presentation
Demonstration
of preparation
of MgSO4
dose
Demonstration
of eliciting
knee jerk
GoI SBA video
on eclampsia
PPT
Flip chart/white
board with
markers
Station for
preparation of
MgSO4 dose
and hammer
(Covered in
ANC package)
Video
4. Identification of
and
management
of threatened
preterm labor
45 Identification of
conditions leading to
threatened PTB
Management of
threatened preterm
birth through ANCS,
MgSO4, Tocolytics,
antibiotics and
preterm newborn care
Interactive
presentation
PPT
Job-aids (GOI
ANCS and
Jhpiego)
5. Stages of labor 10 Stages of labor Interactive
presentation
PPT
6. Ensuring safe
care during 1st
stage of labor
45 Monitoring of 1st stage
of labor plotting &
interpretation of
partograph
Demonstration &
practice of
plotting &
interpreting
partograph
Case studies
Interactive
presentation
Demonstration
station
5 Supportive care during
1st stage of labor
including importance
of birth companion
Interactive
presentation
PPT
20 Protocol for Induction
& augmentation of
labor
Interactive
presentation
PPT and
protocol on
Induction &
augmentation
of labor
30 Prevention, Interactive PPT
48 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S.N Topic Duration Contents Methodology Resources
identification &
management of
prolonged &
obstructed labor
Ruptured uterus
Importance of
partograph in early
identification of
prolonged &
obstructed labor
presentation
Interpretation of
partographs to
diagnose
prolonged &
obstructed labor
Filled
partographs/
Teaching
partograph with
markers & duster
7. Preparing for
safe birth
15 Trays in LR
Prefilled oxytocin
Counselling of mother
and companion on
danger signs & do’s &
don’ts
Group
exercises on
contents of
tray
Interactive
presentation
on trays,
importance of
prefilled
oxytocin &
danger signs
& Do’s &
don’ts during
labor
Job aid on trays
PPT
GoI video on IP
PPT on IPP
8. Conducting
ND, AMTSL,
ENBC,/NBR
90 ND
AMTSL
ENBC
NBR- Basic &
advanced
Interactive
presentation on
ND, AMTSL &
ENBC including
Inj. Vitamin K
Demonstration &
practice on ND,
AMTSL, ENBC &
NBR
Demonstration
Stations
PPT
Job-aids on
AMTSL, NBR,
BMWM
Skill checklists on
ND, AMTSL,
ENBC & NBR
9. Conducting
complicated
delivery
45 Assisted vaginal
delivery (AVD)-
vacuum extraction
Videos
Demonstration on
conducting AVD-
vacuum
Interactive
presentation
PPT
Videos and skill
stations
Skills checklist
30 Breech delivery
Interactive
presentation
Videos
Demonstration
breech
PPT
Videos and skill
stations
Skills checklist
30 Shoulder dystocia Demonstration of
shoulder dystocia
Interactive
presentation
Videos
PPT
Videos and skill
stations
Skills checklist
10. Review of care
of mother & NB
soon after
birth=4th stage
for first 2 hours
15 Observation of mother
every 15 mins.
Observation of NB
every 15 mins
Prevention of
hypothermia, hypoxia
Interactive
presentation
Demonstration
on
breastfeeding
PPT
Demonstratio
n Station
BF poster and
skill CL
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 49
S.N Topic Duration Contents Methodology Resources
in NB
Breastfeeding
11. Prevention,
identification
and
management
of infection in
mother
20 Prevention,
Identification &
management of
maternal sepsis
Interactive
presentation
PPT
12. Prevention,
identification
and
management
of PPH
60 PPH prevention
strategy from
antenatal to
postpartum period
Identification &
management of shock
and PPH
Blood loss activity
Bimanual uterine
compression, aortic
compression
MRP
Condom tamponade
Interactive
presentation
Blood loss
activity
Demonstration
on Bimanual
uterine
compression,
aortic
compression &
MRP
Condom
tamponade
Video on
aortic
compression
GoI SBA Video
on PPH
PPT
Demonstration
Station for blood
loss activity
Videos
13. Prevention,
identification &
management
of
Hypothermia/h
yperthermia in
newborn
15 Prevention,
identification &
management of
Hypothermia/hyperthe
rmia in newborn
Importance of labor
room preparation, skin-
to-skin contact and
early initiation of
breastfeeding in
prevention of
hypothermia
Interactive
presentation
Group exercise
on prevention of
hypothermia from
woman in labor
till postpartum
period
PPT
Flip chart with
markers
14. Prevention,
identification &
management
of
hypoglycemia
in NB
15 Prevention,
identification &
management of
hypoglycemia in
newborn
Interactive
presentation
Group exercise
on prevention of
hypoglycemia
from woman in
labor till
postpartum
period
PPT
Flip chart with
markers
15. Prevention,
identification &
management
of
infection/neon
atal sepsis in NB
15 Prevention, identification
& management of
infection in NB
Interactive
presentation
Group exercise
on prevention of
infection from
woman in labor
till postpartum
period
PPT
Flip chart with
markers
50 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S.N Topic Duration Contents Methodology Resources
16. Prevention,
identification &
management
of prematurity
related
complications
(hypothermia &
feeding
problems)
60 Care of small sized
babies (preterm &
SGA)
KMC for prevention of
hypothermia
Assisted feeding
Oro-gastric tube
insertion & feeding
Interactive
presentation
Demonstration of
KMC, EBM, spoon
feeding, oro-
gastric tube
insertion &
feeding
GoI Video on oro-
gastric tube
insertion
PPT
Demonstration
Station
Video
GoI KMC poster
Skill checklists
17. Early
identification &
initial
management
of congenital
malformations
in newborn
10 Early identification &
initial management of
congenital
malformations in
newborn
Interactive
presentation
PPT
18. Identification &
management
of
hyperbilirubine
mia in newborn
15 Identification &
management of
hyperbilirubinemia in
newborn- physiological vs
pathological
Interactive
presentation
PPT
19. Infection
Prevention
45 Sources of infection
Mode of spread of
infection
6 Universal precautions
Hand-wash, PPE,
processing of
instruments, disposal of
sharps, cleaning of
environment and BMW
management
Do’s & Don’ts in IP
Interactive
presentation
Demonstrations
Video
PPT
Demo station
Video on
processing of
instruments
20. Do’s and Don’ts
of all four
stages of labor
15 Game on good and
harmful practices of all
stages of labor
Discuss how the
harmful practices can
be converted into
good one
Game on good
and harmful
practices of all
stages of labor
Discuss how the
harmful practices
can be
converted into
good one
Do’s and Don’ts
written chits
Bowl
21. Caesarean
section
20 Preparation,
procedure and post
caesarean care
Interactive
presentation
Video
PPT
Video
22. Labor room
and OT
organization
and sterilization
30 Infrastructure & layout
HR
Equipment and
supplies
Video on
labor room/OT
organization
Small group
exercise on
labor room
and OT
organization -
Interactive
Video
Flip chart,
markers
Stickers of
equipment &
supplies
Job-aid on
contents of 7
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 51
S.N Topic Duration Contents Methodology Resources
presentation
with labor
room pics
trays
PPT on
contents of 7
trays & PPH &
eclampsia
kits
GoI MNH
toolkit
23. Labor room
team building
15 Importance of LR staff
working as team
BCC
Team building
exercise
Emergency
drill
Script of
emergency
drill
Related
station for
simulation
24. Communicatio
n skills
15 Communication skills-
verbal & nonverbal
BCC
Interactive
presentation
Role
play/video
PPT on
communicati
on skills
Role play
scenario/vid
eo
25. Recording and
reporting
30 Case record
Birthing register
Monthly reporting
format
Data for action-
review of dashboard
indicators
Discussion with
handouts
Case sheets
Birthing register,
monthly
reporting
formats
List of
dashboard
indicators
52 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Course Outline for Postpartum Care
(This includes indicative durations of various sessions. The facilities may want to implement these trainings in a modular manner, based on the availability of providers.)
S.N Topic Duration Contents Methodology Resources
1 Postpartum
care package
30 Definition and
importance of
postpartum period
Elements of post-partum
care
Timing of PNC visits -
within 48 hours, 3rd
day, 7th day, 6
weeks and 6 months
Content:
History &
examination
Management
of any
condition
during PNC
Counselling for
PNC care
Integration with other
services - PPTCT, PPFP
and immunization of
baby
Interactive
presentation
PPTs
Flip charts
Markers
Job-aids
2 Postpartum
examination
30 Examination of mother
General
examination
Breast examination
Per-abdominal
examination
Perineal
examination
Examination of baby
Vitals
Color, respiration,
feeding
Interactive
presentation
PPT
Pictorial
diagrams of
examination
3 Prevention,
identification
and
management
of postpartum
lactational
and breast
complications
20 Identification and
management of
postpartum lactational
and breast conditions
Interactive
presentation
PPT
4 Post-partum
depression/
post-partum
blues
20 Identification and
management
Interactive
presentation
PPT
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 53
S.N Topic Duration Contents Methodology Resources
5 Prevention,
identification
and
management
of DVT
15 Prevention, identification
and management of
DVT
Interactive
presentation
PPT
6 Discharge
Counselling for
routine PNC
care of
Mother and
baby
45 Danger signs for mother
and baby
Nutrition – balanced diet
for mother
Rest & general care
Hygiene
Breast examination and
care
Exercises
Supplementation
PPFP
Breast feed for baby ,
Complimentary feeding
Delayed bathing of baby
Care of the baby’s cord
Rooming in of baby
Immunization for the
baby
Importance and
schedule of Follow-up
Interactive
presentation
Role plays
PPT on
Post-partum
period
Role play
scenarios
Pictorial job-
aid
RI Schedule
SCC for
danger signs
7 Do’s and
Don’ts
15 Game on good and
harmful practices
Discuss how the harmful
practices can be
converted into good one
Game on good
and harmful
practices
Discuss how the
harmful practices
can be
converted into
good one
Do’s and
Don’ts written
chits
Bowl
8 Referral/
Discharge
protocols
15 When to discharge/refer
after normal labor, C-
section
Examination & criteria for
discharge
Interactive
presentation
PPTs
54 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Annexure 1: Assessment Tool for Use of Core Technical Standards for Supporting
the Quality Assurance Systems (Accreditation, Regulation etc.)
