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Quality of routine labor and delivery care in Uttar Pradesh, India: Are private facilities better?

In India, the percentage of women who delivered in a health facility increased from roughly 35% in 2000 to 79% in 2014 ( Despite this progress, given India's massive population, 15% of global maternal deaths took place in India in 2015 (, suggesting substantial gaps in quality of care at the time of birth. Researchers have noted that women in India tend to associate private facilities with higher quality of care ( compared to public facilities. While studies of public facilities in India have indicated generally poor quality Of care (, evidence from private facilities--particularly for normal labor and delivery--is scarce.

Measuring quality of care in public and private facilities

In an effort to address this evidence gap, a recent article from the Bulletin of the World Health Organization ( assessed the quality of essential obstetric and newborn care during routine labor and delivery in Uttar Pradesh, India. The authors from the London School of Hygiene & Tropical Medicine and Sambodhi Research and Communications conducted clinical observations of 275 mother-newborn pairs at 18 public facilities and eight private facilities in Uttar Pradesh. For each clinical observation, the authors assessed 42 items related to quality of care and, using a comprehensive framework, mapped their observations onto 17 essential obstetric and neonatal care practices:

The researchers found poor quality of care in both public and private facilities. Unqualified personnel were found to provide institutional maternity care in up to 59% of all deliveries, and a number of life-saving clinical practices such as partograph use for monitoring labor, screening for pre-eclampsia/eclampsia and active management of the third stage of labor were rarely observed. Additionally, researchers noted the provision of women-centered, respectful maternity care ( practices in just 4% of deliveries.

Overall, 45% of recommended practices were completed for women giving birth in the private sector compared to 33% in the public sector. For obstetric care, private sector clients received 40% of the recommended practices compared to 28% in the public sector. Similarly, 51% of the recommended neonatal care practices were completed in the private sector compared to 39% in the public sector:
Overall poor quality of care at the time of birth

                                   Total  Public  Private
Obstetric care Index (9 items)     30.6%  28.3%   40.0%
Neonatal care (8 items)            41.4%  39.0%   51.0%
Essential care at birth(17 items)  35.7%  33.3%   45.0%

Note: Table made from bar graph.

The authors also found a statistically significant difference between sectors for specific indicators: Regular partograph use for monitoring labor, assessment of maternal blood loss after childbirth and measures for the prevention of maternal infection during childbirth were performed more frequently in the private sector compared to the public sector:

* Enlarge graph (

Implications for research, policy and practice

According to the authors, the findings from this study have several implications for global maternal health research, policy and practice:

'A systematic effort to measure and identify quality gaps during labor and childbirth is required, particularly in high-burden settings in India and elsewhere'.

'There should be further research to identify the reasons for unqualified personnel providing institutional maternity services in both public and private sector facilities'.

'The private sector provides a substantial and increasing proportion of maternity services across the world. Therefore, research, programs, policy and advocacy efforts to improve quality of care at the time of birth should also include private sector facilities',

'We need to develop tailored quality improvement initiatives at facilities in both sectors with regular auditing of the actual care processes and link these to functional accountability mechanisms'.

The views expressed in this piece are those of the author(s), and do not necessarily reflect the views of the Institute or the United Nations University, nor the programme/project donors.

Read more on the papers published in the WHO Bulletin theme issue 'Measuring quality of care' at the UNU-WIDER's lauch event website


This article was originally published by Maternal Health Task Force blog (



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Table 1. Framework used for the assessment of essential care at birth,
India, 2015

Timing                     Obstetric care
                    Clinical practice    Observed items

On admission and    Regular monitoring   Is labour monitored regularly
during first stage  of labour using a    with partograph?
of labour           partograph
                    Measures for the     Are hands washed before
                    prevention of        examination and are sterile
                    maternal infection   gloves put on before vaginal
                    during admission     examination?
                    Screening for        Is blood pressure monitored
                    pre-eclampsia and    and urine tested for
                    eclampsia            proteins?
From second         Measures for the     Are sterile gloves put on
stage of labour     prevention of        before vaginal examination
to completion of    maternal infection   and are vulva and perineum
childbirth          during childbirth    cleaned with antiseptic?
                    Active               Is uterotonic given within
                    management of        minute of birth, is the cord
                    the third stage of   clamped and is there
                    labour               controlled cord traction?
                    Assessment of        Are the placenta and
                    maternal blood loss  membranes
                                         checked for completeness, is
                                         the vagina checked for tears
                                         and is there monitoring of
                                         bleeding postpartum?
                    Use of woman-        Is process of labour
                    centred respectful   explained
                    care practices       to the mother or support
                                         person at least once, is
                                         companion allowed to be with
                                         the mother during labour, is
                                         mother informed before
                                         examination, is visual
                                         ensured and is mother asked
                                         about choice of position?
                    Avoidance            Is an enema given, is the
                    of harmful or        pubic area shaved, is fundal
                    unnecessary          pressure applied to hasten
                    interventions for    delivery of baby or placenta,
                    mother               is there uterine lavage after
                                         delivery, is there manual
                                         exploration of the uterus
                                         after delivery and is there
                                         use of episiotomy without any
                    Avoidance            Does the health worker
                    of harmful or        restrict mother's fluid and
                    unnecessary health   food intake during labour; do
                    worker behaviour     they insult, shout or
                                         the mother during labour and
                                         childbirth; and, do they hit,
                                         pinch or slap the mother
                                         during labour and
Timing                     Fetal or neonatal care
                    Clinical practice    Observed items
On admission and    Check fundal         Is fundal height checked
during first stage  height and fetal     and is fetal presentation
of labour           presentation         checked?
                    Regular monitoring   Is fetal heart rate
                    of fetal heart rate  monitored at regular
From second         Health workers       Is ventilation bag
stage of labour     prepared for         available and is neonatal
to completion of    resuscitation if     mask available and laid
childbirth          required             out?
                    Neonatal cord care   Is cord cut with a sterile
                    Appropriate          Is neonate dried properly;
                    thermal care of      is skin-to-skin contact
                    neonate              between neonate and
                                         mother initiated and is the
                                         neonate covered with a dry
                    Assessment of        Is the Apgar score assessed
                    Apgar score          one minute after birth and
                                         is it assessed five minutes
                                         after birth?
                    Initiation of early  Did the mother initiate
                    breastfeeding        breastfeeding within hour
                                         of birth?
                    Avoidance            Is their routine aspiration
                    of harmful or        of neonate's nose, is the
                    unnecessary          neonate slapped and is the
                    practices for        neonate held upside down?

Note: We assessed nine obstetric care and eight neonatal care
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Publication:WIDER Angle
Article Type:Reprint
Geographic Code:9INDI
Date:Jun 1, 2017
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