Study settings, study design and sampling
A structured checklist was used to assess 201 private sector healthcare facilities that offer obstetric care in 24 districts across the states of Maharashtra, Jharkhand and Uttar Pradesh. Uttar Pradesh is the most populous state in India with a population of 199 million. Maharashtra and Jharkhand are 2nd and 13th most populous states in India (out of 28 states) with a population of 112 million and 33 million respectively (21). With respect to performance on maternal health, while Uttar Pradesh and Jharkhand are poor performing states with maternal mortality ratio (MMR) of 165 and 201 respectively, Maharashtra is a better performing state with MMR of 61(22).
Baseline assessments for the Manyata program at these facilities were conducted from November 2016 to March 2017 (year 1 facilities) and from December 2017 to March 2018 (year 2 facilities). The criteria for including private healthcare facilities in the Manyata program are that the facility: 1) is registered with local health authorities, 2) provides maternity services, 3) has an owner or in-charge who is a member of FOGSI, and 4) expresses willingness to participate in the Manyata program by paying a nominal fee and submitting letter of intent to FOGSI.
Study tool
The assessment checklist was based on the standards for improving quality of maternal and newborn care in health facilities by WHO and endorsed by FOGSI (23,24). It includes 16 clinical standards that focus on: patient care during the antenatal period (one standard), the intrapartum period (13 standards), the postpartum period (one standard), and caesarean section (one standard). Each standard includes four or five essential elements and has five or six verification criteria, which ensure the objective assessment of providers’ skills and knowledge.
Assessors recorded “Y” for each verification criterion that the provider or facility met and “N” for unmet criteria. If all of the verification criteria listed under a standard were met, the standard was considered as met and given a score of 1. If any verification criteria were not met, the entire standard was considered unmet and given a score of zero. The facility score was calculated as the total number of standards met; the highest possible score was 16.
Data collection
Manyata Program Officers, who were either nursing professionals or doctors, conducted the baseline assessments. They were oriented and trained on the assessment methodology and technical components of the standards as part of the program’s Training of Trainers (ToT). These three-day ToTs were conducted by the program’s clinical team, which consisted of senior obstetricians with public health experience. Assessments at each facility were usually spread across two days and required 4-6 working hours per day, using a mixed methods approach.
Each verification criterion was assessed using one of the following four methods: 1) direct observation of service providers during skills demonstration on mannequins or during provision of actual care; 2) hospital record reviews to check for the implementation of practices; 3) provider interviews to assess knowledge; or 4) physical verification of the presence of drugs, supplies, functional equipment, and instruments in the labor room. Verification criteria related to provider skills were assessed through observations, those related to provider knowledge were assessed through interviews, those related to routine practices at the facility were assessed through record reviews, and those related to availability of drugs and equipment were assessed through physical verification.
In addition, information on facility characteristics, such as facility type based on the availability of services, average monthly delivery load, availability of human resources, and number of hospital beds, were collected when the facility registered for the Manyata program. For availability of human resources, data on number of qualified nursing staff per facility was collected. Qualified nursing staff refers to those nursing personnel who have undergone formal training under any of the Indian Nursing Council prescribed programs (25).
Data analysis
For the purpose of this analysis, a separate dataset was created by combining the baseline assessment data with the facility characteristics data. Data were cleaned and checked for completeness. We computed the mean number of standards met by the facilities, the proportion of facilities that met each individual standard, and the proportion of facilities that met a set number of standards. We analyzed variations in the mean number of standards met by various facility characteristics and the availability of essential supplies. To identify determinants of the number of standards met by a facility, we conducted a multivariable linear regression analysis, with number of standards met by facilities as the dependent variable and facility characteristics and availability of essential supplies as independent variables. We used independent sample t test and ANOVA for comparing means of two and three subgroups respectively. A p-value of less than 0.05 was considered as statistically significant. Statistical Package for the Social Sciences (SPSS), version 24, were used to carry out the data analysis.