ANC Standards
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Source
(Y/N/NA)
Comments
Applicability
(ANC-Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus in all ANC visits
1.1 Establishes gestational age
1.1.1
Establishes concurrence between LMP
and fundal height for estimation of
gestational age
ANC UPWARDS
1.1.2
Uses an ultrasound scan in the first or
second trimester to confirm gestational
age where possible
ANC UPWARDS
1.2
Takes appropriate history
(medical, surgical, obstetric
and personal) and performs
general and systemic
examination
(Box 1)
1.2.1
Takes appropriate history (medical,
surgical, obstetric and personal) and
performs general and systemic
examination
ANC UPWARDS
1.3 Records weight of pregnant
woman during all ANC visits 1.3.1
Records weight of pregnant woman
during all ANC visits ANC UPWARDS
1.4 Conducts abdominal
examination 1.4.1
Conducts abdominal examinations as
appropriate ANC UPWARDS
1.5 Records FHR 1.5.1
Functional
doppler/fetoscope/stethoscope is
available
ANC UPWARDS
55 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Source
(Y/N/NA)
Comments
Applicability
(ANC-Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1.5.2 Records FHR as appropriate ANC UPWARDS
1.6
Performs PV examination
during 4th ANC visit (37weeks
or more) to check for pelvic
adequacy (Box 2)
1.6.1 Uses correct technique for PV
examination ANC UPWARDS
1.6.2 Rules out CPD and records PV
examination findings ANC UPWARDS
1.6.3 Adequate sterile equipment, gloves and
supplies are available ANC UPWARDS
2 Provider screens for key clinical conditions that may lead to complications during pregnancy
2.1 Testing facilities/linkage to
testing facilities are available 2.1.1
Provision/easy access for following tests -
Hb estimation, proteinuria strips, OGTT,
HIV testing, POC/RPR for syphilis, blood
grouping and typing, blood glucose
estimation, malaria testing, HBsAg and
urine routine and microscopy is available
ANC UPWARDS
2.2 Screens for anemia 2.2.1 Estimates Hb at each scheduled ANC
visit ANC UPWARDS
2.3 Screens for hypertensive
disorders of pregnancy
2.3.1 Functional BP instrument and
stethoscope at point of use is available ANC UPWARDS
2.3.2 Records BP at each ANC visit ANC UPWARDS
2.3.3 Performs proteinuria testing during each
scheduled ANC visit ANC UPWARDS
2.4 Screens for DM (as per
relevant national guidelines) 2.4.1
Uses/Refers for standard 75gm OGTT for
screening of GDM at first ANC visit and
repeats OGTT test at second ANC visit
(24 -28 weeks) if negative in first
screening
ANC UPWARDS
56 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Source
(Y/N/NA)
Comments
Applicability
(ANC-Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
2.5 Screens for HIV
2.5.1
Screens/refers for HIV during first ANC visit
in all cases, and in fourth ANC visit in high
risk cases
ANC UPWARDS
2.5.2 Facilitates testing and treatment of
spouse/partner ANC UPWARDS
2.6
Screens for hepatitis B (if
applicable and as per
relevant national guidelines)
2.6.1 Screens/refers for HBsAg testing during
first ANC visit in all cases ANC UPWARDS
2.7 Screens for syphilis 2.7.1
Screens/refers for syphilis in first ANC visit
in all cases, and in fourth ANC visit in high
risk cases
ANC UPWARDS
2.8 Screens for malaria 2.8.1 Screens for malaria as per the national
guidelines. ANC UPWARDS
2.9 Establishes blood group and
Rh type during first ANC visit 2.9.1
Establishes blood group and Rh type
during first ANC visit ANC UPWARDS
3 Provider ensures adequate preventive care for key clinical conditions which can lead to complications in pregnancy
3.1 Ensures adequate preventive
care for anemia
3.1.1
Prescribes IFA supplementation to all
pregnant woman as per relevant
national guidelines
ANC UPWARDS
3.1.2
Prescribes single dose of albendazole
(400mg) after first trimester (preferably
during the second trimester)
ANC UPWARDS
3.2 Ensures adequate preventive
care for neonatal tetanus 3.2.1
Ensures two doses of tetanus toxoid one
month apart as early as possible ANC UPWARDS
57 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Source
(Y/N/NA)
Comments
Applicability
(ANC-Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
3.3
Ensures adequate preventive
care for pre-eclampsia/
eclampsia
3.3.1 Prescribes calcium supplementation
1.5-2gms per day 20 weeks onwards ANC UPWARDS
3.4 Ensures adequate preventive
care for malaria
3.4.1 Advises all women to sleep under long-
lasting insecticide treated bed nets ANC UPWARDS
3.4.2
Prescribes intermittent prophylaxis
treatment of malaria (if applicable) as
per national guidelines
ANC UPWARDS
58 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Intra- & Immediate Postpartum Care Standards
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus at the time of admission
1.1
Elicits comprehensive
obstetric, medical and
surgical history and conducts
examination
(Box 1)
1.1.1 Documents obstetric, medical and
surgical history in case record
BEmONC
UPWARDS
1.1.2
Documents the presentation and lie of
the fetus in the case record at
admission
BEmONC
UPWARDS
1.2 Assesses gestational age
correctly 1.2.1
Assesses and records gestational age
through either LMP or Fundal height or
USG (if available)
BEmONC
UPWARDS
1.3 Records fetal heart rate
1.3.1
Functional
Doppler/fetoscope/stethoscope at
point of use is available
BEmONC
UPWARDS
1.3.2 Records FHR at admission BEmONC
UPWARDS
1.4 Records mother’s blood
pressure
1.4.1 Functional BP instrument and
stethoscope at point of use is available
BEmONC
UPWARDS
1.4.2 Records mother`s BP at admission BEmONC
UPWARDS
1.5 Records mother’s
temperature
1.5.1 Functional thermometer at point of use
is available
BEmONC
UPWARDS
1.5.2 Records mother' s temperature at
admission
BEmONC
UPWARDS
59 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
2 Provider ensures respectful and supportive care for the pregnant woman coming in for delivery
2.1
Treats pregnant woman and
her companion cordially and
respectfully (RMC), ensures
privacy and confidentiality
for pregnant woman during
her stay
2.1.1 Curtains are installed in labor room to
ensure privacy to pregnant woman
BEmONC
UPWARDS
2.1.2
Treats pregnant woman and her
companion cordially and respectfully
(RMC), ensures privacy and
confidentiality for pregnant woman
during her stay
BEmONC
UPWARDS
2.2
Encourages the presence of
birth companion during
labor
2.2.1 Encourages the presence of birth
companion during labor
BEmONC
UPWARDS
2.3
Explains danger signs and
important care activities to
pregnant woman and her
companion during the stay
(for the woman and her
newborn)
2.3.1
Explains danger signs and important
care activities to pregnant woman and
her companion during the stay (for the
woman and her newborn)
BEmONC
UPWARDS
3 Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly
3.1
Monitors progress of labor
regularly on various
parameters (Box 9)
3.1.1
Initiates partograph plotting when
cervical dilatation is >=4 cms in
appropriate column on the alert line
BEmONC
UPWARDS
3.1.2 Plots all parameters in the partograph BEmONC
UPWARDS
60 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
3.2
Interprets partograph
correctly and adjusts the
care according to findings
3.2.1
If parameters are not normal, identifies
complications, records the diagnosis
and makes appropriate adjustments in
the birth plan
BEmONC
UPWARDS
4 Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried immediately)
4.1
Delivers the baby and places
on mother’s abdomen to
conduct immediate
newborn care - drying and
assessment of baby's
breathing
4.1.1 Places two pre-warmed towels on
mother's abdomen before delivery
BEmONC
UPWARDS
4.1.2 Delivers and places the baby on
mother's abdomen
BEmONC
UPWARDS
4.1.3 Dries the baby immediately and wraps
in second warm towel
BEmONC
UPWARDS
4.2 Performs delayed clamping
of cord 4.2.1
If baby's breathing is normal, delays the
clamping of cord for 1-3 minutes till the
cord pulsations stop
BEmONC
UPWARDS
4.3 Assesses the newborn for any
congenital anomalies
4.3.1 Records presence or absence of any
congenital anomalies
BEmONC
UPWARDS
4.3.2 Ensures specialist attention for
newborns with congenital anomalies
BEmONC
UPWARDS
4.4 Ensures early initiation of
breastfeeding 4.4.1
Initiates breast feeding within one hour
of birth
BEmONC
UPWARDS
61 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
4.5 Weighs the baby and
administers Vitamin K
4.5.1 Baby weighing scale is available BEmONC
UPWARDS
4.5.2 Vitamin K injection is available BEmONC
UPWARDS
4.5.3 Records baby weight and
administration of vitamin K
BEmONC
UPWARDS
5 Provider performs newborn resuscitation if baby does not cry immediately after birth
5.1
Performs recommended
initial steps for resuscitation
within first 30 seconds
5.1.1
Checks for functionality of neonatal
resuscitation kit and availability of
shoulder roll before every delivery
BEmONC
UPWARDS
5.1.2
Performs following steps within first
30 seconds on mothers abdomen:
Suction if indicated; dries the baby and
rubs the back 2-3 times; immediate
clamping and cutting of cord; and
shifting to radiant warmer if baby still
not breathing
BEmONC
UPWARDS
5.1.3
Performs following steps within first
30 seconds under radiant warmer:
Positioning, Suctioning, Stimulation,
Repositioning (PSSR)
BEmONC
UPWARDS
5.2
Initiates bag and mask
ventilation for 30 seconds if
the baby is still not breathing
5.2.1 Functional ambu bag with mask (size 0
and 1) is available
BEmONC
UPWARDS
5.2.2 Initiates bag and mask ventilation for
30 seconds if baby still not breathing
BEmONC
UPWARDS
62 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
5.3
Takes appropriate action if
baby doesn’t respond to
ambu bag ventilation after
golden minute
5.3.1
Functional oxygen cylinder (with
wrench) and new born mask are
available
BEmONC
UPWARDS
5.3.2
Assesses breathing, if baby still not
breathing, continues bag and mask
ventilation; starts oxygen
BEmONC
UPWARDS
5.3.3 Checks heart rate/cord pulsations BEmONC
UPWARDS
5.3.4 Calls for advance help/arranges
referral
BEmONC
UPWARDS
5.4
*Performs next level of
resuscitation in babies not
responding to initial
resuscitation- when chest rise
is seen after bag and mask
but heart rate continues to
be < 60/pm (only at facilities
where specialist care for
newborn or SNCU is
available)
5.4.1
Performs chest compressions at the
rate of 3 compressions to 1 breath till
the heart rate is > 60 beats/minute
*Only at facilities
where specialist
care for newborn
or SNCU is
available
63 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
6 Provider performs Active Management of Third Stage of Labor (AMTSL)
6.1
Performs AMTSL and
examines the placenta
thoroughly
6.1.1 Palpates mother's abdomen to rule out
second baby
BEmONC
UPWARDS
6.1.2 Administers injection Oxytocin 10 I.U.
IM/IV within one minute of delivery of
baby
BEmONC
UPWARDS
6.1.3 Performs controlled cord traction (CCT)
during contraction
BEmONC
UPWARDS
6.1.4 Performs uterine massage
BEmONC
UPWARDS
6.1.5 Checks placenta and membranes for
completeness before discarding
BEmONC
UPWARDS
7 The facility adheres to universal infection prevention protocols
7.1
Instruments and re-usable
items are adequately and
appropriately processed
after each use
7.1.1 Facilities for sterilization of instruments
are available
BEmONC
UPWARDS
7.1.2 Instruments are sterilized after each use
BEmONC
UPWARDS
7.1.3
Delivery environment such as labor
table, contaminated surfaces and
floors are cleaned after each delivery
BEmONC
UPWARDS
7.2
Biomedical waste is
segregated and disposed of
as per the guidelines
7.2.1 Color coded bags for disposal of
biomedical waste are available
BEmONC
UPWARDS
7.2.2 Biomedical waste is segregated and
disposed of as per the guidelines
BEmONC
UPWARDS
64 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
7.3
Performs hand hygiene
before and after each
procedure, and sterile gloves
are worn during delivery and
internal examination
7.3.1
Performs hand hygiene before and
after each procedure, and sterile
gloves are worn during delivery and
internal examination
BEmONC
UPWARDS
8 Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)
8.1 Identifies mothers with severe
PE/E
8.1.1 Dipsticks for proteinuria testing in labor
room are available
BEmONC
UPWARDS
8.1.2 Records BP at admission BEmONC
UPWARDS
8.1.3
Identifies danger signs such as severe
headache, blurring of vision, difficulty
breathing, epigastric pain, reduced
urine output; or presence of
convulsions
BEmONC
UPWARDS
8.2
In cases of severe PE/E, gives
correct first dose of MgSO4
and refers to higher center or
manages appropriately
(Box 4)
8.2.1 MgSO4 (at least 14 ampoules) is
available
BEmONC
UPWARDS
8.2.2
Gives correct first dose of MgSO4 (5 mg
with 1 ml of 2% Xylocaine in each
buttock deep IM (10 mg)) and refers to
higher center
BEmONC
UPWARDS
8.2.3
Injection MgSO4 is appropriately
administered (5 mg with 1 ml of 2%
Xylocaine in each buttock deep IM (10
mg); 4gms (8ml) with 12 ml Normal
saline IV slowly followed by
BEmONC
UPWARDS
65 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
maintenance dose of 5mg with 1 ml of
2% Xylocaine in alternate buttock
deep IM every 4 hours for 24 hours after
the last convulsion or delivery
whichever occurs later)
8.3 Facilitates prescription of
anti-hypertensives (Box 5)
8.3.1 Antihypertensive are available BEmONC
UPWARDS
8.3.2
Facilitates prescription or prescribes
anti-hypertensives in case of
hypertension in pregnancy
BEmONC
UPWARDS
8.4
Ensures specialist attention
for care of mother and
newborn
8.4.1 Ensures specialist attention for care of
mother and newborn
BEmONC
UPWARDS
9 Provider identifies and manages Postpartum Hemorrhage (PPH)
9.1
Assesses uterine tone and
bleeding per vaginum
regularly after delivery
9.1.1 Assesses uterine tone and bleeding per
vaginum regularly
BEmONC
UPWARDS
9.2
Performs initial steps of
management as per the
protocol in case of PPH
9.2.1 Calls for help /assistance, while
continuing uterine message
BEmONC
UPWARDS
9.2.2 Starts IV fluids BEmONC
UPWARDS
9.2.3 Manages shock if present BEmONC
UPWARDS
9.2.4 Identifies specific cause of PPH BEmONC
UPWARDS
66 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
9.3 Manages atonic PPH
9.3.1
Initiates 20 IU oxytocin drip in 1000 ml of
ringer lactate/normal saline at the rate
of 40-60 drops per minute
BEmONC
UPWARDS
9.3.2 Continues uterine massage BEmONC
UPWARDS
9.3.3 If uterus is still relaxed, gives other
uterotonics as recommended
BEmONC
UPWARDS
9.3.4
If uterus is still relaxed, performs
mechanical compression in the form of
bimanual uterine compression or
external aortic compression or balloon
tamponade
BEmONC
UPWARDS
9.3.5
If uterus is still relaxed, refers to higher
center while continuing mechanical
compression
BEmONC
UPWARDS
9.4
Manages PPH due to
retained placenta/placental
bits
9.4.1
Identifies retained placenta if placenta
is not delivered within 30 minutes of
delivery of baby or the delivered
placenta is not complete
BEmONC
UPWARDS
9.4.2
