A Paradigm Shift in Public Health: Transforming Maternal and Newborn Care in Telangana, India

India is poised to become one of the three largest economies in the world by the end of this decade. As one of the world’s great nations, India played an important role in shaping the Sustainable Development Goals that make up the United Nations development agenda between 2015 and 2030. Indeed, the Sustainable Development Goals mirror India’s national development goals on many levels, not the least of which is Goal Three: Good Health and Wellbeing.

Much like others in the global community, India wants to ensure healthy lives and promote wellbeing for all individuals. However, in reality India is far from achieving this goal. The health sector in India has made enormous gains over the past few decades. Life expectancy rose, disease incidence declined, and many diseases such as polio and tetanus have been eradicated.

Despite these achievements, many public health challenges remain. Communicable diseases like HIV and tuberculosis continue, and new outbreaks of mosquito borne diseases like dengue and chikungunya are of particular concern. In addition, India faces a rising tide of non communicable and sometimes chronic diseases, such as heart disease, cancer, and diabetes.

In the face of these challenges stand ongoing concerns around the maternal mortality ratio and infant mortality rate. Both remain unacceptably high and too much focus is put on childbirth itself and not the periods before or after. More than 659,000 newborn babies die every year in India. It is the highest number of newborn deaths in the world. India also accounts for twenty percent of all maternal deaths worldwide, with more than 150 women dying in India each day due to preventable causes related to pregnancy and childbirth.

Reaching the global Sustainable Development Goals and achieving India’s own national development goals is no small feat. Every great journey begins with a single step. In April 2016, the Indian Ministry of Health and Family Welfare took one giant leap toward reaching development targets on maternal and newborn mortality. To improve the quality of care during the intrapartum and post partum period, the ministry released guidelines for the standardization of all labor rooms. The guidelines help states reorganize their labor rooms for maximum efficiency and quality service delivery.

Thanks to the dynamic leadership of its Chief Minister and the vision of the Commissioner of Health and Family Welfare, the state of Telangana was one of the first states to adopt these guidelines. It committed to standardizing services and infrastructure at all delivery points across the state that experienced high delivery caseloads. In Telangana, 502 of the 841 birthing units at public health facilities are high load delivery units. These high load delivery units facilitate more than two hundred deliveries each month. Together, they account for more than 98 percent of all public sector deliveries. Currently in Telangana, less than one third of all pregnant women choose to deliver in a public health facility. This raises serious concerns around the quality of healthcare services in the public health system and the availability and accessibility of those services.

Given the scale of the challenge, the Department of Health and Family Welfare Telangana decided to tackle the standardization of labor rooms in three phases. To begin, the government invited ACCESS Health International, the Indian Institute of Public Health, and UNICEF to discuss and develop the action plan to implement the national labor room guidelines across the state. Twentyfive technical experts from the partner organizations, representatives from the Department of Health and Family Welfare and engineers from Telangana Medical Services and Infrastructure Development Corporation developed an assessment format and plan of action. The technical experts were divided into teams. Each team included an engineer from the Telangana Medical Services and Infrastructure Development Corporationto help develop renovation plans for the labor rooms. The assessment for the phase one facilities started inDecember 2016.The assessment focusedon five important areas: infrastructure, human resources, equipment, supplies, and protocols.

ACCESS Health International was focused on developing an information technology platform that would allow for rapid data collection during the assessment period and help with the dissemination of the assessment findings. The technology was designed to help assessors quickly collect and analyze data. ACCESS Health also facilitated assessments in the public health facilities themselves, with the help of their Quality Improvement Associates who work closely with staff in the birthing units as part of the ACCESS Health Safe Care, Saving Lives Program. Safe Care, Saving Lives is a quality improvement program that will reduce neonatal and perinatal mortality by fifteen percent over a four year period. The Safe Care, Saving Lives team are all experts in improving the quality of maternal and newborn care. The assessment teams visited 291 facilities between November 2016 and May 2017. Hospital staff, district program managers, district medical and health officers, and the district coordinators of hospital services actively participated and supported the teams.

The assessment findings revealed that none of the health facilities had standard labor rooms and standard birthing tables. Mothers had privacy during childbirth in only eleven percent of labor rooms. Adequate lighting was available in only twelve percent. Functional handwashing facilities were only available in sixteen percent of labor rooms. A dedicated dirty utility area for infectious and non infectious waste was available in only one quarter of all labor rooms. The essential equipment for conducting deliveries and providing essential newborn care to babies was also not available in the majority of the facilities. The information technology platform developed by ACCESS Health clearly highlighted these gaps using a color coded score.

Following the assessment, the government of Telangana committed approximately two million U.S. dollars for the standardization of the 291 labor rooms. By May 2017, the government had already standardized 178 birthing units. Standardizing the labor rooms includes making sure that each room is laid out in the most efficient manner, making sure there is adequate space for triage and adequate drugs, equipment and human resources. Prior to this process, many labor rooms in public health facilities were dirty, gloomy, poorly ventilated, and poorly maintained. They have been transformed into clean, ventilated, adequately illuminated, corporate style facilities. The work on the final 113 labor rooms is expected to be completed by August 2017. Early analysis of the impact of these changes show significant success. Deliveries in public health facilities have increased by fourteen percent in the last six months, from 100,000 between April and September 2016 to 114,000 in the subsequent six month period.

Women delivering in government hospitals in Telangana are now entitled to roughly two hundred U.S. dollars after delivery. They are also given a kit which contains clothes, quality baby soaps, baby oil, baby powder, mosquito nets, toys, napkins, and diapers for their newborn. To improve the record keeping in facilities the department of health has introduced uniform case recording formats. ACCESS Health International will support the department in developing and institutionalizing a labor room management information system.

Thanks to these initiatives, the government is expecting to see a surge in deliveries in public health facilities and a commensurate decline in maternal and neonatal mortality. The government plans to improve the quality of care in these revamped facilities by focusing on capacity building of the staff and process improvement. The transformation of labor rooms in Telangana serves as a model for other states and, indeed, other countries, to follow. The Department of Health has been invited to share a poster at the Annual National Innovations and Good Practices 2017 summit held annually by the Ministry of Health and Family Welfare, Government of India in July 2017.