Indian Journal of Public Health

: 2016  |  Volume : 60  |  Issue : 4  |  Page : 323--328

Rollout of quality assurance interventions in labor room in two districts of Bihar, India

Jyoti Sharma1, Sutapa B Neogi2, Preeti Negandhi1, Monika Chauhan3, Siddharth Reddy4, Ghanshyam Sethy5,  
1 Associate Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, Delhi-NCR, Haryana, India
2 Additional Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, Delhi-NCR, Haryana, India
3 Project Associate, Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, Delhi-NCR, Haryana, India
4 Health Officer, UNICEF, Bihar, India
5 Health Specialist, UNICEF, Bihar, India

Correspondence Address:
Jyoti Sharma
Indian Institute of Public Health-Delhi, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon, Delhi-NCR, Haryana


Background: Quality of care at the facilities during childbirth remains a major concern. Improved quality could have the greatest dividend in saving maternal and newborn lives. Objective: The objective of this study was to implement quality assurance measures in the labor rooms of select public health facilities in two districts of Bihar. Methods: The labor room quality assurance intervention was implemented in two districts, Gaya and Purnea in Bihar. Health facilities having >200 deliveries/month were assessed using labor room quality assurance checklist developed by the Ministry of Health and Family Welfare. The critical gaps affecting service delivery were identified, and a list of priority actions for quality improvement was developed. An intervention model was rolled out in consultation with the district authorities focusing on the building blocks of the health system. The interventions were implemented from August 2014 to March 2016 in selected facilities after which an assessment was conducted. Results: Initial assessment of labor room was conducted in 24 facilities. After 2 years of intervention, there was a definite improvement in quality assurance scores in most facilities. The infection control scores increased by 20 points in Gaya (from 40 to 59.9) and 10 points in Purnea (from 57.6 to 67.1). The highest gain in scores was observed in quality management component in Gaya (from 6.2 to 58.2). The model attempted to incorporate all the elements of the health system to ensure scalability and sustainability. Conclusion: It is possible to have an implementable quality assurance mechanism within public health system with sustained efforts and commitment.

How to cite this article:
Sharma J, Neogi SB, Negandhi P, Chauhan M, Reddy S, Sethy G. Rollout of quality assurance interventions in labor room in two districts of Bihar, India.Indian J Public Health 2016;60:323-328

How to cite this URL:
Sharma J, Neogi SB, Negandhi P, Chauhan M, Reddy S, Sethy G. Rollout of quality assurance interventions in labor room in two districts of Bihar, India. Indian J Public Health [serial online] 2016 [cited 2021 Jan 19 ];60:323-328
Available from:

Full Text


India continues to intensify its efforts to reduce maternal and neonatal mortality, through the initiatives launched under the umbrella of the National Rural Health Mission (presently National Health Mission).[1] The mandates of the mission are to promote institutional deliveries and improve the quality of care (QoC). A rise in institutional deliveries has been achieved through increased availability of health-care facilities, services, and financial incentives under Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram.[2],[3] Despite the rapid improvement in skilled birth attendance and facility births, progress in achieving desired outcomes and impact remained slow.[4],[5] Evidence shows that highest number of maternal and newborn deaths occur during delivery and immediately after that. In India, four maternal complications (hemorrhage, sepsis and obstructed/prolonged labor, hypertensive disorders) and three newborn complications (prematurity and low birth weight, sepsis, and intrapartum causes, mostly birth asphyxia) contribute to approximately 60% and 70% mortality, respectively. In addition, women who perceive the quality of facility-based care to be poor may choose to avoid facility-based deliveries, where life-saving interventions could be available.[6] Therefore, QoC remains a central issue. Adequate focus on improving quality of obstetric services can contribute substantially to outcomes for women and their infants.[7]

Analysis of effect and cost of scaling up of available interventions suggests that improving the QoC around the time of birth could have the greatest impact resulting in triple returns in terms of saving lives of mothers and newborns, preventing stillbirths and disabilities.[8] Recent estimates indicate that improving QoC during childbirth can help save lives of 1325 million neonates and 113,000 women as well as prevent 531,000 stillbirths annually by 2020.[9] To achieve quality in service delivery where substantial coverage has been achieved, context-specific challenges need to be identified and addressed.[10],[11] Strengthening of building blocks of the health system by integrated planning and service delivery is required to ensure high quality and effective health services during and around childbirth at the public health facilities.[12] The objective of this study was to implement quality assurance measures in the labor rooms of selected public health facilities in two districts of Bihar.