Initiates 20 IU oxytocin drip in 1000 ml of
ringer lactate/normal saline at the rate
of 40-60 drops per minut
BEmONC
UPWARDS
9.4.3 Refers to higher center if unable to
manage
BEmONC
UPWARDS
9.4.4 Performs MRP BEmONC
UPWARDS
67 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/ N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
10 Provider ensures care of newborn with small size at birth
10.1 Facilitate specialist care in
newborn weighing <1800 gm 10.1.1
Facilitates specialist care in newborn
<1800 gm (refer to FBNC/seen by
pediatrician)
BEmONC
UPWARDS
10.2 Facilitates assisted feeding
whenever required 10.2.1
Facilitates assisted feeding whenever
required
BEmONC
UPWARDS
10.3
Facilitates thermal
management including
kangaroo mother care
10.3.1 Facilitates thermal management
including KMC
BEmONC
UPWARDS
(C-section Standards)
11 Provider reviews clinical practice related to C-section at regular intervals
11.1
Ensures classification as per
Robson’s criteria and reviews
indications and
complications of C-section
at regular intervals
11.1.1
Ensures that all C‐section cases are
classified as per the modified Robson’s
criteria and rates of different
categories are monitored
CEmONC
11.1.2 Reviews all cases of induction and C-
section through a clinical audit CEmONC
11.1.3 Ensures that rate of complications of C-
sections are periodically monitored CEmONC
68 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Post Natal Care Standards
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
1 Provider ensures adequate postpartum care package is offered to the mother and newborn
1.1 Ensures at least 4 postpartum
visits for the mother
1.1.1
Ensures minimum 4 postpartum visits for
the mother: after discharge at 2 - 3 days
(If discharged early), 7-14 days, 6 weeks
and 6 months after delivery (or as per
national guidelines)
BEmONC
UPWARDS
1.1.2
Prepares postpartum visit schedule and
shares written record with the mother
and her family
BEmONC
UPWARDS
1.1.3 Ensures additional 2 to 3 visits in cases of
babies with any complication
BEmONC
UPWARDS
1.2
Conducts proper physical
examination of mother and
newborn
1.2.1
Conducts mother’s examination: breast,
perineum for inflammation; status of
episiotomy/tear suture; lochia; calf
tenderness/redness/swelling; abdomen
for involution of uterus, tenderness or
distension
1.2.2
Conducts newborn’s examination:
assesses feeding of baby; checks
weight, temperature, respiration, color
of skin and cord stump
69 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
1.3
Identifies and appropriately
manages maternal and
neonatal sepsis
1.3.1 Checks mother's temperature
BEmONC
UPWARDS
1.3.2 Gives correct regimen of antibiotics
BEmONC
UPWARDS
1.3.3 Checks baby’s temperature and other
looks for other signs of infections
BEmONC
UPWARDS
1.3.4 Gives correct regime of
antibiotics/refers for specialist care
BEmONC
UPWARDS
1.4
Identifies and appropriately
manages postpartum
maternal depression
1.4.1 Makes correct diagnosis of postpartum
maternal depression after ruling out
postpartum blues based on history
BEmONC
UPWARDS
1.4.2 In cases of postpartum blues, provides
emotional support and counsel’s family
on the condition. Follows up in 2 weeks,
and refers for specialist care if required
BEmONC
UPWARDS
1.4.3 In cases of postpartum depression,
provides emotional support and refers
for specialist care
BEmONC
UPWARDS
1.5 Ensures to offer FP services
1.5.1 A basket of choice of PPFP services is
available at the facility
BEmONC
UPWARDS
1.5.2 Provider is trained for PPFP services
being offered at the facility
BEmONC
UPWARDS
70 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Annexure 2: Assessment Tool for Use of Comprehensive Set of Technical Standards
for Guiding the Quality Improvement Process
ANC Standards
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus in all ANC visits
1.1 Establishes gestational age
1.1.1
Establishes concurrence between LMP
and fundal height for estimation of
gestational age
ANC UPWARDS
1.1.2
Uses an ultrasound scan in the first or
second trimester to confirm gestational
age where possible
ANC UPWARDS
1.2
Takes appropriate history
(medical, surgical, obstetric
and personal) and
performs general and
systemic examination
(Box 1)
1.2.1
Takes appropriate history (medical,
surgical, obstetric and personal) and
performs general and systemic
examination
ANC UPWARDS
1.3
Records weight of
pregnant woman during all
ANC visits
1.3.1 Records weight of pregnant woman
during all ANC visits ANC UPWARDS
1.4 Conducts abdominal
examination 1.4.1
Conducts abdominal examinations as
appropriate ANC UPWARDS
1.5 Records FHR 1.5.1 Functional doppler/fetoscope/ ANC UPWARDS
71 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
stethoscope is available
1.5.2 Records FHR as appropriate ANC UPWARDS
1.6
Performs PV examination
during 4th ANC visit
(37weeks or more) to
check for pelvic adequacy
(Box 2)
1.6.1 Uses correct technique for PV
examination ANC UPWARDS
1.6.2 Rules out CPD and records PV
examination findings ANC UPWARDS
1.6.3 Adequate sterile equipment, gloves and
supplies are available ANC UPWARDS
2 Provider screens for key clinical conditions that may lead to complications during pregnancy
2.1
Testing facilities/linkage to
testing facilities are
available
2.1.1
Provision/easy access for following tests -
Hb estimation, proteinuria strips, OGTT,
HIV testing, POC/RPR for syphilis, blood
grouping and typing, blood glucose
estimation, malaria testing, HBsAg and
urine routine and microscopy is
available
ANC UPWARDS
2.2 Screens for anemia 2.2.1 Estimates Hb at each scheduled ANC
visit ANC UPWARDS
2.3 Screens for hypertensive
disorders of pregnancy
2.3.1 Functional BP instrument and
stethoscope at point of use is available ANC UPWARDS
2.3.2 Records BP at each ANC visit ANC UPWARDS
2.3.3 Performs proteinuria testing during each
scheduled ANC visit ANC UPWARDS
2.4 Screens for DM (as per 2.4.1 Uses/Refers for standard 75gm OGTT for ANC UPWARDS
72 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
relevant national
guidelines)
screening of GDM at first ANC visit and
repeats OGTT test at second ANC visit
(24 -28 weeks) if negative in first screening
2.5 Screens for HIV
2.5.1
Screens/refers for HIV during first ANC
visit in all cases, and in fourth ANC visit in
high risk cases
ANC UPWARDS
2.5.2 Facilitates testing and treatment of
spouse/partner ANC UPWARDS
2.6
Screens for hepatitis B (if
applicable and as per
relevant national
guidelines)
2.6.1 Screens/refers for HBsAg testing during
first ANC visit in all cases ANC UPWARDS
2.7 Screens for syphilis 2.7.1
Screens/refers for syphilis in first ANC visit
in all cases, and in fourth ANC visit in
high risk cases
ANC UPWARDS
2.8 Screens for malaria 2.8.1 Screens for malaria as per the national
guidelines. ANC UPWARDS
2.9
Establishes blood group
and Rh type during first
ANC visit
2.9.1 Establishes blood group and Rh type
during first ANC visit ANC UPWARDS
3 Provider ensures adequate preventive care for key clinical conditions which can lead to complications in pregnancy
3.1 Ensures adequate
preventive care for anemia 3.1.1
Prescribes IFA supplementation to all
pregnant woman as per relevant
national guidelines
ANC UPWARDS
73 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
3.1.2
Prescribes single dose of albendazole
(400mg) after first trimester (preferably
during the second trimester)
ANC UPWARDS
3.2
Ensures adequate
preventive care for
neonatal tetanus
3.2.1 Ensures two doses of tetanus toxoid one
month apart as early as possible ANC UPWARDS
3.3
Ensures adequate
preventive care for
pre-eclampsia/eclampsia
3.3.1 Prescribes calcium supplementation 1.5-
2gms per day 20 weeks onwards ANC UPWARDS
3.4 Ensures adequate
preventive care for malaria
3.4.1 Advises all women to sleep under long-
lasting insecticide treated bed nets ANC UPWARDS
3.4.2
Prescribes intermittent prophylaxis
treatment of malaria (if applicable) as
per national guidelines
ANC UPWARDS
4 Provider performs adequate management of anemia
4.1
Performs adequate
management of anemia
(Box 3)
4.1.1
Provides IFA supplementation to all
pregnant women as per relevant
national guidelines
ANC UPWARDS
4.1.2
Provides therapeutic oral iron in case of
diagnosed severe anemia and refers to
higher facility if further management not
available and/or pregnant woman is
not responding
ANC UPWARDS
4.1.3 Provides parenteral iron therapy if
woman is not responding
BEmONC
UPWARDS
74 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
4.1.4
Performs blood transfusion in woman
with Hb < 7gm/dl beyond 34 weeks of
gestation
CEmONC
4.1.5
Prescribes single dose of albendazole
(400mg) after first trimester (preferably
during the second trimester)
BEmONC
UPWARDS
5 Provider performs adequate management of hypertensive disorders of pregnancy
5.1
Confirms hypertension and
identifies pregnant woman
with severe PE/E
5.1.1 Dipstick for proteinuria testing in labor
room is available
BEmONC
UPWARDS
5.1.2 Records BP ANC UPWARDS
5.1.3
Identifies danger signs such as severe
headache, blurring of vision, difficulty
breathing, severe epigastric pain,
reduced urine output; or the presence
of convulsions
ANC UPWARDS
5.2
Manages hypertension
using recommended anti-
hypertensives (Box 5)
5.2.1 Provides anti-hypertensives if diastolic BP
is more than 110 mmHg
BEmONC
UPWARDS
5.3
In cases of severe PE/E,
gives correct first dose of
MgSO4 and refers to higher
center if further
management is not
available (Box 4)
5.3.1 MgSO4 (at least 14 ampoules) is
available ANC UPWARDS
5.3.2 Gives correct first dose of MgSO4 and
refers to higher center ANC UPWARDS
6 Provider performs adequate management of Gestational Diabetes Mellitus (GDM)
75 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
6.1 Initiates MNT in all
diagnosed GDM cases 6.1.1 Provides MNT for 2 weeks ANC UPWARDS
6.2 Initiates insulin therapy if
required
6.2.1 Initiates insulin therapy if PPPG >=120
mg/dl after 2 weeks of MNT
BEmONC
UPWARDS
6.2.2 Monitors 2hr PPPG once every week
once insulin dose is stable
BEmONC
UPWARDS
6.2.3 Continues insulin and MNT in such cases
throughout pregnancy
BEmONC
UPWARDS
6.3 Initiates fetal surveillance
6.3.1 Monitors FHR by auscultation in each
ANC visit
BEmONC
UPWARDS
6.3.2 Counsels pregnant woman for Daily
Fetal Activity Assessment
BEmONC
UPWARDS
6.4
Ensures specialist attention
for care of pregnant
woman and newborn
during labor
6.4.1
Ensures specialist attention for care of
pregnant woman and newborn during
labor
ANC UPWARDS
7 Provider performs adequate management of communicable conditions in pregnant woman- HIV, Malaria and Syphilis
7.1
Appropriately manages HIV
seropositive cases (If ART
center) (Box 13) or refers to
an ART center (If not ART
center)
7.1.1
Ensures continued ART for those who are
already on ART irrespective of CD4 cell
count
BEmONC
UPWARDS
7.1.2 Initiates lifelong ART for seropositive
pregnant woman who are not on ART
BEmONC
UPWARDS
7.1.3 If not ART center, refers pregnant
woman to ART center for ART initiation ANC UPWARDS
76 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
7.2
Appropriately manages
syphilis in pregnant woman
and spouse/partner (Box 6)
7.2.1 Facility has easy access to
Penicillin/Erythromycin
BEmONC
UPWARDS
7.2.2 Rules out history of allergy to Penicillin BEmONC
UPWARDS
7.2.3
Manages early and late stage of syphilis
using appropriate doses of Benzathine
Benzyl Penicillin
BEmONC
UPWARDS
7.2.4 If allergic to penicillin, gives erythromycin
in appropriate doses
BEmONC
UPWARDS
7.2.5 Facilitates testing and treatment of
spouse/partner using the same guideline
BEmONC
UPWARDS
7.3
Adequately manages
malaria in pregnancy
(Box 7)
7.3.1
Manages malaria in first trimester:
uncomplicated malaria using oral
Quinine and oral Clindamycin for 7 days
or as per national guidelines
BEmONC
UPWARDS
7.3.2
Manages malaria in 2nd and 3rd
trimester: uncomplicated malaria using
Artemether/Lumefantrine OR
Artesunate/Amodiaquine according to
national malaria treatment policy
BEmONC
UPWARDS
7.3.3
Manages severe malaria using
parenteral Artesunate or as per national
guidelines
BEmONC
UPWARDS
77 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
8 Provider manages threatened preterm labor
8.1 Identifies threatened
preterm birth
8.1.1 Establishes that the pregnant woman is
in true labor
ANC UPWARDS
8.1.2 Correctly estimates gestational age ANC UPWARDS
8.1.3 Establishes conditions leading to PTB
(APH, PPROM, severe PE/E, vaginal
infections, uterine over-distension)
ANC UPWARDS
8.2
Essential medicines for
managing PTB are
available
8.2.1 Ensures availability of Dexamethsone,
MgSO4 antibiotics and nifedipine
ANC UPWARDS
8.3
Appropriately manages
conditions leading to PTB
(For GA 24 - 37 weeks)
8.3.1 Gives erythromycin (or injection penicillin
or any other appropriate antibiotic as
recommended) in case of PPROM
BEmONC
UPWARDS
8.3.2 Gives at least first dose of injection
MgSO4 in case of severe PE/E or
complete dose (if facility available)
ANC UPWARDS
8.4
Ensures interventions to
facilitate fetal maturity and
protection if GA is <34
weeks (Box 8)
8.4.1 Additionally, If GA is 24 - 32 weeks, gives
ANCS for lung maturity and MgSO4 for
neuroprotection if delivery is expected
within 24 hours
BEmONC
UPWARDS (ANCS
at ANC-only
facility also)
8.4.2 If gestational age is 32 - 34 weeks, gives
ANCS for lung maturity and considers
nifedipine as a tocolytic for 24 to 48 hrs
BEmONC
UPWARDS
(ANCS at ANC-
only facility also)
78 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
8.5
Ensures heightened
monitoring and care (GA
between 34-37 weeks)
8.5.1 If gestational age is between 34-37
weeks, monitors frequently and prepares
for PTB
BEmONC
UPWARDS
8.6 Prepares for specialist care
for newborn
8.6.1 Prepares for specialist attention for
newborn care
BEmONC
UPWARDS
9 Provider counsels pregnant woman on care during pregnancy
9.1
Shares a written schedule
of ANC visits with the
pregnant woman
9.1.1 ANC card/ any other format of written
schedule is available ANC UPWARDS
9.1.2 Briefs the pregnant woman on
scheduled ANC visits ANC UPWARDS
9.2
Counsels pregnant woman
and her
husband/partner/compani
on on Birth Preparedness
and Complication
Readiness (BPCR) at least
during last trimester
9.2.1
Develops a birth plan with the woman
and her husband/partner/companion
including all preparations for normal
birth (Financial/transport planning, birth
companion) and complications
ANC UPWARDS
9.3
Counsels pregnant woman
and her
husband/partner/compani
on on Importance of
lifestyle modification at
least during first trimester
9.3.1
Provider counsels pregnant woman and
her husband/partner/companion on
balanced nutritious diet, adequate rest,
exercises, maintaining personal hygiene,
substance abuse and domestic
violence
ANC UPWARDS
79 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
9.4
Counsels pregnant woman
and her
husband/partner/compani
on on Importance of
optimal newborn care at
