Overall, the quality of care around childbirth at private healthcare facilities was poor. Three-fourths of facilities enrolled in the Manyata program met only four or fewer of the 16 FOGSI-endorsed clinical standards; only one facility met more than 12 of the standards. This is similar to findings from the few other studies carried out in Uttar Pradesh and Maharashtra that have evaluated the quality of care in private healthcare facilities (21–23). However, the results are noteworthy as private health care facilities are generally perceived to be more efficient and provide better quality of services (24). This is probably the reason why Indian families who can afford to pay prefer private sector services over the public health system, despite the added expense (25).
One reason why the quality of care may be so poor at these private sector healthcare facilities is the lack of qualified staff. We found that the mean number of standards met was higher at facilities with at least one qualified nurse or midwife on staff, although this difference was not statistically significant. Almost half of all nursing staff engaged in maternity care services at these private healthcare facilities were unqualified, and 13% of facilities did not have a single qualified nurse or midwife on staff. These findings are similar to a previous analysis by Rao et al (26), which estimated that 58.4% of nurses and midwives serving in the private healthcare facilities of India were unqualified. Likewise, a 2001 survey of private health care providers in Delhi (27) found that 41% were unqualified. In the absence of regulatory requirements for staffing, private facilities may employ unskilled staff to increase profit margins and compromise quality in the process (28).
Clinical care processes in private healthcare facilities in India are largely individually driven as the government does not mandate the uniform use of standard care practices in the private sector. This heightens the importance of professional organizations like FOGSI in standardizing care practices, as they can play a critical role in reviewing and prescribing care protocols to members (29).
The baseline assessment found that standards related to the assessment of pregnant women on admission and assisting pregnant women to have a safe and clean birth were met by relatively more facilities, while standards related to managing complications – which are relatively rare – were met by very few facilities. This needs to be seen in the context of the assessment methodology, which considered the facility team (clinician and nursing staff) as a unit of measurement in assessing adherence to standards of care. Nursing staff are fully involved in routine care and thus could demonstrate their capabilities during the assessment. However, management of complications is heavily dependent on specialists at the facilities with limited involvement of nursing staff. This may be why the team could not demonstrate adherence to standards on management of complications.
Notably, the standard for respectful and supportive care was met by just one in six private healthcare facilities. Respectful care is a key component of quality of care, and mistreatment and poor quality of clinical care are closely interlinked (30). The poor adherence to respectful care further correlates with existing evidence in both high (31–35) and low income settings (36–38), but contradicts the widespread perception that private healthcare facilities are more likely to provide respectful and supportive care due to their customer service orientation and concerns that a negative reputation on this front could hamper their profits.
A deeper look into the data revealed that the main reason why facilities did not meet the standard for respectful and supportive care was because of their failure to allow a birth companion during labor, which was one of the verification criteria for this standard. This hesitation in allowing a companion in the labor room may stem from fear of interference. Also, it is likely that many providers are not aware of the benefits of this practice for maternity outcomes (39).
Delivery load was a significant determinant of quality of care in the multiple linear regression; facilities with a moderate delivery load, between 20 and 50 deliveries per month, met significantly more standards than facilities with either lower or higher delivery loads. This load may be optimal because it ensures that staff receive regular practice but, at the same time, are not overburdened. Patient load and time spent with each patient by private providers have a significant bearing on the quality of health care (39). The other significant factor in the regression was the availability of at least 70% of the essential items required for carrying out recommended practices. This corroborates previous studies (37, 38) that have found adequate supplies and infrastructure are important determinants of the quality of care in private sector healthcare facilities.
Among the three states where the Manyata program has been implemented, Uttar Pradesh and Jharkhand perform more poorly than Maharashtra on social and health indicators. Uttar Pradesh and Jharkhand score considerably below the national average of 0.639 on the Human Development Index (40), while Maharashtra scores above the national average. In addition, the private sector’s contribution to institutional deliveries is greater in Maharashtra (45.8%) as compared to Uttar Pradesh (34.4%) and Jharkhand (32.5%) (41–43). However, this assessment found that the quality of care in private healthcare facilities was poor across all three states and did not vary significantly between states. This is corroborated by existing literature on the quality of care in private healthcare facilities in states like Maharashtra that found poor standards of care in small private health care facilities (21).
Strengths and Limitations
Our analysis is an important addition to the scarce literature on the quality of maternity care in the private healthcare facilities of India. The fact that the facilities assessed came from both higher (Maharashtra) and lower performing states (Uttar Pradesh and Jharkhand) in terms of key maternal health indicators is a major strength of this study. In addition, the assessment standards are based on WHO standards for improving quality of maternal and newborn care in health facilities and endorsed by FOGSI. Therefore, the findings will be comparable with future studies that use similar standards and approach. However, there are some limitations to the interpretation of the findings. The facilities included in the analysis had voluntarily opted to participate in the Manyata program, so the sample may not be truly representative of private healthcare facilities across the three states. Facilities voluntarily opting to participate in the Manyata program for getting Manyata certified may differ from general private health care facilities in terms of being more conscious about importance of quality parameters or standards. In addition, direct observations of providers’ skills were an important component of the assessment methodology and therefore, the findings are liable to the Hawthorne effect.