 Materials and Methods

The labor room quality assurance intervention was implemented in two high priority districts, Gaya and Purnea. The study was divided into three phases: initial assessment, implementation of intervention, and postintervention assessment. An initial assessment of select health facilities in both the districts having a delivery load of more than 200 per month was conducted. The target facilities were assessed for quality components using labor room quality assurance checklist developed and validated by the Ministry of Health and Family Welfare, Government of India.[13] This checklist assesses quality assurance in labor rooms on eight parameters that include service provision, patient rights, inputs, support services, clinical services, infection control, quality management, and outcome. Information related to each parameter was obtained using different methods specified in the checklist including observation, staff interview, record review, and client interview. Within each of the eight parameters listed in the checklist, data on some key variables/checkpoints were obtained, and each variable was scored. The variable was assigned a score of 2 for full compliance, 1 for partial compliance, and 0 for noncompliance. All checkpoints were given equal weightage for scoring. Each parameter had a maximum score of 100; since there were eight parameters, the final score assigned to a particular delivery point was from a maximum of 800. On summation of the scores of all eight parameters, each facility was graded as being either fully complaint (100%), partially compliant (50%–99%), or noncompliant (<50%). The details of baseline assessment are discussed elsewhere.[14]

Based on the initial assessment, the critical gaps affecting service delivery were identified, and a list of priority actions for infection control, biomedical waste management, infrastructure and equipment availability and maintenance was developed. Interventions were planned to address and overcome these critical gaps. Implementation was carried out with the support of and in consultation with the District Health Societies of the respective districts as well as the State Health Society Bihar (SHSB). Efforts were put in to equip the facilities and health-care staff with required logistics and skills to facilitate the improvement of the quality of services. The implementation phase lasted for 2 years (from August 2014 to March 2016). An assessment was conducted in April 2016 to gain an understanding of the outcome of the interventions.

Ethical considerations

This study was approved by the Institutional Ethics Committee of the Indian Institute of Public Health-Delhi. Consent was taken from facility in-charge, staff members, and clients who were interviewed, before data collection. Data were collected by a team of trained interviewers and subsequently entered into a database for analyses. No identifiable information was used during the analyses, and confidentiality was maintained.


Initial assessment of labor room was conducted in 24 facilities (10 in Gaya and 14 in Purnea). The average composite score of facilities in Gaya was recorded 361.3, while in Purnea, it was 475.2 out of a total of 800. The average score of facilities on infection control (49 in Gaya and 57.6 in Purnea) and quality management parameter (6.2 in Gaya and 54.5 in Purnea) was lowest among all parameters in both the districts.

Intervention model for quality assurance in labor rooms

The intervention model was envisaged keeping in mind the building blocks of health system that was finalized in consultation with the district authorities. Meetings and workshops were held with doctors, nurses, and program managers to discuss the challenges and most effective solutions within the given constraints specific to the district and the given facilities. The intent was to inculcate a sense of ownership and responsibility to manage the labor rooms. Official letters were issued by state quality assurance cell and necessary approvals were taken to help roll out the intervention activities. In facilities, for the items where no funds were earmarked in the Program Implementation Plan, Rogi Kalyan Samitis provided the requisite financial support.

Quality assurance was discussed during monthly meetings of doctors and auxiliary nurse midwives (ANMs), and its implementation was emphasized during training sessions organized specifically focusing on labor room quality processes. In addition, all the facilities were visited monthly by field team to follow-up the status of progress of quality improvement intervention at the facilities. On-the-site training and demonstrations were provided by the field team during visits on upkeep of equipment, biomedical waste management, infection control practices.

The key points included in the intervention model are summarized in [Table 1].{Table 1}

The activities toward implementation of the model continued for almost 2 years after which an assessment was done. The results [Table 2] demonstrated a definite improvement in quality assurance scores in most of the facilities with Gaya faring better than Purnea [Figure 1] and [Figure 2]. During the intervention period, the scores for infection control were increased by 20 points in Gaya (from 40 to 59.9) and 10 points in Purnea (from 57.6 to 67.1). The highest gain in scores was observed in quality management component in Gaya district (from 6.2 to 58.2).{Table 2}{Figure 1}{Figure 2}


The quality assurance intervention for labor rooms in Bihar seemed to be successful in initializing changes after 2 years of implementation. The response was better for infection control, support services clinical services, and patient rights components. The results of this intervention show that regular follow-up and supportive supervision based on a cycle of assessment, feedback, and actions at public health facilities backed by health system support can lead to quality improvement at the public health facilities.