least during last trimester
9.4.1
Counsels pregnant woman and her
husband/partner/companion on
importance of exclusive and on
demand breast feeding
ANC UPWARDS
9.4.2
Counsels pregnant woman and her
husband/partner/companion on
importance of optimal newborn care
including thermal management and
immunization
ANC UPWARDS
9.4.3
Counsels pregnant woman and her
husband/partner/companion on
identification of warning signs and
when/where/how to seek care
ANC UPWARDS
9.5
Counsels pregnant woman
and her
husband/partner/compani
on on postpartum family
planning in all ANC visits
9.5.1
Provider counsels pregnant woman and
her husband/partner/companion on
return of fertility and importance of
healthy timing and spacing of
pregnancy
ANC UPWARDS
9.5.2
Provider counsels pregnant woman and
her husband/partner/companion on all
available family planning methods and
help them choose appropriate method
ANC UPWARDS
80 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
10 The facility adheres to universal infection prevention protocols
10.1
Instruments and re-usable
items are adequately and
appropriately processed
after each use
10.1.1 Facilities for sterilization of instruments
are available
ANC UPWARDS
10.1.2 Instruments are sterilized after each use ANC UPWARDS
10.1.3
Delivery environment such as labor
table, contaminated surfaces and floors
are cleaned after each delivery
ANC UPWARDS
10.2
Biomedical waste is
segregated and disposed
of as per the guidelines
10.2.1 Color coded bags for disposal of
biomedical waste are available
ANC UPWARDS
10.2.2 Biomedical waste is segregated and
disposed of as per the guidelines
ANC UPWARDS
10.3
Performs hand hygiene
before and after each
procedure and sterile
gloves are worn during
delivery and internal
examination
10.3.1
Performs hand hygiene before and after
each procedure, and sterile gloves are
worn during delivery and internal
examination
ANC UPWARDS
81 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Intra- and Immediate Postpartum Care Standards
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus at the time of admission
1.1
Elicits comprehensive
obstetric, medical and
surgical history and
conducts examination
(Box 1)
1.1.1 Documents obstetric, medical and
surgical history in case record
BEmONC
UPWARDS
1.1.2
Documents the presentation and lie
of the fetus in the case record at
admission
BEmONC
UPWARDS
1.2 Assesses gestational age
correctly 1.2.1
Assesses and records gestational age
through either LMP or Fundal height
or USG (if available)
BEmONC
UPWARDS
1.3 Records fetal heart rate
1.3.1
Functional Doppler/fetoscope/
stethoscope at point of use is
available
BEmONC
UPWARDS
1.3.2 Records FHR at admission BEmONC
UPWARDS
1.4 Records mother’s blood
pressure
1.4.1
Functional BP instrument and
stethoscope at point of use is
available
BEmONC
UPWARDS
1.4.2 Records mother`s BP at admission BEmONC
UPWARDS
1.5 Records mother’s
temperature
1.5.1 Functional thermometer at point of
use is available
BEmONC
UPWARDS
1.5.2 Records mother' s temperature at
admission
BEmONC
UPWARDS
82 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
2 Provider ensures respectful and supportive care for the pregnant woman coming in for delivery
2.1
Treats pregnant woman
and her companion
cordially and respectfully
(RMC), ensures privacy
and confidentiality for
pregnant woman during
her stay
2.1.1 Curtains are installed in labor room to
ensure privacy to pregnant woman
BEmONC
UPWARDS
2.1.2
Treats pregnant woman and her
companion cordially and respectfully
(RMC), ensures privacy and
confidentiality for pregnant woman
during her stay
BEmONC
UPWARDS
2.2
Encourages the presence
of birth companion during
labor
2.2.1 Encourages the presence of birth
companion during labor
BEmONC
UPWARDS
2.3
Explains danger signs and
important care activities to
pregnant woman and her
companion during the stay
(for the woman and her
newborn)
2.3.1
Explains danger signs and important
care activities to pregnant woman
and her companion during the stay
(for the woman and her newborn)
BEmONC
UPWARDS
3 Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly
3.1
Monitors progress of labor
regularly on various
parameters (Box 9)
3.1.1
Initiates partograph plotting when
cervical dilatation is >=4 cms in
appropriate column on the alert line
BEmONC
UPWARDS
3.1.2 Plots all parameters in the partograph BEmONC
UPWARDS
3.2
Interprets partograph
correctly and adjusts the
care according to findings
3.2.1
If parameters are not normal,
identifies complications, records the
diagnosis and makes appropriate
adjustments in the birth plan
BEmONC
UPWARDS
83 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
4 Provider assists the pregnant woman to have a safe and clean birth
4.1
Conducts PV examination
at admission and every
four hours in active labor or
as per clinical indication
4.1.1
Records the finding of PV
examination (in Case
sheet/Partograph during active
phase of labor)
BEmONC
UPWARDS
4.2
Performs PV examination in
a safe and clean manner
(Box 2)
4.2.1 Performs hand hygiene with correct
technique
BEmONC
UPWARDS
4.2.2 Wears gloves on both the hands with
correct technique
BEmONC
UPWARDS
4.2.3 Cleans the perineum appropriately
before PV examination
BEmONC
UPWARDS
4.2.4 Soap, running water and sterile
gloves are available
BEmONC
UPWARDS
4.2.5
Antiseptic solution and sterile
gauze/pad in the PV tray are
available
BEmONC
UPWARDS
84 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
4.3
Allows spontaneous
delivery of head by
maintaining flexion and
giving perineal support;
manages cord round the
neck; assists in delivery of
shoulders and body
4.3.1
Allows spontaneous delivery of head
by maintaining flexion and giving
perineal support; manages cord
round the neck; assists in delivery of
shoulders and body
BEmONC
UPWARDS
4.4 Performs an episiotomy
only if indicated (Box 11)
4.4.1 Performs an episiotomy only if
indicated
BEmONC
UPWARDS
4.4.2 Records the reason for episiotomy BEmONC
UPWARDS
5 Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried immediately)
5.1
Delivers the baby and
places on mother’s
abdomen to conduct
immediate newborn care -
drying and assessment of
baby's breathing
5.1.1 Places two pre-warmed towels on
mother's abdomen before delivery
BEmONC
UPWARDS
5.1.2 Delivers and places the baby on
mother's abdomen
BEmONC
UPWARDS
5.1.3 Dries the baby immediately and
wraps in second warm towel
BEmONC
UPWARDS
5.2 Performs delayed
clamping of cord 5.2.1
If baby's breathing is normal, delays
the clamping of cord for 1-3 minutes
till the cord pulsations stop
BEmONC
UPWARDS
5.3 Assesses the newborn for
any congenital anomalies
5.3.1 Records presence or absence of any
congenital anomalies
BEmONC
UPWARDS
5.3.2 Ensures specialist attention for
newborns with congenital anomalies
BEmONC
UPWARDS
85 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
5.4 Ensures early initiation of
breastfeeding 5.4.1
Initiates breast feeding within one
hour of birth
BEmONC
UPWARDS
5.5 Weighs the baby and
administers Vitamin K
5.5.1 Baby weighing scale is available BEmONC
UPWARDS
5.5.2 Vitamin K injection is available BEmONC
UPWARDS
5.5.3 Records baby weight and
administration of vitamin K
BEmONC
UPWARDS
6 Provider performs newborn resuscitation if baby does not cry immediately after birth
6.1
Performs recommended
initial steps for resuscitation
within first 30 seconds
6.1.1
Checks for functionality of neonatal
resuscitation kit and availability of
shoulder roll before every delivery
BEmONC
UPWARDS
6.1.2
Performs following steps within first 30
seconds on mothers abdomen:
Suction if indicated; dries the baby
and rubs the back 2-3 times;
immediate clamping and cutting of
cord; and shifting to radiant warmer if
baby still not breathing
BEmONC
UPWARDS
6.1.3
Performs following steps within first 30
seconds under radiant warmer:
Positioning, Suctioning, Stimulation,
Repositioning (PSSR)
BEmONC
UPWARDS
86 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
6.2
Initiates bag and mask
ventilation for 30 seconds if
the baby is still not
breathing
6.2.1 Functional ambu bag with mask (size
0 and 1) is available
BEmONC
UPWARDS
6.2.2 Initiates bag and mask ventilation for
30 seconds if baby still not breathing
BEmONC
UPWARDS
6.3
Takes appropriate action if
baby doesn’t respond to
ambu bag ventilation after
golden minute
6.3.1
Functional oxygen cylinder (with
wrench) and new born mask are
available
BEmONC
UPWARDS
6.3.2
Assesses breathing, if baby still not
breathing, continues bag and mask
ventilation; starts oxygen
BEmONC
UPWARDS
6.3.3 Checks heart rate/cord pulsations BEmONC
UPWARDS
6.3.4 Calls for advance help/arranges
referral
BEmONC
UPWARDS
6.4
*Performs next level of
resuscitation in babies not
responding to initial
resuscitation- when chest
rise is seen after bag and
mask but heart rate
continues to be < 60/pm
(only at facilities where
specialist care for newborn
or SNCU is available)
6.4.1
Performs chest compressions at the
rate of 3 compressions to 1 breath till
the heart rate is > 60 beats/minute
*Only at facilities
where specialist
care for newborn
or SNCU is
available 6.4.2
If the heartrate persists to be
undetectable or < 60 beats/minute,
administers epinephrine (1:10000),
0.1 - 0.3 ml/kg i.v.
87 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
7 Provider performs Active Management of Third Stage of Labor (AMTSL)
7.1
Performs AMTSL and
examines the placenta
thoroughly
7.1.1 Palpates mother's abdomen to rule
out second baby
BEmONC
UPWARDS
7.1.2 Administers injection Oxytocin 10 I.U.
IM/IV within one minute of delivery of
baby
BEmONC
UPWARDS
7.1.3 Performs controlled cord traction
(CCT) during contraction
BEmONC
UPWARDS
7.1.4 Performs uterine massage
BEmONC
UPWARDS
7.1.5 Checks placenta and membranes for
completeness before discarding
BEmONC
UPWARDS
8 Provider assesses condition of mother and baby before shifting them from labor room
8.1 Looks for signs of infection
in baby 8.1.1 Looks for signs of infection in baby
BEmONC
UPWARDS
8.2 Looks for signs of
hypothermia in baby 8.2.1 Measures baby's temperature
BEmONC
UPWARDS
8.3 Looks for signs of infection
in mother 8.3.1 Looks for signs of infection in mother
BEmONC
UPWARDS
88 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
8.3.2 Functional thermometer at point of
use is available
BEmONC
UPWARDS
8.3.3 Records mother's temperature BEmONC
UPWARDS
8.4 Records blood pressure of
mother
8.4.1
Functional BP instrument and
stethoscope at point of use is
available
BEmONC
UPWARDS
8.4.2 Records mother's BP
BEmONC
UPWARDS
9 The facility adheres to universal infection prevention protocols
9.1
Instruments and re-usable
items are adequately and
appropriately processed
after each use
9.1.1 Facilities for sterilization of instruments
are available
BEmONC
UPWARDS
9.1.2 Instruments are sterilized after each
use
BEmONC
UPWARDS
9.1.3
Delivery environment such as labor
table, contaminated surfaces and
floors are cleaned after each delivery
BEmONC
UPWARDS
9.2
Biomedical waste is
segregated and disposed
of as per the guidelines
9.2.1 Color coded bags for disposal of
biomedical waste are available
BEmONC
UPWARDS
9.2.2 Biomedical waste is segregated and
disposed of as per the guidelines
BEmONC
UPWARDS
89 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
9.3
Performs hand hygiene
before and after each
procedure, and sterile
gloves are worn during
delivery and internal
examination
9.3.1
Performs hand hygiene before and
after each procedure, and sterile
gloves are worn during delivery and
internal examination
BEmONC
UPWARDS
10 Provider induces labor only when indicated (based on history and findings of examination)
10.1
Induces labor only when
indicated
(Box 12)
10.1.1 Records the reasons for induction BEmONC
UPWARDS
10.1.2
Performs induction only if C-section
service is available at the facility (or
can be transported without delay to
such a facility - Uganda)
BEmONC
UPWARDS
10.2
Uses only recommended
technique for induction of
labor
10.2.1
Uses only recommended methods for
induction of labor as per the Bishop's
score
BEmONC
UPWARDS
10.3 Monitors the progress of
labor 10.3.1
Records the progress of labor, fetal
heart rate and status of medication in
partograph every 30 minutes
BEmONC
UPWARDS
10.4
Appropriately manages
the hyper stimulation of
uterus due to use of
uterotonics
10.4.1
Uses betamimetics (terbutaline) for
management of hyperstimulation of
uterus
BEmONC
UPWARDS
90 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
11 Provider augments labor only when indicated (based on history and findings of examination)
11.1 Augments labor only when
indicated
11.1.1
Ensures ambulation of pregnant
woman, presence of birth
companion as methods of improving
progress of labor before considering
augmentation of labor
CEmONC
11.1.2
Augments labor only when there is a
confirmed delay in progress of labor
as identified through partograph
CEmONC
11.1.3 Records the reasons for
augmentation CEmONC
11.1.4
Performs augmentation only when
C-section services are available at
the facility
CEmONC
11.2
Carefully assesses the
condition of pregnant
woman before considering
augmentation of labor
11.2.1
Rules out CPD or presence of any
other reasons which may lead to
obstruction of labor such as
mal-presentation/malposition or
scarred uterus, prior to augmentation
CEmONC
11.3
Ensures appropriate
supportive care to
pregnant woman
11.3.1
Ensures continuous companionship,
adoption of mobility, upright position
and adequate hydration of pregnant
woman
CEmONC
11.4 Uses correct technique for
augmentation of labor 11.4.1
Uses Oxytocin only or Oxytocin with
amniotomy for augmentation of
labor
CEmONC
91 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
11.4.2
Uses low initial dose and gradual
increase of Oxytocin for
augmentation
CEmONC
11.4.3 Does not use Misoprostol for
augmentation CEmONC
11.5
Monitors maternal and
fetal well-being
continuously
11.5.1 Records maternal and fetal
conditions in the partograph CEmONC
12 Provider identifies and manages HIV in pregnant woman and newborn
12.1
Checks for test results or
recommends testing if not
done
12.1.1 Rapid HIV kits are available BEmONC
UPWARDS
12.1.2 Checks for test results or recommends
testing if not done
BEmONC
UPWARDS
12.2
Appropriately manages
HIV seropositive cases (if
ART center) (Box 13) or
refers (if not ART center)
12.2.1 If ART center, ART drugs are available BEmONC
UPWARDS
12.2.2 Provides ART for seropositive mother BEmONC
UPWARDS
12.2.3 Links mother and newborn to ART
center for continuous follow-up
BEmONC
UPWARDS
12.2.4 If not ART center, Nevirapine tablet is
available
BEmONC
UPWARDS
12.2.5
Provides Nevirapine to (HIV
seropositive) pregnant woman and
refers her to ARTC after delivery
BEmONC
UPWARDS
92 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
12.2.6 Follows universal precautions during
care of mother and newborn
BEmONC
UPWARDS
12.3
Appropriately manages
newborn of HIV
seropositive mother
