Introduction
Despite significant decline in maternal and under-5 child deaths over last two decades, 275 000 maternal death and 5.9 million under-5 deaths including 2.7 million neonatal deaths still occur every year, over 90% of them in the low/middle-income countries (LMIC).1 2 Due to slower decline of neonatal deaths, its contribution to under-5 deaths has increased from 36% in 1990 to 46% in 2015.1 3 Additionally, a burden of approximately 2.1 million stillbirths every year, unnoticed so far, has also become a major concern.3 The childbirth and first 24 hours thereafter is the most critical period as nearly half of total stillbirths and maternal and neonatal deaths occur during this period.4 5
Increase in institutional deliveries in India from 38.7% in 2005–2006 to 78.9% in 2015–2016 has not translated into commensurate gains in maternal and neonatal survival but has largely shifted the mortality burden from the community to the facilities.6–8 This has been attributed to low quality of care (QoC) in the facilities and improving the QoC in addition to universal coverage of evidence-based interventions has therefore been identified as a key strategy to achieve Sustainable Development Goals of significantly reducing maternal, fetal and neonatal mortality by 2030.9 Improved QoC is expected to save nearly 113 000 maternal deaths, 531 000 stillbirths and 1 325 000 neonatal deaths every year globally.10
Most of the evidence on improvement in QoC has emanated from high-income countries, which have strong and functional health systems. Systematic reviews demonstrate dearth of good-quality evidence on interventions, which can improve QoC of maternal and newborn health in LMICs with weaker health systems.10 Recently, a large cluster-randomised trial (BetterBirth study) undertaken in Uttar Pradesh state of India focused on implementation of coaching-based WHO safe childbirth checklist (BetterBirth checklist) as a tool to drive QoC in small facilities.11 The trial reported a modest improvement in adherence to essential practices around the time of childbirth but no change in perinatal deaths, maternal deaths or maternal severe complications.
The QoC is a multifaceted concept which envisions that the clients receive good-quality evidence-based care (provision of care) and are also treated well (experience of care). Providing good QoC which is safe, timely, effective, efficient, equitable and patient centred requires a robust health system. Improvement in healthcare processes needs ‘structure’ to be in place in the form of skilled and committed human resource, infrastructure, information system, equipment and supplies, financing, and leadership/governance. The Donabedian and WHO models emphasise the importance of both robust ‘structure’ and ‘processes’ in order to achieve desirable health outcomes.6 12
We hypothesised that quality management activities driven by facility teams with external facilitation and comprising activities to build capacity of the providers, regular review of key inputs and outcomes to identify gaps and closing those gaps through facility teams’ improvement efforts will increase the uptake of essential practices around the time of childbirth in primary health centres (PHC). The improved QoC would enhance the faith of community and families, which would improve utilisation of the PHC services.