High-quality health services delivery is a result of a well-functioning system at the facilities that include skilled and motivated teams equipped with necessary medicines and commodities, an enabling environment (evidence-based practices and client-centered, respectful maternity care services) along with robust facility management and administrative systems.[15] Interventions piloted in labor rooms as reported from different parts of the country and elsewhere focused on specific aspects such as improving clinical care [16] through skill-focused training and refresher courses.[17],[18],[19] Jhpiego, in partnership with the Children's Investment Fund Foundation and the state governments of Rajasthan, Andhra Pradesh, Telangana, and Gujarat, is using the Safe Childbirth Checklist (SCC) to improve the QoC at public health facilities in these states.[20] SCC is a simple tool that helps the service providers to remember to perform safe care practices during and immediately after childbirth – although these aspects were central to our interventions also, we realized that skills would transform into actions only in the presence of a conducive environment. This realization was put into practice by adopting a holistic approach where every aspect of health system strengthening was touched on. It meant intervening at the health systems level for scalability and sustainability in the long run. Reflections were observed in the enhancement of infection control measures, support services and clinical services that do not largely depend on factors such as infrastructural issues and human resources which usually take a long time to change.

Preliminary results show that though there was a visible improvement in the infrastructure of labor rooms and availability of supplies, yet the availability of an adequate number of delivery sets, adherence to sterilization protocol for infection control and clean practices were still major challenges, especially during rush hours. The scarcity of staff has been incriminated as a gap that affects the quality of services in the long run.[21] Uneven distribution of skilled health-care workforce, poor quality of training and posttraining follow-ups and supervision are identified as major bottlenecks in any quality improvement initiative.[11],[15],[21],[22],[23] This was partly addressed by periodic monitoring visits, on-site trainings, and frequent interaction with staff to keep their motivation level high.[24] This may have worked as a short-term measure but can in no way overcome the pitfalls of having a shortage of staff, especially in labor rooms where skilled workforce is of utmost importance.[25],[26],[27] In Bihar, there is an acute shortage of qualified and trained nurses, and ANMs irrespective of their training status are often seen as a substitute. This may tide over the crisis and manage the load of normal deliveries but cannot be seen as an alternative to skilled nurses, especially for complicated labor. In our case, the intervention worked well in facilities where hospital manager, labor room staff, and medical officers worked together as a team in a dynamic and supportive environment.

Nevertheless, this model had its challenges and barriers in terms of sustaining the practices during rush hours, on the days when the patient load was high, transfer of skilled staff from the facilities and poor coordination between team members at the facility.

The interventions centered around improving district and subdistrict facilities play a pivotal role in the implementation of Maternal Newborn Health programs. The model was owned by the health-care providers. They were involved in the planning, prioritizing, and implementation of activities. The multi-country analysis of health system bottlenecks emphasized financial barrier as a critical bottleneck.[15] Our experiences revealed that it does not require a major financial investment to make changes visible. Discussions with local authorities and persistence can reveal effective and efficient means to tackle most of the basic problems. With minimal investment, we could mobilize some funds from district plan/RKS for the intervention. Despite issues with availability of infrastructure, logistics, and skilled staff, few facilities did show a way for improvement.


Sustainability is the key to any quality improvement measure. We, therefore, followed the path of health system strengthening. That actually meant less improvement than what we had originally envisaged but whatever little improvement has happened is likely to continue beyond the intervention period. There is a will to improve the quality of health service delivery at the state and district levels. It is possible to bring about sustained improvement with continued efforts and commitment.


Authors are thankful to Quality Assurance Cell, SHSB for supporting the study and provide necessary support. We appreciate the encouragement and guidance provided by Ms. Jyoti Verma from SHSB. We acknowledge the efforts of Public Health Foundation of India-UNICEF field team: Dr. Tarique Ahmed Khan, Dr. Aftab, Dr. Suman Bharadwaj, Dr. Swati Katoch, Dr. Poonam Banga, Dr. Rashid Ahmed Khan, Shirish Tiwari, and Shalini Kumari. We are grateful to all health managers, staff nurses and ANMs, and medical officers working at the facilities for their sincere efforts and cooperation.