12.3.1 Nevirapine syrup is available BEmONC
UPWARDS
12.3.2 Provides syrup Nevirapine to
newborns of HIV seropositive mothers
BEmONC
UPWARDS
13 Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)
13.1 Identifies mothers with
severe PE/E
13.1.1 Dipsticks for proteinuria testing in
labor room are available
BEmONC
UPWARDS
13.1.2 Records BP at admission BEmONC
UPWARDS
13.1.3
Identifies danger signs such as severe
headache, blurring of vision, difficulty
breathing, epigastric pain, reduced
urine output; or presence of
convulsions
BEmONC
UPWARDS
13.2
In cases of severe PE/E,
gives correct first dose of
MgSO4 and refers to
higher center or manages
appropriately (Box 4)
13.2.1 MgSO4 (at least 14 ampoules) is
available
BEmONC
UPWARDS
13.2.2
Gives correct first dose of MgSO4 (5
mg with 1 ml of 2% Xylocaine in each
buttock deep IM (10 mg)) and refers
to higher center
BEmONC
UPWARDS
93 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
13.2.3
Injection MgSO4 is appropriately
administered (5 mg with 1 ml of 2%
Xylocaine in each buttock deep IM
(10 mg); 4gms (8ml) with 12 ml
Normal saline IV slowly followed by
maintenance dose of 5mg with 1 ml
of 2% Xylocaine in alternate buttock
deep IM every 4 hours for 24 hours
after the last convulsion or delivery
whichever occurs later)
BEmONC
UPWARDS
13.3 Facilitates prescription of
anti-hypertensives (Box 5)
13.3.1 Antihypertensive are available BEmONC
UPWARDS
13.3.2
Facilitates prescription or prescribes
anti-hypertensives in case of
hypertension in pregnancy
BEmONC
UPWARDS
13.4
Ensures specialist attention
for care of mother and
newborn
13.4.1 Ensures specialist attention for care of
mother and newborn
BEmONC
UPWARDS
14 The facility has services available for conducting assisted vaginal delivery as clinically appropriate
14.1
Reviews the pregnant
woman for suitability for
vacuum extraction
14.1.1
Performs vacuum extraction when
indicated: vertex presentation, term
fetus, cervix fully dilated and fetal
head at +2 station, no fetal pole
palpable per abdomen
BEmONC
UPWARDS
94 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
14.1.2
Documents the indication for
vacuum extraction and takes
consent
BEmONC
UPWARDS
14.2
Performs vacuum
extraction using
appropriate technique
14.2.1
Functional vacuum extraction
equipment are available in labor
room
BEmONC
UPWARDS
14.2.2 Ensures that the woman's bladder is
empty
BEmONC
UPWARDS
14.2.3 Uses correct technique for applying
vacuum cup and traction
BEmONC
UPWARDS
14.2.5 Monitors FHR and attachment of the
cup in between contractions
BEmONC
UPWARDS
14.3 Identifies failure of vacuum
extraction
14.3.1
Identifies failure if fetal head does not
advance with each pull or fetus is
undelivered after three pulls with no
descent or after 30 minutes or cup
slips off the head twice at the proper
direction of the pull
BEmONC
UPWARDS
14.3.2 In cases of failure refers the case for a
C-section
BEmONC
UPWARDS
15 Provider effectively manages special obstetric conditions- shoulder dystocia and mal-presentations
15.1
Identifies and effectively
manages shoulder
dystocia
15.1.1
Identifies the case of shoulder
dystocia, keeps calm and shouts for
help (seeks assistance)
BEmONC
UPWARDS
95 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
15.1.2
Performs basic management: with
pregnant woman on her back, asks
her to flex both thighs bringing her
knees towards the chest (Mc Robert's
position). Asks assistants to push her
flexed knees against her chest
BEmONC
UPWARDS
15.1.3 Applies suprapubic pressure BEmONC
UPWARDS
15.1.4 Does not give fundal pressure or pulls
baby's head
BEmONC
UPWARDS
15.1.5 Performs episiotomy if required to
enlarge the vaginal opening
BEmONC
UPWARDS
15.1.6 Ensures specialist attention if basic
management fails
BEmONC
UPWARDS
15.1.7
Tries to deliver posterior arm or
performs internal rotational
maneuvers
BEmONC
UPWARDS
15.1.8
If not being able to manage, refers
the woman for specialist care/C-
section
BEmONC
UPWARDS
15.2 Effectively manages
breech delivery
15.2.1
Attempts breech delivery only when
the facilities of assisted vaginal
delivery and C-section are available
CEmONC
15.2.2 If pregnant woman agrees, conducts
the delivery by C-section CEmONC
96 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
15.2.3
If pregnant women is willing for
vaginal delivery and there are no
contraindications for vaginal breech
delivery, prepares for the vaginal
breech delivery
CEmONC
15.2.4 Performs episiotomy if required CEmONC
15.2.5
Performs breech delivery using
different maneuvers depending upon
type and presentation of breech
CEmONC
15.3 Effectively manages other
mal-presentations 15.3.1
Identifies other mal-presentations and
ensures appropriate specialist
care/referral for C-section
BEmONC
UPWARDS
16 Provider identifies and manages Postpartum Hemorrhage (PPH)
16.1
Assesses uterine tone and
bleeding per vaginum
regularly after delivery
16.1.1 Assesses uterine tone and bleeding
per vaginum regularly
BEmONC
UPWARDS
16.2
Performs initial steps of
management as per the
protocol in case of PPH
16.2.1 Calls for help /assistance, while
continuing uterine message
BEmONC
UPWARDS
16.2.2 Starts IV fluids BEmONC
UPWARDS
16.2.3 Manages shock if present BEmONC
UPWARDS
16.2.4 Identifies specific cause of PPH BEmONC
UPWARDS
97 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
16.3 Manages atonic PPH
16.3.1
Initiates 20 IU oxytocin drip in 1000 ml
of ringer lactate/normal saline at the
rate of 40-60 drops per minute
BEmONC
UPWARDS
16.3.2 Continues uterine massage BEmONC
UPWARDS
16.3.3 If uterus is still relaxed, gives other
uterotonics as recommended
BEmONC
UPWARDS
16.3.4
If uterus is still relaxed, performs
mechanical compression in the form
of bimanual uterine compression or
external aortic compression or
balloon tamponade
BEmONC
UPWARDS
16.3.5
If uterus is still relaxed, refers to higher
center while continuing mechanical
compression
BEmONC
UPWARDS
16.4
Manages PPH due to
retained
placenta/placental bits
16.4.1
Identifies retained placenta if
placenta is not delivered within 30
minutes of delivery of baby or the
delivered placenta is not complete
BEmONC
UPWARDS
16.4.2
Initiates 20 IU oxytocin drip in 1000 ml
of ringer lactate/normal saline at the
rate of 40-60 drops per minute
BEmONC
UPWARDS
16.4.3 Refers to higher center if unable to
manage
BEmONC
UPWARDS
16.4.4 Performs MRP BEmONC
UPWARDS
98 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
17 Provider ensures care of newborn with small size at birth
17.1
Facilitate specialist care in
newborn weighing <1800
gm
17.1.1
Facilitates specialist care in newborn
<1800 gm (refer to FBNC/seen by
pediatrician)
BEmONC
UPWARDS
17.2 Facilitates assisted feeding
whenever required 17.2.1
Facilitates assisted feeding whenever
required
BEmONC
UPWARDS
17.3
Facilitates thermal
management including
kangaroo mother care
17.3.1 Facilitates thermal management
including KMC
BEmONC
UPWARDS
18 Provider performs management of hypoglycemia in newborn
18.1 Identifies neonatal
hypoglycemia 18.1.1
Identifies neonatal hypoglycemia
(Blood Glucose (BG) < 45mg/dl) or
through clinical signs and symptoms)
CEmONC
18.2 *Manages neonatal
hypoglycemia
18.2.1
Allows direct breastfeeding if baby is
able to suck or gives formula feed if
mother is not able to breastfeed the
baby, continues feeding if the baby
responds
BEmONC
UPWARDS
18.2.2
Establishes IV line if blood glucose
level is less than 25 mg/dl and gives IV
bolus of 10% dextrose (2 ml/kg body
weight) followed by IV infusion of 10%
dextrose (100 ml/kg/day)
*Only at facilities
where specialist
care for
newborn or
SNCU is
available 18.2.3
If IV line cannot be established
quickly, gives 2ml/kg body weight of
10% glucose trough gastric tube
99 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y /
N /
NA
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
18.2.4
If BG level is less than 25 mg/dl 30
minutes after initiation of IV therapy,
repeats the bolus dose and refers to
higher center
19 Provider performs management of hyperbilirubinemia in newborn
19.1 Identifies neonatal
hyperbilirubinemia 19.1.1
Identifies neonatal hyperbilirubinemia
through history (previous baby with
jaundice, G6PD deficiency, Rh
incompatibility), clinical picture of
jaundice (appears in first 24 hours of
life or infant shows symptoms or signs
of a serious illness), and serum bilirubin
level. Jaundice (Total serum bilirubin
(TSB) is > 18 mg/dL or rises by > 5
mg/dL/day)
CEmONC
19.2 *Manages neonatal
hyperbilirubinemia
19.2.1
Begins phototherapy in cases of
serious jaundice as per serum bilirubin
level or clinical condition ( Day 1: on
any part of the body, Day 2: on arms
and legs, Day 3: on hands and feet)
*Only at facilities
where specialist
care for
newborn or
SNCU is
available 19.2.2
Continues phototherapy if serum
bilirubin level is at or above risk factor
level (Day 2: 13mg/dl, Day 3:
16mg/dl, Day 4 and after: 17 mg/dl).
Discontinues phototherapy below
these levels
100 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
(C-Section Standards)
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
(Y/N
)
20 Provider makes proper preparation and adheres to standard procedure and technique of C‐Section
20.1 Makes correct indication
and ensures general
preparation for C‐section
20.1.1
Decides upon the need for C-section
based on indications and mentions
indications in the mother records
CEmONC
20.1.2
Ensures informed consent has been
obtained for the C-section (where
appropriate and possible, obtains signed
written consent from mother to proceed)
CEmONC
20.1.3
Facilitates appropriate pre-anesthetic
check-up including necessary lab tests
of pregnant woman
CEmONC
20.1.4 Ensures counselling on PPFP method and
provides as per request CEmONC
20.2
Adheres to standard
procedure and protocols for
conducting C-section
20.2.1 Prepares the woman for the C‐Section,
inserts an IV line and starts IV fluids CEmONC
20.2.2 Ensures a single dose of prophylactic
antibiotics 15-60 minutes before surgery CEmONC
20.2.3 Correctly performs all steps of the
C-section to deliver the baby (babies) CEmONC
20.2.4 Correctly performs AMTSL and ENBC CEmONC
101 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification Criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC Only/
BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y/N
/NA
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
(Y/N
)
21 Provider ensures appropriate postoperative monitoring course and postnatal care for the mother
21.1
Correctly monitors
postoperative course and
ensures postnatal care for
the mother
21.1.1
Monitors vitals, vaginal/surgical site
bleeding and contraction of uterus and
urine output
CEmONC
21.1.2 Ensures breastfeeding within 1 hour
after delivery CEmONC
21.1.3 Ensures mothers are mobilized within
6-12 hours after surgery CEmONC
21.1.4 Records relevant information in the
mother’s records CEmONC
22 Provider reviews clinical practice related to C-section at regular intervals
22.1
Ensures classification as per
Robson’s criteria and
reviews indications and
complications of C-section
at regular intervals
22.1.1
Ensures that all C‐section cases are
classified as per the modified Robson’s
criteria and rates of different categories
are monitored
CEmONC
22.1.2 Reviews all cases of induction and
C-section through a clinical audit CEmONC
22.1.3 Ensures that rate of complications of
C-sections are periodically monitored CEmONC
102 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Post Natal Care Standards
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y|
N/N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1 Provider ensures adequate postpartum care package is offered to the mother and newborn
1.1 Ensures at least 4 postpartum
visits for the mother
1.1.1
Ensures minimum 4 postpartum visits for
the mother: after discharge at 2-3 days
(If discharged early), 7-14 days, 6 weeks
and 6 months after delivery (or as per
national guidelines)
BEmONC
UPWARDS
1.1.2
Prepares postpartum visit schedule and
shares written record with the mother
and her family
BEmONC
UPWARDS
1.1.3 Ensures additional 2 to 3 visits in cases of
babies with any complication
BEmONC
UPWARDS
1.2
Conducts proper physical
examination of mother and
newborn
1.2.1
Conducts mother’s examination: breast,
perineum for inflammation; status of
episiotomy/tear suture; lochia; calf
tenderness/redness/swelling; abdomen
for involution of uterus, tenderness or
distension
1.2.2
Conducts newborn’s examination:
assesses feeding of baby; checks
weight, temperature, respiration, color
of skin and cord stump
1.3
Identifies and appropriately
manages maternal and
neonatal sepsis
1.3.1 Checks mother's temperature
BEmONC
UPWARDS
1.3.2 Gives correct regimen of antibiotics
BEmONC
UPWARDS
103 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y|
N/N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
1.3.3 Checks baby’s temperature and other
looks for other signs of infections
BEmONC
UPWARDS
1.3.4 Gives correct regime of
antibiotics/refers for specialist care
BEmONC
UPWARDS
1.4
Identifies and appropriately
manages postpartum
maternal depression
1.4.1 Makes correct diagnosis of postpartum
maternal depression after ruling out
postpartum blues based on history
BEmONC
UPWARDS
1.4.2 In cases of postpartum blues, provides
emotional support and counsel’s family
on the condition. Follows up in 2 weeks,
and refers for specialist care if required
BEmONC
UPWARDS
1.4.3 In cases of postpartum depression,
provides emotional support and refers
for specialist care
BEmONC
UPWARDS
1.5 Ensures to offer FP services
1.5.1 A basket of choice of PPFP services is
available at the facility
BEmONC
UPWARDS
1.5.2 Provider is trained for PPFP services
being offered at the facility
BEmONC
UPWARDS
2 Provider counsels the mother on care for herself and her baby
2.1 Counsels mother on care of
herself and the baby
2.1.1 Counsels on danger signs of mother and
baby
BEmONC
UPWARDS
2.1.2 Counsels on exclusive and on demand
breast feeding to mother
BEmONC
UPWARDS
2.1.3
Counsels on the importance of
maintaining hygiene (hand hygiene,
perineal hygiene)
BEmONC
UPWARDS
104 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S. No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and Sources
(Y/N/NA)
Comments
Applicability
(ANC
Only/BEmONC/
CEmONC)
Ob
serv
atio
ns
Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
Y|
N/N
A
# C
he
ck
ed
# P
rac
tic
ed
(Y/N
)
(Y/N
)
2.1.4
Counsels on importance of adequate
nutrition for mother and growth
monitoring for baby
BEmONC
UPWARDS
2.1.5 Counsels on postnatal exercises
2.2
Counsels on return to fertility,
healthy timing and spacing
of pregnancy and PPFP
2.2.1 Counsels on RTF, HTSP and PPFP
BEmONC
UPWARDS
2.3 Counsels on immunization for
the newborn 2.3.1
Counsels on importance of complete
immunization and links them to
immunization services
BEmONC
UPWARDS
105 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Input Standards
S.
