Lucknow, India—The delivery was normal, the mother was fine, but her newborn son hadn’t cried yet. Sarita Pal, the nurse assisting with the birth, acted quickly. As the mother’s worried and expectant looks followed her, Pal scooped up the unresponsive baby, thoroughly dried him, immediately cut the cord and moved the baby over to the newborn corner. There, she positioned him appropriately, then stimulated him and used her recent training to resuscitate the baby by using the Ambu bag and mask. On Pal’s second attempt, the baby opened his eyes and cried loudly.
“The look on the mother’s face was as if I had given life to her child. She looked so happy when the baby smiled back at her in her arms,” recalls the 26-year-old nurse.
Pal attributes her ability to act quickly, appropriately and confidently in resuscitating the newborn to her participation in a Jhpiego-supported quality improvement initiative in private health care institutions in Uttar Pradesh and Jharkhand. The hospital in Lucknow city, where Pal works, is one of the 145 health institutions participating in this initiative. In Uttar Pradesh, a state that still suffers from poor health indicators and where close to 20 percent of deliveries occur in the private sector, the need to ensure quality in private health care facilities cannot be understated.
Jhpiego, in collaboration with Merck for Mothers and the Federation of Obstetric and Gynecological Societies of India, has been implementing this program, “Leveraging Private Enterprise for Improved Access to Maternal and Newborn Health Services in India,” at private health facilities in 11 large cities of these two states since 2014. Under this program, more than 1,000 providers have been supported to provide quality and respectful care, especially during labor and immediately following birth—the period most critical for a mother and her newborn.
The process of quality improvement involves an intensive, two-day training using 27 performance standards in four prime areas: normal labor and delivery including immediate newborn care; management of complications; postnatal care for the mother and newborn; and postpartum family planning, including counseling and insertion skills for the postpartum intrauterine contraceptive device. Testing of the providers’ skills on key, evidence-based, lifesaving practices before and after the training showed a remarkable improvement in their scores, which increased from an average of 39 percent to 70 percent of the performance standards met. As a follow-up to the training, regular supportive supervision visits by Jhpiego help to ensure that the standards are followed across an institution and create an enabling environment for delivery of quality services.
Just ask Pal how the program has transformed her practice: “Earlier when I used to see a patient in a complication, I used to feel scared. Now I am calm because I know what I am doing. I feel more confident to handle complications now, even in the absence of the doctor.”
Speaking with health care providers at the facility, one learns that—along with updated knowledge and skills to perform several essential practices like plotting partographs to monitor progress of labor and carrying out newborn resuscitation and active management of third stage of labor—nurses are using the best practice of placing the newborn on the mother’s belly right after birth. In addition, mothers are taught and encouraged to perform kangaroo mother care, a practice of swaddling the baby to the mother’s chest to help underweight newborns thrive and grow.
“Quality of care for us now means an infection-free delivery—for the mother, the child and even us,” says Pal. “Giving respect to the patient [also] means ensuring quality and the training has helped us become more polite and cooperative with the patients.”
While it is mostly nurses who conduct normal deliveries, doctors also have benefited from this program. “My staff has had a tremendous change …. [The nurses] have learned basic [case] management where they can handle more things even if I am not present. I trust them now,” says Dr. Anita Singh, who also attended the Jhpiego training. “It has assured me that they can decide when to call me and when they can handle a situation on their own. My work pressure has really become less.”
Having been actively involved in this program, Dr. Anita shares her key lesson learned: “We now acknowledge the pain a patient is going through and give her the needed psychological support to be able to push at regular intervals. Patient respect is the most important factor that stood out for me in the program.”
 Maternal mortality ratio: 285 (Sample Registration System 2013); neonatal mortality rate: 49, infant mortality rate: 68 (Annual Health Survey 2013).