Financial support and sponsorship

Financial support for the study was provided by UNICEF, Bihar.

Conflicts of interest

Ghanshyam Sethy and Siddharth Reddy are affiliated to UNICEF Bihar (Sponsor of the study and supplement).


1National Rural Health Mission: About NHRM. Available from: [Last cited on 2016 Oct 12].
2Janani Suraksha Yojna. Available from: [Last cited on 2016 Oct 12].
3Janani Shishu Suraksha Karyakaram. Available from: [Last cited on 2016 Oct 14].
4Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation. Lancet 2010;375:2009-23.
5Randive B, Diwan V, De Costa A. India's Conditional Cash Transfer Programme (the JSY) to promote institutional birth: Is there an association between institutional birth proportion and maternal mortality? PLoS One 2013;8:e67452.
6Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: An overview of the evidence. Reprod Health 2014;11 Suppl 2:S1.
7Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011;114:4-9.
8Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: Progress, priorities, and potential beyond survival. Lancet 2014;384:189-205.
9Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014;384:347-70.
10Van Lerberghe W, Matthews Z, Achadi E, Ancona C, Campbell J, Channon A, et al. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet 2014;384:1215-25.
11Dickson KE, Kinney MV, Moxon SG, Ashton J, Zaka N, Simen-Kapeu A, et al. Scaling up quality care for mothers and newborns around the time of birth: An overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth 2015;15 Suppl 2:S1.
12SRS. Maternal Mortality in India 1997-2003-Trends, Causes and Risk Factors. New Delhi; 2006. Available from: [Last cited on 2016 Oct 12].
13Assessor's Guidebook for Quality Assurance in District Hospitals. New Delhi: Ministry of Health and Family Welfare, Government of India; 2013.
14Neogi SB, Sharma J, Negandhi P, Chuhan M. Quality Assurance in Labour Rooms (with emphasis on Infection Control) in Two Districts in Bihar; 2014. Available from: [Last cited on 2016 Oct 14].
15Sharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr G, Lavender T, et al. Quality care during labour and birth: A multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015;15 Suppl 2:S2.
16Iyengar K, Jain M, Thomas S, Dashora K, Liu W, Saini P, et al. Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India. BMC Pregnancy Childbirth 2014;14:270.
17Jayanna K, Bradley J, Mony P, Cunningham T, Washington M, Bhat S, et al. Effectiveness of onsite nurse mentoring in improving quality of institutional births in the primary health centres of high priority districts of Karnataka, South India: A cluster randomized trial. PLoS One 2016;11:e0161957.
18Das A, Nawal D, Singh MK, Karthick M, Pahwa P, Shah MB, et al. Impact of a nursing skill-improvement intervention on newborn-specific delivery practices: An experience from Bihar, India. Birth 2016;43:328-35.
19Dettrick Z, Firth S, Jimenez Soto E. Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence. PLoS One 2013;8:e83070.
20Improving Quality of Maternal and Newborn Health in India; 2015. Available from: [Last cited on 2016 Oct 12].
21Bhattacharyya S, Srivastava A, Avan BI, Graham WJ. Quality care at childbirth in the context of health sector reform program in India: Contributing factors, challenges and implementation lesson. Health Syst Policy Res 2012;1:2.
22Sri S, Sarojini N, Khanna R. Maternal Deaths and Denial of Maternal Care in Barwani District, Madhya Pradesh: Issue and Concerns. Bhopal, India. Bhopal: Jana Swasthya Abhiyan, CommonHealth, Sama-Resource Group for Women and Health; 2011.
23Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, et al. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bull World Health Organ 2007;85:783-90.
24Salam RA, Lassi ZS, Das JK, Bhutta ZA. Evidence from district level inputs to improve quality of care for maternal and newborn health: Interventions and findings. Reprod Health 2014;11 Suppl 2:S3.
25WHO. Access for all to Skilled, Motivated, and Supported Health Workers: Background Paper for the Global Strategy for Women's and Children's Health; 2010. Available from: [Last cited on 2016 Oct 12].
26WHO. Making Pregnancy Safer: The Critical Role of the Skilled Attendant: A Joint Statement by WHO, ICM and FIGO; 2004. Available from: [Last cited on 2016 Oct 12].
27Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: Findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014;384:1129-45.