No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and
Sources (Y/N/NA)
Comments
Applicability (ANC
Only/BEmONC/
CEmONC) Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
1 Adequately resourced and properly organized labor room is available
1.1
Adequately resourced and
well organized labor room
is available
1.1.1
Adequate number of labor tables are
available in labor room (as per the
delivery load: 1 for < 20, 2 for 20-99,
4 for 100-199, 6 for 200-499, use
formula for calculation* for > 500
deliveries per month) *Formula for calculation = {(Projected
labor events in a year)*(Average length of
stay)}/ {(365)*(Occupancy rate)}
BEmONC Upwards
1.1.2
Adequate space is available in labor
room for placement of required labor
tables (labor tables have a distance
of at least 3’ from the side wall, at
least 2’ from head end wall, and at
least 6’ in between two tables)
1.1.3
Adequate privacy is maintained in
labor room through use of
partition/curtains
BEmONC Upwards
1.1.4 Adequate facility (chair/stool) for birth
companions is available BEmONC Upwards
1.1.5
Adequate number of sterilized delivery
trays as per the delivery load are
available (at least 2 per labor table)
BEmONC Upwards
1.1.6 Functional NBCA is available in the
labor room (Box 14) BEmONC Upwards
106 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S.
No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and
Sources (Y/N/NA)
Comments
Applicability (ANC
Only/BEmONC/
CEmONC) Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
1.1.7
NBCA is in the labor room with easy
accessibility from the labor tables (if
required, can be accessed from labor
tables within 5 seconds) and is open
on three sides for ease of movement
BEmONC Upwards
1.1.8 Labor room has adequate availability
of all the necessary supplies (Box 15) BEmONC Upwards
1.1.9
Functional toilet and washing area
with 24-hour running water supply is
available
BEmONC Upwards
1.1.10 Labor room has adequate lighting,
ventilation and temperature control BEmONC Upwards
2 Adequately trained human resources are available in appropriate number
2.1 Adequately trained human
resources are available in
appropriate number 2.1.1
Adequate SBA trained staff is
available for conducting normal
vaginal deliveries (as per delivery
load: 2 nurses for < 100, 4 for 100-200,
8 for 200-500 and 10 for > 500
deliveries per month)
BEmONC Upwards
2.1.2
Adequately trained personnel are
available for conducing assisted
vaginal deliveries
BEmONC Upwards
2.1.3 ObGyn/Specialist is available for
complication management BEmONC Upwards
2.1.4 ObGyn/appropriately trained staff is
available for conducting C-section CEmONC
107 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
S.
No. Standard Verification criteria
Re
spo
nse
(Y
/N/N
A)
Triangulation and
Sources (Y/N/NA)
Comments
Applicability (ANC
Only/BEmONC/
CEmONC) Ca
se r
ec
ord
s
Pro
vid
er
inte
rvie
w
Ph
ysi
ca
l
ve
rific
atio
n
# C
he
ck
ed
# P
rac
tic
ed
( Y
/N )
( Y
/N )
2.1.5 Anesthetist is available for performing
C-sections CEmONC
2.1.6 Adequately trained support staff is
available as per the delivery load BEmONC Upwards
3 Operation theatre is adequately equipped for conducting C-Section
3.1 Operation theatre is
adequately equipped for
conducting C-Section
3.1.1
Number of OT tables in the OT is
appropriate as per the C-section
delivery load
CEmONC
3.1.2 Adequate supplies and equipment
are available in the OT for C-section CEmONC
3.1.3 Anesthesia tray with functional Boyle's
apparatus is available CEmONC
3.1.4 OT has adequate lighting, ventilation
and temperature control CEmONC
3.1.5
OT complex has provision for
separate washing area with 24-hour
running water supply
CEmONC
3.1.6 OT complex has functional toilet and
staff resting/changing area CEmONC
3.1.7 Functional newborn care area is
available in the OT (Box 14) CEmONC
3.1.8
Adequate supplies and equipment are
available for conducting advanced
adult/newborn resuscitation
CEmONC
108 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Annexure 3: Boxes with Technical Details of Practices
Covered Under Key Standards
Box 1: Appropriate surgical and obstetric history
Review of clinical history of the woman in labor of the woman in labor
Danger symptoms/
signs of labor
Vaginal bleeding
Rupture of membranes
Convulsions
Severe headache and
blurred vision
Severe abdominal pain
Respiratory difficulty
Fever
Obstetric history
Number of pregnancies
Number of abortions
Number of normal deliveries
Number of caesarean sections,
forceps, or vacuum
Any intraabdominal surgeries
Number of stillbirths
Number of children alive
Number of newborns who died
during the first month
Number of children who died
after first month
Date and outcome of the last
pregnancy
Questions about current labor
When the painful regular
contractions began
How frequently they are
occurring
If her “bag of waters” broke:
when, what colour, and what
smell it had
Whether she feels the baby’s
movements
Whether she has any doubts
or concerns about her labor,
and responds using easy-to-
understand language
Medical history
Existing conditions:
Cardiovascular disease (eg. hypertension, rheumatic heart disease)
Other conditions (eg. kidney disease, diabetes, thyroid, hematological or autoimmune disorders,
epilepsy, malignancy, severe asthma, HIV, hepatitis B or hepatitis C infection)
Psychiatric disorders, Obesity or underweight and Female genital mutilation
Lifestyle considerations -history of alcohol and drug misuse
Mental Health and psychosocial factors
Experience in previous pregnancies
Recurrent miscarriage
Preterm birth
Pre-Eclampsia/Eclampsia
Rh Incompatibility
Any Uterine surgery
Ante and Postpartum hemorrhage
Puerperal psychosis
Four or more previous births
Stillbirth or neonatal death
Small or large for gestational age baby
Baby with congenital abnormality
Source – adapted from NICE (2008)
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 109
Box 2
Steps for PV examination
Do P/V examination only when required/indicated to minimize the infection
Maintain privacy and dignity of women at all times
Ask woman to empty her bladder
Wash the hands properly before & after each vaginal examination
Wears plastic apron and surgical gloves
Explains the woman about the procedure & always take consent before doing it.
Cleans perineum with antiseptic swab, discards the soiled swab in yellow container
Separate labia with the non-examining hands
Uses middle & index finger of Right/Left Hand and inserts them into vagina at 12’ O Clock -6’ O clock
position
Judges the dilatation of cervix-in cms
Assesses the adequacy of the pelvis by noting well curved sacrum and inability to reach both Ischial
spines at the same time
Removes gloves and puts them into 0.5 % chlorine solution
Informs the woman about the progress of labor
Records the information on the partograph, if cervical dilatation is 4cm and above
Box 3
Management of Anemia
Moderate anemia (Hb 7-11.5 g/dl):
Give iron 120 mg once daily and folic acid 400 mcg
once daily for three months
If woman is in the 2nd or 3rd trimester, give
anthelmintic: Mebendazole 500 mg stat orally
Advise about nutrition: animal proteins, legumes,
dark green vegetables, and sources of vitamin C,
IPTp-SP and use of ITNs
Severe anemia (< 7 g/dl):
Refers/admits the woman to the hospital
for evaluation
Gives iron 120 mg daily and folic acid 400
mcg daily
Advises to continue taking FeFo for three
months after delivery
Box 4
Immediate Management of Severe pre-eclampsia/ Eclampsia
MgSO4 is the drug of choice for prevention and control of eclampsia seizure
MgSO4 is a very safe drug with very little side effects. Toxicity due to MgSO4 is rare and can be given
safely even by midwives.
First dose of MgSO4 at peripheral health facility is 5-5 gm of 50% (w/v) in each buttock deep IM.
Immediate referral should be made to ensure that the client reaches higher facility within 2 hrs
At higher facility loading dose of MgSO4 is 4 gm 20% IV (8 ml MgSO4+12 ml of NS/DW in 20 ml syringe
in 5-10 minutes) followed by 5-5 gm 50% in each buttock deep IM with 1 ml of 2% Xylocaine
Continue maintenance dose of MgSO4- 5 g deep IM with 1 ml of 2% Xylocaine in alternate buttocks
every four hours, for 24 hours after birth/last convulsion, whichever is later
Monitor vital signs (pulse, blood pressure, respiration), reflexes, urine output and fetal heart
Toxicity signs- Watch for toxicity signs before every maintenance dose
Urine output less than 25 to 30 ml/hour
Absent knee jerk (DTR)
Respiratory rate <16/minute-
Withhold next dose in case of presence of any toxicity sign. Give antidote – Inj. Calcium gluconate
10 ml 10 % in 10 minutes slow IV for respiratory toxicity
110 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Box 5
Anti-Hypertensive in management of severe Pre-eclampsia/Eclampsia
Anti-Hypertensive need to be given if Diastolic BP >110 mm Hg
Target should be to maintain diastolic BP between 90-100 mm Hg
In case of severe Pre-eclampsia, use of tab Nifedipine or Inj. labetalol is recommended for initial
control of BP
There is no role of diuretics as anti-hypertensive
There is no preferred choice of anti-hypertensive and drugs can be used as per the availability and
experience of the provider.
Start tab Nifedipine as 10 mg stat and can be repeated after 30minutes if BP is not controlled.
Maintenance doses can be given as 10 mg 8 hrly (maximum 80 mg/day). However, Nifedipine should
not be given sub-lingual
Or, Start Inj. Labetalol 20 mg IV bolus and repeat 40 mg IV after 10 minutes if BP is not controlled.
Repeat 80 mg every 10 minutes (Maximum 220 mg/day) with cardiac monitoring till BP is controlled.
Maintenance dose is tab Labetalol 100 mg 12 hrly
Continue BP monitoring
Box 6
Management of Syphilis in Pregnancy
Every pregnant woman to be screened for syphilis as early as possible, preferably in first trimester.
Women who are at high risk for syphilis, should be screened again in the third trimester or at the time
of delivery
Ensure institutional delivery at (FRUs/higher level institutions) of all syphilis-positive pregnant women
Testing of spouse/partner of syphilis-positive women should be mandatory followed by treatment as
per protocol for those found positive
For management of early stage (primary and secondary syphilis of <2 years’ duration; RPR titre< 1:8
approx) syphilis, A single intramuscular
Injection of 2.4 million IU benzathine benzyl penicillin (Drug of choice). If client is allergic to penicillin,
Erythromycin, 500 mg orally, QID for 15 days
OR Azithromycin, 2 gm orally as a single dose can be given
For management of Late stage (tertiary > 2 years or unknown duration, RPR titer>1:8 approx.) syphilis,
A total of three intramuscular injections of 2.4 million IU benzathine benzyl penicillin once a week for 3
weeks should be given. Alternatively, Erythromycin, 500 mg orally, 4 times daily for 30 days can also
be given if client is allergic to penicillin
Benzathine penicillin injection is the only effective treatment for preventing congenital syphilis,
perinatal deaths, stillbirths and preterm deliveries in pregnant women with syphilis.
For the treatment of syphilis during pregnancy, NO PROVEN ALTERNATIVES TO PENICILLIN exists.
All infants of pregnant women treated with a non-penicillin regimen should be treated at birth as if
mother was not sufficiently treated.
Alternative to penicillin should be considered ONLY for those syphilis positive pregnant women who
have a history of severe penicillin allergy (e.g. anaphylaxis)
Erythromycin estolate is contraindicated because of drug-related hepatotoxicity. Only erythromycin
base or erythromycin ethyl succinate should be used.
Follow-up-should be done during postnatal care (PNC) visits and in addition, at 6 months and 24
months after the treatment is administered
The partner or spouse should be treated with the same regimen.
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 111
Box 7
Treatment regimens for uncomplicated malaria
When symptoms of malaria are present but there is no evidence of any vital organ being seriously
affected, malaria is said to be 'uncomplicated'. According to the 2010 Guidelines for treatment of
malaria issued by the government of India, the treatment regimens to be followed in pregnant women
with uncomplicated malaria are as follows:
P. falciparum infection
First trimester of Pregnancy: Quinine 10 mg/kg of body weight, three times a day for 7days [11].
It is important to note that Quinine can reduce Blood Sugar, so any woman taking Quinine must eat
something before or immediately after the Quinine pills.
Second or third trimester of pregnancy: ACT or Artemisinin Combination Therapy.
Drugs Number of tablets
Day 1 Day 2 Day 3
Artesunate 50 mg 4 4 4
Sulfadoxine 500 mg+
Pyrimethamine 25 mg 3 0 0
P. vivax infection
As per local guidelines.
Box 8
Conditions that lead to preterm birth:
Antepartum hemorrhage
Preterm premature rupture of membranes
Severe Pre-eclampsia
Infections in the vaginal canal
Over distension of the uterus
Antenatal corticosteroids to be used:
Injection Dexamethasone 6mg IM 12 hourly – total of 4 doses or
Injection Betamethasone 12 mg once a day – total 2 doses
Box 9
Parameters on Partograph:
To measure every 30 mins:
Fetal heart rate
Number of Contractions in a 10 minute interval
Strength of contraction
To measure every 4 hours:
Maternal Blood pressure and Pulse rate
Maternal Temperature
Cervical dilatation (through a PV examination)
Color of liquor
Medications – as provided
Box 10
112 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Birth kit and infection prevention materials:
Sterile tray
Two hemostats (clamps); One scissors
One cord clamp or sterile tape or sterile tie
Four sterile towels (two for baby and two for mother)
Sterile gauze to clean baby’s mouth and nose if needed
One syringewith10IU of oxytocin or misoprostol 600 mcg
Two pairs of sterile or HLD gloves
One plasticcontainerwith0.5%chlorine solution for decontamination
One plastic container with a plastic liner to dispose the placenta
One plastic container with a plastic liner for medical waste (gauze, etc.)
One sharps container at point of use to dispose of needle and syringe
One leak proof container to dispose of soiled linen
Clean plastic or rubber apron and face shields (or mask and goggles)
Closed‐toes hoes
Episiotomy kit (for cases who require episiotomy)
Privacy conditions for the woman:
Ensures that she remains covered with a sheet (as appropriate)
Separates the area with curtains, sheets, or screens, as appropriate
Ensures that the minimum number of individuals are present during birth (the provider/s attending the
birth and a companion—the individual chosen by the woman)
Box 11
Indication for perform episiotomy:
Breech, shoulder dystocia, forceps, vacuum, poorly healed 3rd or 4th degree tear, FGC or fetal
distress.
Assistance in delivering the baby:
Quickly palpates to determine cord around the neck; if it is loose, slides it over the baby’s head; if it is
very tight, clamps it in two places and cuts it before unravelling it from around the baby’s neck
Allows spontaneous external rotation of the head without manipulation
Carefully takes the baby’s head in both hands and applies gentle downward traction until the
anterior shoulder has emerged (no neck holding) and guides the baby’s head and chest upward
until the posterior shoulder has emerged, OR allows the baby pops freely protecting only the head of
the baby, if the woman is in the vertical position
Holds the baby by the trunk and places it onto a dry towel/cloth on the mother’s abdomen
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 113
Box 12
Indications for Induction of labor:
Induction of labor is recommended for women who are known with certainty to have reached 41
weeks (> 40 weeks + 7 days) of gestation. (Does not apply to settings where gestational age is not
reliably estimated).
