Background:

• The percentage of institutional births in India has doubled from 38.7% to 78.9% in the decade 2015-16, according to the National Family Health Survey (NFHS-4).However, this increase in coverage has not translated in commensurate reduction of maternal and newborn mortality and stillbirths. One of the major factors being inadequacies in the quality of care provided in health facilities.The current figures of maternal mortality ratio of 130 and neonatal mortality rate of 24 suggest that though there has been tremendous improvement in maternal newborn healthcare indicators, there still exists a vast scope to achieve the targets set for our country.
• It is estimated that approximately 46% maternal deaths, over 40% stillbirths and 25% of under-5 deaths take place on the day of the delivery. Half of the maternal death each year can be prevented if we provide higher quality health care.Quality of care is increasingly recognized as a critical aspect of the unfinished maternal and newborn health agenda, mainly with respect to care around labour and delivery and in the immediate postnatal period.
• In this respect, Ministry of Health and Family Welfare has launched program ‘LaQshya’- quality improvement initiative in labour room & maternity OT, aimed at improving quality of care for mothers and newborn during intrapartum and immediate post-partum period.

Overview of LaQshya

Ministry of Health & Family Welfare, Government of India launched an ambitious program LaQshyaon 11^th December 2017 with following objectives:

• Reduce maternal and newborn morbidity and mortality
• Improve quality of care during delivery and immediate post-partum period
• Enhance satisfaction of beneficiaries, positive birthing experience and provide Respectful Maternity Care (RMC) to all pregnant women attending public health facilities.

Target Beneficiaries:

• LaQshya program will benefit every pregnant woman and newborn delivering in public health institutions. Program will improve quality of care for pregnant women in labour room, maternity Operation Theatre and Obstetrics Intensive Care Units (ICUs) & High Dependency Units (HDUs).

Following facilities are being taken under LaQshya initiative on priority:

• All Government Medical College hospitals.
• All District Hospitals & equivalent healthy facilities.
• All designated FRUs and high case load CHCs with over 100 deliveries/60 (per month) in hills and desert areas.

Institutional Arrangements

• Under the National Health Mission, the Stateshave been supported in creating Institutional framework for the Quality Assurance – State Quality Assurance Committee (SQAC), District Quality Assurance Committee (DQAC), and Quality Team at the facility level. These committees will also support implementation of LaQshya interventions. For specific technicalactivities and program management, special purpose groups have been suggested, and these groups will be working towards achievement of specific targets and program milestones in close coordination with relevant structures within institutional arrangementthe QA organizational framework.
• National Mentoring Group includesmembers of the Programme Divisions,IEC Division, NHSRC, NIHFW, AIIMS,and Medical Colleges, Nursing colleges,Schools of Public Health, ProfessionalAssociations, Hospital Planners, ITprofessionals, Development Partners,Empanelled external assessors & eminent professionals.
• State level- State NHM, Departments of Health and Medical Education would jointly createinstitutional arrangement for seamless flow of support and removal of the bottle-necks, if any for implementation of this initiative.

State Mentoring Group – State Mission Director would constitute the State mentoring group, consisting of programme officers, suitable faculty of AIIMS and other eminent National Institutions and Medical Education Department, State Nodal Officers for Quality, IEC, procurement, infrastructure,State Level Development Partners and eminent professionals.

• District level- Coaching Team- An external multidisciplinary team, responsible for mentoring one or more labour rooms, would comprise of District Family Welfare Officer/RCHO (equivalent), district/divisional quality consultants, nursing instructors/mentors from the functional skill labs, faculty of nearest medical colleges and representatives of professional associations and development partners. The coaching team in districts with medical college could include one or more retired faculty members as a coach for medical college labour rooms and operation theatre. In early phase, one coaching team could mentor four or five districts since training every district coaching team in a short span of time may not be possible. All coaching teams must be trained in skills lab/Dakshata, so that they are proficient mentors.

• Facility Level- Quality circles are informal groups of the staff in each department that work closely to improve the QOC there. For example, Quality Circle in a labour room involvesGynaecologist,Paediatrician, Matrons and Nursing Staff & Support Staff. In the Operational Theatre, anesthetist would also be a member of the Quality circle. The Quality Circles works in coordination with facility level quality team headed by the Medical Superintendent or facility-in-charge.

Key Features:

• LaQshya program envisagesto improve quality of care in labour room and maternity OT.
• Under the initiative, multi-pronged strategy has been adopted such as improving Infrastructure upgradation, ensuring availability of essential equipment, providing adequate Human Resources, capacity building of health care workers and improving quality processes in labour room.
• Implementation of ‘fast-track’ interventions (NQAS assessment, Trainings, Mentoring, Reviews etc.)
• Capacity-building of healthcare workers by skill-based training like Dakshta & improving quality processes in the labour room.
• To strengthen critical care in Obstetrics, dedicated Obstetric ICUs at Medical College Hospital level and Obstetric HDUs at District Hospital are operationalized under LaQshya program.

Strategies

• Reorganizing/aligning LabourRoom & Maternity Operation Theatre layout as per Standard Guidelines issued by the Ministry of Health & Family Welfare, Government of India.
• Ensuring all Government Medical College Hospitals, District Hospitals have dedicated obstetric HDUs and Obstetric ICU as per GoI MOHFW Guidelines, for managing complicated pregnancies that require life-saving critical care.
• Ensuring strict adherence to clinical protocols for management and stabilization of the complications before referral to higher centers.
• Continued mentoring and hand holding support to improvise skills.
• Regular MDSR, C-section audit and Referral audits & linkage among lower level facilities.
• Collating best quality practices across States which can be replicated by other States.

Quality Improvement cycles-

• 6 focused quality improvement cycles (Documentation, RMC, Timely management of complications in pregnancy,judicious use of oxytocin, essential and emergency newborn care, infection prevention and biomedical waste management) each for two months.
• First month for improvement followed by second month for sustaining improvement.
• Improvement using PDCA approach and quality tools.
• Each cycle supported by onsite coaching team visits.
• Support resource package for each cycle.
• Onsite training and monitoring by coaches.
• Documentation of improvement activities.

Digital Innovation

• LaQshya Web portal- All LaQshya related data will be uploaded on the portal for prompt report generation as well as visualization of dashboard to monitor progress in key maternal new born indicators at various levels (facility, District, State & National)
• Safe delivery App- Job aid as well as training tool for health workers.

Certification, Incentives & Branding:

• Quality Improvement in labour room and maternity OT will be assessed through NQAS (National Quality Assurance Standards). Every facility achieving 70% score on NQAS will be certified as LaQshya certified facility.
• Furthermore, branding of LaQshya certified facilities will be done as per the NQAS score. Facilities scoring more than 90%, 80% and 70% will be given Platinum, Gold and Silver badge accordingly.
• Facilities achieving NQAS certification, defined quality indicators and 80% satisfied beneficiaries will be provided incentive of Rs. 6 lakhs, Rs.3 lakhs and Rs.2 lakhs for Medical College Hospital, District Hospital and FRUs respectively.

Way forward:

• New innovations for escalating quality of health care services for mothers & newborn.
• Increased satisfaction of beneficiaries and positive Birthing experience.
• Increased demand of services from beneficiaries of public health facilities.
• LaQshya certification of all health facilities.
• Sustained efforts to achieve SDG targets and goals related to maternal newborn health.
• Maintain and accelerate unprecedented progress – end all preventable maternal, newborn and child deaths.