Induction of labor is recommended for women with pre-labor rupture of membranes at term.
IUD.
Inductions are not recommended for:
Induction of labor is not recommended in women with an uncomplicated pregnancy at gestational
age less than 41 weeks.
If gestational diabetes is the only abnormality, induction of labor before 41 weeks of gestation is not
recommended (except in uncontrolled diabetes and placental insufficiency).
Induction of labor at term is not recommended for suspected fetal macrosomia.
Inductions should not be performed solely because of patient or care provider preference.
Ref: WHO recommendations for induction of labor SOGC Clinical Practice Guideline, No. 296,
September 2013 (Replaces No. 107, August 2001) Induction of Labor
Recommended methods/medications for induction:
Low dose Prostaglandins E2 (cervical and vaginal) is effective agents of cervical ripening and
induction of labor for an unfavourable cervix.
(Intravaginal prostaglandins E2 is preferred over intracervical prostaglandins E2)
Prostaglandins are not to be used in settings of vaginal birth after caesarean section.
If prostaglandins are not available, intravenous oxytocin alone should be used for induction of labor.
Amniotomy alone is not recommended for induction of labor.
Immediately after the initiation of intravenous oxytocin, it is advisable to monitor closely the
oxytocin infusion rate, response of the uterus to oxytocin, and fetal heart rate.
Oral misoprostol (25 μg, 2-hourly) or vaginal low dose misoprostol (25 μg, 6-hourly) is recommended
for induction of labor.
Misoprostol is not recommended for women with previous caesarean section.
In the third trimester, for women with a dead or anomalous fetus, oral or vaginal misoprostol is
recommended for induction.
Intracervical Foley catheters are acceptable agents that are safe both in the setting of a vaginal
birth after Caesarean section and in the outpatient setting.
The combination of balloon catheter plus oxytocin is recommended as an alternative method
when prostaglandins (including misoprostol) are not available or are contraindicated.
Sweeping membranes is recommended for reducing formal induction of labor.
Ref: WHO recommendations for induction of labor/SOGC Clinical Practice Guideline, No. 296,
September 2013 (Replaces No. 107, August 2001) Induction of Labor
114 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Box 13
Care and information to an HIV positive mother and her exposed infant
ARVs for mother and baby
All infants born to HIV
positive mothers should
receive a course of
medication for PMTCT,
which is linked to the
drug regimen that the
mother is taking and the
infants feeding method:
Breastfeeding
The infant should
receive once-daily
NVP from birth until
age 6 weeks.
Not breastfeeding
The infant should
receive once-daily
NVP (or twice-daily
AZT) from birth until
age 4–6 weeks.
The mother should be
given Option B+ drugs
for life (see standards
10)
Factors that increase risk
of HIV transmission during
breast-feeding
New HIV infection
during the
breastfeeding period
Mixed feeding (breast
and other feeds)
Breast problems
(mastitis, breast
abscesses, cracked
nipple)
Oral disease in the
infant
Preterm and low birth
weight infants
Maternal nutrition
Future care plan for HIV
positive women
Discusses ongoing
support of counselling
on infant feeding
Provides
Cotrimoxazole for OI
prophylaxis
Discusses need for
Early Infant Diagnosis
at 6 weeks
Discusses plans for
early access to
medical care and
treatment for mother
and infant
Fixes appointment
date for both the
mother and the baby
that coincides with
immunization
schedule
Information on chosen method of infant
feeding
Benefits of exclusive breastfeeding:
Complete diet for infant; Protects against
infectious diseases (diarrhea and
pneumonia)
Protects against allergies in babies;
Reduces risk of maternal hemorrhage
Acts as a natural method of birth spacing
for the first six months
Is free, pre-warmed, clean and safe, and
immediately ready on demand
Gives the mother control; Offers the first
bonding between mother and baby
Risks:
Increases risk of HIV transmission to the
exposed infant and young child
Increased demand on mother’s additional
stores which might be already
compromised
Tips for exclusive breast feeding
Tells the woman to continue exclusive
breastfeeding for at least 6 months
Tells the woman to seek medical advice in
case of breast problems
Encourages the woman to maintain breast
health
Observes the positioning and attachment
of baby and demonstrates proper
positioning and attachment if needed
Tells the woman to avoid pre-lacteal feeds
and mixed feeding
Benefits of replacement feeding
Reduces the risk of HIV transmission to the
exposed infant and young child
Reduces demand on mother’s additional
nutrition stores which might be already
compromised
Risks of replacement feeding
Increases risk of infectious disease in the
infant (contaminated milk or equipment
causes diarrhea and may lead to
malnutrition and death)
It is difficult to ensure cleanliness of feeding
equipment
Formula offers no protection against
infection or allergies as it does not contain
the anti-infective agents that are normally
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 115
Care and information to an HIV positive mother and her exposed infant
passed from the mother to the baby
High costs
Over dilution or under dilution may result in
malnutrition
Formula supplies cannot be guaranteed
Tip for replacement feeding
Ensures that woman has decided to not
breastfeed and to rather use replacement
feeding
Assesses affordability, feasibility,
acceptability, sustainability and safety of
replacement feeding
Demonstrates preparation of replacement
feeding from formula.
Asks the mother to repeat the information
and to provide return demonstration
Emphasizes to the mother the importance
of not breastfeeding at all if she has
chosen this method
Explains the risks of bottle feeding and
advises mother to avoid it and use cup:
Using clean dry cup
Not keeping the cup with milk open
Wash the cup after use
116 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Annexure 4: Key Resources Referred During
Development of Standards of Care*
Antenatal standards
1. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy, WHO (2013); http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf
2. Antenatal Care, Opportunities of Africa’s Newborns- Practical data, policy and programmatic support for newborn care in Africa, WHO (2010); http://www.who.int/pmnch/media/publications/oanfullreport.pdf
3. Guideline: Calcium supplementation in pregnant women. WHO (2013); http://apps.who.int/iris/bitstream/10665/85120/1/9789241505376_eng.pdf
4. The diagnosis and treatment of malaria in pregnancy; Royal College of Obstetricians and Gynaecologists (April 2010); https://www.rcog.org.uk/globalassets/documents/guidelines/gtg54bdiagnosistreatmentmalariapregnancy0810.pdf
5. Guidelines for Ante-natal care and skilled attendance at birth by ANMs and LHVs, Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) (2005); http://www.indiannursingcouncil.org/pdf/SBA-MODULE-Guideline-for-Antenatal-Care.pdf;
6. National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus, MoHFW (December 2014); http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/National_Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_Mellitus.pdf ;
7. Screening for Syphilis during pregnancy-Technical and operational guidelines, MoHFW (December 2014); http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/Syphilis_Doc_Low-res_5th_Jan.pdf
8. National Guidelines for Deworming in Pregnancy, MoHFW, GOI (December 2014); http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/_National_Guidelines_for_Deworming_in_Pregnancy.pdf
9. Guidelines for Ante-natal care and skilled attendance at birth by ANMs/LHVs/SNs, MoHFW, GOI (April 2010); http://www.nhp.gov.in/sites/default/files/anm_guidelines.pdf
Intrapartum and Immediate postpartum standards
1. Managing Complications in Pregnancy and Childbirth- A guide for midwives and doctors, WHO(2007); http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 117
2. WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WHO(2011); http://apps.who.int/iris/bitstream/10665/44703/1/9789241548335_eng.pdf
3. WHO recommendations for the prevention and treatment of postpartum haemorrhage, WHO(2012) ;http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
4. WHO recommendations for Induction of Labour (2014); http://apps.who.int/iris/bitstream/10665/44531/1/9789241501156_eng.pdf
5. WHO recommendations for Augmentation of Labour(2014); http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf
6. Guidelines on basic Newborn Resuscitation, WHO(2012); http://apps.who.int/iris/bitstream/10665/75157/1/9789241503693_eng.pdf
7. WHO recommendations on interventions to improve preterm birth outcomes, WHO (2015); http://apps.who.int/iris/bitstream/10665/183037/1/9789241508988_eng.pdf
8. Guidelines For The Management Of Breech Presentation Including External Cephalic Version (ECV),NHS (2014); http://www.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11198&type
9. Green top guideline no. 42 Shoulder Dystocia, Royal College of Obstetricians and Gynaecologists (March 2012); https://www.rcog.org.uk/globalassets/documents/guidelines/gtg42_25112013.pdf
10. Threatened Preterm Birth Care A Global Curriculum(2015); http://www.mcsprogram.org/wp-content/uploads/2015/12/Grenier-1.pdf
11. Managing Puerperal Sepsis-Midwifery education module 4, WHO; http://www.who.int/maternal_child_adolescent/documents/4_9241546662/en/
12. Early essential Newborn care, WHO(2014); http://iris.wpro.who.int/bitstream/handle/10665.1/10798/9789290616856_eng.pdf
13. DAKSHATA- Empowering Providers for Improved MNH Care during Institutional Deliveries; Ministry of Health and Family Welfare, Government of India, (April 2015)
14. Guidance Notes on Use of Uterotonics during labour; MoHFW, GOI, (September 2015)
15. Facility based Newborn care operational guide, MoHFW, GOI(2011); http://164.100.130.11:8091/rch/FNBC_Operational_Guideline.pdf
C-section Standards 1. Jhpiego SBMR Global Performance Standards, Sept 2014
118 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Postnatal Standards
1. Managing Complications in Pregnancy and Childbirth- A guide for midwives and doctors, WHO(2007); http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf
2. Pregnancy, Childbirth, Postpartum and newborn care A guide for essential practice, WHO(2006); https://www.k4health.org/sites/default/files/3%20WHO_guide%20for%20essential%20practice%20PCPNC%202006.pdf
3. Postnatal Care, Opportunities of Africa’s Newborns-Practical data, policy and programmatic support for newborn care in Africa, WHO (2010); http://www.who.int/pmnch/media/publications/oanfullreport.pdf
4. DAKSHATA- Empowering Providers for Improved MNH Care during Institutional Deliveries; Ministry of Health and Family Welfare, Government of India, (April 2015)
*Not in chronological order
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Annexure 5: S0Ps for using Standards-Based
Assessment Tool
About Tool A Standards Assessment tool will be used to collect data to assess the practices followed at individual facility at regular intervals (recommended once every 6 months).
Contents of Tool Tool comprises of the following sections:
Facility details/Identifiers
Standards, Components & Verification criteria
Triangulation methods Facility Details/Identifiers:
Data Element Explanation Response
State State name where facility exists. Also
name of province/country can be
added if applicable
Write name of the State
District District Name where facility exists Write name of the district
Facility Name Name of the facility Write name of the facility
Provider/In
Charge name
Name of Provider/ In Charge name Mention name of provider/ In charge
(Labor room) of facility
Date of
assessment
Date when assessment is done in
DD/MM/YYYY format (e.g. 05/09/2012)
Write the date when assessment is done
for the facility
Name of the
assessor
Name of the person(s) who performed
the assessment.
Write name of the assessor(s)
Snapshot of Tool
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The number of standards in the tool varies depending on the type of facility. Each standard contains a set of components which should be followed in order to meet the standard. Each component can be verified by verification criteria, which the assessor triangulates by either directly observing clients or through demonstration on models, or triangulated through case records, providers’ interviews and physical verification of the instrument(s)/equipment required to perform a practice. The cells of relevant triangulation methods for each verification criteria have been kept open for data entry, while the other methods which are not relevant for criteria have been shaded dark. The table below explains about each verification criteria and the type of response that should be entered
Triangulation
Criteria Explanation Response
Observation Observation of practices at facility.
This can be done either by directly observing
the practice of provider on clients (if
available) or asking them to demonstrate skills
on models.
If provider correctly performs the skills
according to verification criteria, mark it as ‘Y’.
If provider is not able to practice correctly,
then mark as ‘N’.
If there are no cases for observation, the
response will be NA and other triangulation
methods will be applied.
Observation of any practice performed by
provider has most priority. If the case is
available at facility to observe, there is no
further need to triangulate that practice
through other methods
Y/N/NA
Case records Triangulation of relevant practice through
case records should be done if the
observation is not possible.
At least 5 case records need to be checked.
Number of case records
checked
Number of case records
indicating the performance of
practice
Providers
interview Providers` knowledge is assessed by asking
questions relevant to performing the
practice/skill to be verified.
(E.g. Questions to ask for triangulating the
recording BP at admission: What examinations
you perform at time of admission? Probe
further if BP is measured at admission, also ask
to perform the procedure if performed)
Attempt should be made to interview
maximum number of providers.
Y/N
Physical
Verification Availability of instruments/supplies is checked
physically at intended point of use.
If available mark ‘Y’, if not available mark ‘N’.
Y/N
Decision rules:
Decision rule for triangulation criteria:
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 121
If verification is possible by means of observation, no further triangulation is required. The relevant verification criterion is considered as ‘Y’ if the practice/skill observed is being correctly performed on the client as per the standards. If observation is not possible, then go for further triangulation methods as below.
For case records, 50% or more of checked case records should indicate that the practice is performed at the facility.
For Provider interview, all provider(s) interviewed should correctly respond for the verification criteria to be considered as ‘Y’.
For physical verification, the instruments/supplies should be physically checked at intended point of use.
For a verification criteria to be considered as ‘Y’, all relevant triangulations for that particular criteria should indicate the performance of that practice or skill by the provider.
For a standard to be considered as ‘Y’ in the Response column, all the verification criteria under the practice should have score of ‘Y’ in the Score column.
A standard will be scored either 0 or 1 depending on the responses. If the responses of all practices performed under a standard are ‘Y’, then the standard will score 1 point. If one or more responses for practices under a standard is ‘N’, the standard scores 0 points.
122 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Example of decision rule
Interpretations
Verification criteria 1.1.1: Observation was possible and the practice under observation was performed hence the score = ‘Y’. No further triangulation was required.
Verification criteria 1.4.1: Observation was possible and practice under observation was not performed hence the score = ‘N’. No further triangulation was required.
Verification criteria 1.5.1: The instrument could be physically verified at intended point of use, hence the score = ‘Y’.
Verification criteria 1.3.1: Observation was not possible (‘NA’), hence further triangulation was done. a. 5 Case records were checked, out of which 3 indicated practice was performed
(i.e. more than 50%). b. Providers were interviewed and the correct response was obtained.
Since all triangulation methods indicate that practice is being performed at the facility, the score is ‘Y’.
Verification criteria 1.6.3: The instrument could not be physically verifies at intended point of use, hence score = ‘N’.
Verification criteria 1.5.2: Observation was not possible (‘NA’), hence further triangulation was done. c. 5 Case records were checked, out of which 2 indicated practice was performed
(i.e. less than 50%). The practice is negative. d. Providers were interviewed and they gave correct responses.
Since all triangulation methods do not indicate that practice is being performed, the score is ‘N’.
Verification criteria 1.6.1 is ‘N’ ‘since observation was not possible (NA) and provider did not give correct response when interviewed.’
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 123
Standard no. 1 will be scored as 0 as verification criteria 1.4.1, 1.5.2, 1.6.1, 1.6.2 & 1.6.3 are ‘N’.
124 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Annexure 6: Template for Action Planning
State: Facility Type: Assessor Name:
District: Facility Name: Date (dd/mm/yyyy):
S.
No
.
Sta
nd
ard
Un
me
t
Ve
rific
atio
n
Crite
ria
Re
aso
n
An
aly
sis
(Sk
ill G
ap
-1;
Re
sou
rce
Ga
p
– 2
, Pro
toc
ol
Pro
ce
ss G
ap
–
3,
Oth
ers
spe
cify
)
Pla
n o
f
Ac
tio
n
Ad
ditio
na
l
Su
pp
ort
ive
Ac
tio
n
Pe
rso
n
Re
spo
nsi
ble
Tim
elin
e
Summary
Total standards
=
Number of Standards
Observed = _______
Number of Standards
Achieved = ______
% Standards Achieved =
________
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Annexure 7: Client Case Record Template
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Annexure 8: ANC & PNC Card Template
Registration No.
Name:
Husband Name:
Age:
Address:
Mobile No.
Education:
Religion:
Obstetrics history:
Gravida Parity Abortion Living children
Previous LSCS Yes No
Other complications: _______________________
Lab Tests
Blood group:
HIV:
HBsAg:
VDRL:
Gestational age estimation
LMP : ____/____/________
EDD : ____/____/________
ANC 1 ANC 2 ANC 3 ANC 4
Date:
Gestational Age (in
weeks):
Weight (Kgs):
Vitals
BP:
Pulse:
Temperature:
FHR:
Investigation
Hb:
Urine Sugar:
Urine protein:
Malaria:
USG finding :
Other:
Any complication /
Remarks:
Counselling done:
Calcium
supplementation:
Tetanus Toxoid :
IFA:
Treatment given:
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 143
Postnatal Visit Card
Mother
Registration No.:
Name:
Age:
Type of Delivery:
Husband’s Name:
Address:
Mobile No.
Education:
Religion:
PNC 1 PNC 2 PNC 3 PNC 4
Date:
Vitals
BP:
Pulse:
Temperature:
Breast Examination:
Any complication /
Remarks:
Treatment given:
Counselling on
danger sings:
Counselling on
breast feeding:
PPFP counselling:
Baby
Name:
DOB:
Weight at Birth:
Any complication at Birth:
PNC 1 PNC 2 PNC 3 PNC 4
Date:
Vitals
Temperature:
Pulse:
Respiratory Rate:
Heart Rate:
Weight:
Height
Any complication /
Remarks:
Treatment given:
Immunization:
Kangaroo Mother
Care for small baby:
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Annexure 9: Birthing Register Template
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Annexure 10: Monthly Progress Report Format
Facility: City: State:
Provider name (If applicable): Month and year:
S. No. Data element Numbers in the reporting
month
A Obstetric Services
A1 Total number of normal deliveries in the facility
A2 Total number of assisted deliveries in the facility (Vacuum/Forceps)
A3 Total number of caesarean deliveries in the facility
A4 Number of live births in the facility
A5 Number of still births in the facility
A6 Number of intrauterine deaths in the facility
A7 Number of maternal deaths in facility in the month
A8 Number of new born deaths in facility in the reported month
B Complicated Deliveries Managed
at facility
Referred to
higher
center
B1 Mothers with post-partum hemorrhage
B2 Mothers with sepsis
B3 Mothers with pre-eclampsia
B4 Mothers with eclampsia
B5 Mothers with obstructed labor
B6 Newborns with asphyxia
B7 Number of newborns with sepsis
B8 Number of newborns who were premature births
C Practices
C1 Number of deliveries where partograph was used for monitoring
C2 Number of deliveries where mother’s blood pressure was recorded
at admission
C3 Number of deliveries where mother’s temperature was recorded
at admission
C4 Number of deliveries where oxytocin was given as uterotonic for
active management of third stage of labor
C5 Number of deliveries where misoprostol was given as uterotonic for
active management of third stage of labor
C6 Number of deliveries where baby was dried using clean dry towels
immediately after birth
C7 Number of deliveries where baby was breast fed within 1 hour of
delivery
C8 Number of deliveries where mothers temperature was recorded at
discharge
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S. No. Data element Numbers in the reporting
month
C9 Number of deliveries where baby’s birth weight was recorded
after birth
C10 Number of deliveries where Safe Childbirth Checklist was used
C11 Number of deliveries where baby’s temperature was recorded at
discharge
C12
Number of preterm deliveries (<34 weeks) where antenatal
corticosteroids were administered
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Annexure 11: Process for development of the toolkit
Jhpiego adopted a consultative approach to develop the key elements of the toolkit. Jhpiego organized a side event during the Global Maternal and Newborn Health Conference held in Mexico in November 2015 to first discuss the concept of the toolkit amongst a core group of key stakeholders in quality of care for the private sector. During this consultation, Jhpiego presented an outline of the toolkit. The group participants provided feedback on the structure and applicability of the toolkit. With the intention of building upon the existing resources, Jhpiego did a landscape review of similar existing resources within and outside Jhpiego, including those from WHO, USAID, guidelines from the Government of India, and various professional organizations, as a first step in the process of the development of the toolkit. Available resources were reviewed for applicability to the developing country context. With the background resources, Jhpiego held an international consultation meeting on the toolkit on December 11-12, 2015 in Delhi. The purpose of this meeting intended to initiate the development of a practical toolkit for improving quality of care during childbirth in the private sector, to validate findings from the landscape review, and to gather additional input from partners, various professional bodies, user segments, government representatives, and experts. This consultation was attended by more than 45 participants from India and Uganda, representing development partners working with private sector healthcare providers, private practitioners from FOGSI, representatives from Association of Obstetricians and Gynaecologists of Uganda (AOGU), representatives from Governments of India and Uganda, professional association of obstetricians and nurses, and members of the National Accreditation Board of Hospitals (NABH). Major objectives of the consultation were:
To reinforce and understand specific needs of private sector institutions in developing countries in order to improve the quality of care during childbirth;
To finalize the scope and components of the toolkit for standardizing care during childbirth in private sector institutions;
To define the outline of subcomponents of various toolkit modules; and
To finalize action‐plans and the schedule of activities for the final toolkit. The participants reviewed the needs of the private sector for quality improvement and defined guiding principles for developing the toolkit. Additionally, they determined that the toolkit components should build upon, adapt, and upgrade existing available tools that have been found to be useful in similar contexts. It was also recommended that the toolkit should be user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. To facilitate further discussions, Jhpiego presented a draft outline of the toolkit to the participants which were endorsed by all participants. Subsequently, the participants worked in smaller groups to define the components and sub-components of the toolkit and discussed the details of the proposed standards. One
148 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
Jhpiego staff member was assigned to each group and tasked with the responsibility of coordinating the process of developing the toolkit components. The working groups also developed the plan of action and timelines for content development and finalization in preparation for the next consultation. Following the consultation, based on the recommendations from the groups, Jhpiego prepared drafts of the components of the proposed toolkit, namely a set of quality standards and a customized training course outline, and quality measurement matrices, which were subsequently shared with the respective groups to obtain their feedback and input on the draft versions. As proposed, Jhpiego adopted an iterative approach by incorporating the feedback from the participants on a regular basis to further improve the tools. At each step of developing the toolkit, Jhpiego considered the group’s recommendations to develop one that is user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. Updated drafts of the toolkit components were shared on a regular basis to obtain more input and feedback for further refinement. Additionally, Jhpiego continued developing a repository of references and training material in order to complement the toolkit. The primary focus during this period was to finalize the set of clinical standards which would further help finalize the other two components, specifically the course outline and metrics. As agreed upon in the first consultation, the final draft of the clinical standards was shared with the larger group by mid-February 2016 to obtain their feedback and further input by the end of February. The responses from the participants were considered and incorporated during the brainstorming sessions for refinement of the standards and other components prior to the second consultation. On March 30-31, 2016, Jhpiego, in partnership with the FOGSI, hosted a second consultation on the toolkit for standardizing care during childbirth in private sector institutions with the following objectives:
To share the latest version of the toolkit with the stakeholders;
To finalize the content of various components of the toolkit;
To finalize an action plan with the schedule of activities for field testing of the toolkit; and
To finalize the action plan and way forward for final dissemination. Similar to the first consultation, it included 48 participants representing the private practitioners from FOGSI and AOGU, representatives from the Governments of India and Uganda (GoI and GoU), various development partners working with the private sector healthcare providers in India and Uganda, and members of the National Accreditation Board of Hospitals (NABH). Jhpiego presented the latest version of the toolkit to the participants. The group leaders, in their presentations, unfolded the layout and summary of various components of the toolkit. The vetting of the technical and clinical content of the toolkit’s sub-components was concluded by the working groups. The last recommendations on various components of the standards were recorded for inclusion in the final draft prior to field testing. The participants also engaged in discussions regarding the operational aspects
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 149
of the toolkit including the methodology for use and Standard Operating Procedures (SOPs), and grouped some striking recommendations for finalizing the way forward for the field testing and the final roll-out plan of the toolkit. The meeting concluded with development of a field testing plan and suggestions for the global dissemination of the toolkit. For the field testing of the toolkit, it was decided that:
Field testing in India will involve selected FOGSI facilities in Uttar Pradesh and Jharkhand. This will be carried out by the four Local Chapters: three in UP and one in Jharkhand (including assessment of at least three facilities: one self-assessment and two external facility assessments). In Uganda, the field testing will be carried out by PACE Uganda and other development partners (10 facilities each).
The user feedback would be collected based on qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, course outline description, and on metric and dashboards.
Jhpiego will also undertake in-house mock training on the ANC and PNC components.
The said field testing would be conducted by April 30, 2016. After the second consultation, input and feedback from the participants was incorporated into the standards, and accordingly, changes were made in the course outline and quality measurement matrices. The finalized version of the toolkit was shared with the group to initiate the field testing along with the qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, the course outline description, and on metric and dashboards. The toolkit was field tested in nine private sector facilities across two states (Uttar Pradesh and Jharkhand) in India. Out of these, Jhpiego facilitated testing in three facilities, and in the rest of the facilities, local FOGSI champions facilitated the testing. Qualitative user feedbacks were collected from the users. One important feedback was to present the standards in simpler forms. One potential solution discussed was to keep the standards and the standards-based assessment form separate (earlier these were presented in a single sheet). Users also recommended slightly modifying the verification methodology for standards-based assessment tool. Course outlines were generally found to be suitable to facility needs. A few content related suggestions were made that were included. Modifications were also suggested in the data collection and collation tools. Jhpiego reviewed these suggestions and discussed them with the group leaders for potential solutions. Most of the design related suggestions were agreed to. Appropriate content suggestions were accepted; however, those that deviated from the normative guidelines were not included in consultation with the group members. Data collection tools and metrics were revised based upon relevant suggestions. The final toolkit was reviewed again for ease of presentation, correct technical content, and inclusion of relevant implementation information.
150 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
List of participants in the toolkit development process
S.No Name Organization
1 Leila Varkey Centre for Catalytic Change
2 Hema Divakar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
3 Sadhana Gupta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
4 Priti Kumar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
5 Nevidita Dutta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
6 Meera Lakhtakia Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
7 Alok Sharma Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
8 Shivi Rawat Hindustan Latex Family Planning Promotion Trust (HLFPPT)
9 Anamika Pandey Hindustan Latex Family Planning Promotion Trust (HLFPPT)
10 Meenakshi Dikshit Population Services International (PSI)
11 Sudhir Maknikar John Snow International (JSI)
12 Dinesh Baswal Ministry of Health and Family Welfare, Government of India
13 P. Krishna Kumari MSD for Mothers India
14 Sai Subhasree
Raghavan Solidarity and Action Against the HIV Infection in India (SAATHI)
15 Varun Solidarity and Action Against the HIV Infection in India (SAATHI)
16 Anita Deodhar Trained Nurses Association of India (TNAI)
17 Evelyn P. Kannan Trained Nurses Association of India (TNAI)
18 Sangamitra Trained Nurses Association of India (TNAI)
19 Sharmila Neogi United States Agency for International Development (USAID)
20 Anuradha Jain United States Agency for International Development (USAID)
21 Mahesh Srinivas Pathfinder International, India
22 Mirazzuddin Ansari Pathfinder International, India
23 Gayatri V.
Mahindroo National Accreditation Board of Hospitals (NABH), India
24 Vikrant Prabhakar ACCESS HEALTH
25 Sujatha Rao ACCESS HEALTH
25 Ajay Gambhir National Neonatology Forum (NNF)
26 Krishan Kumar Population Services International
27 Milly N Kaggwa Program for Accessible Health Communication and Education (PACE),
Uganda
28 Anthony K Mugasa Ministry of Health, Uganda
29 Frank M Kaharuza Association of Obstrticians and Gynaecologists of Uganda (AOGU)
30 Hasifah Nalukwago ProFam UGANDA
31 Mariam Luyiga Program for Accessible Health Communication and Education (PACE),
Uganda
32 Tonny Kapsandui Jhpiego, UGANDA
33 Akhil K. Sangal National Neonatology Forum (NNF), India
34 Miriam Namugeere Ministry of Health, Uganda
35 Parvez Menom Jhpiego, India
36 Sai Barath Jhpiego, India
37 Renu Pandey Jhpiego, India
A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 151
S.No Name Organization
38 Suranjeen Prasad Jhpiego, India
39 Meshach Kujur Jhpiego, India
40 Dinesh Singh Jhpiego, India
41 Rashmi Asif Jhpiego, India
42 Bulbul Sood Jhpiego, India
43 Deepti Singh Jhpiego, India
44 Somesh Kumar Jhpiego, India
45 Vikas Yadav Jhpiego, India
46 Sudharsanam Jhpiego, India
47 Prasad Bogam Jhpiego, India
48 Sunita Dhamija Jhpiego, India
152 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings
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