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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
https://doi.org/10.1186/s12884-024-06450-x BMC Pregnancy and Childbirth
*Correspondence:
Shalini Singh
ssing120@jhu.edu
Full list of author information is available at the end of the article
Abstract
Background Poor intrapartum care in India contributes to high maternal and newborn mortality. India’s Labor
Room Quality Improvement Initiative (LaQshya) launched in 2017, aims to improve intrapartum care by minimizing
complications, enforcing protocols, and promoting respectful maternity care (RMC). However, limited studies pose
a challenge to fully examine its potential to assess quality of maternal and newborn care. This study aims to bridge
this knowledge gap and reviews LaQshya’s ability to assess maternal and newborn care quality. Findings will guide
modications for enhancing LaQshya’s eectiveness.
Methods We reviewed LaQshya’s ability to assess the quality of care through a two-step approach: a comprehensive
descriptive analysis using document reviews to highlight program attributes, enablers, and challenges aecting
LaQshya’s quality assessment capability, and a comparison of its measurement parameters with the 352 quality
measures outlined in the WHO Standards for Maternal and Newborn Care. Comparing LaQshya with WHO standards
oers insights into how its measurement criteria align with global standards for assessing maternity and newborn
care quality.
Results LaQshya utilizes several proven catalysts to enhance and measure quality- institutional structures, empirical
measures, external validation, certication, and performance incentives for high-quality care. The program also
embodies contemporary methods like quality circles, rapid improvement cycles, ongoing facility training, and
plan-do-check, and act (PDCA) strategies for sustained quality enhancement. Key drivers of LaQshya’s assessment
are- leadership, sta mentoring, digital infrastructure and stakeholder engagement from certied facilities. However,
governance issues, understang, unclear directives, competency gaps, sta reluctance towards new quality
improvement approaches inhibit the program, and its capacity to enhance quality of care. LaQshya addresses 76% of
WHO’s 352 quality measures for maternal and newborn care but lacks comprehensive assessment of crucial elements:
Appraising LaQshya’s potential in measuring
quality of care for mothers and newborns:
a comprehensive review of India’s Labor Room
Quality Improvement Initiative
ShaliniSingh1* , ZabirHasan1,2, DeepikaSharma3, AmarpreetKaur4, DeekshaKhurana5, J NShrivastava3 and
ShivamGupta6
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Page 2 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
Background
India has made signicant progress in reducing maternal
and new-born mortality since 2005. e health systems
reforms implemented nationwide as part of the National
Health Mission have averted millions of new-born deaths
and saved the lives of thousands of women [1, 2]. Despite
this declining trend, the burden of maternal and neonatal
mortality remains high. e current Maternal Mortality
Ratio (MMR) is 97 per 100,000 live births, and the neona-
tal mortality rate (NMR) is 20 per 1000 live births [3, 4].
Almost half the maternal deaths, 40% of all stillbirths, and
neonatal deaths occur during labor, on the day of birth
[5]. is happens despite having a roster of proven inter-
ventions and technologies that can eectively address the
causes of perinatal mortality [6–8].
While the inequitable arrangements of service deliv-
ery and inecient health systems can be considered the
root cause, poor quality of care is one of the signicant
contributors to the excess mortality among mothers and
children [9–11]. “A lack of quality care in the health facil-
ities of India is perceived as the factor most contributing
to the maternal deaths by family members of deceased
women” [12]. Disrespectful treatment during childbirth
is also widespread, with 70% of women reporting expe-
riencing some form of mistreatment [13]. To develop
eective solutions, better measurements of healthcare
quality are needed to pinpoint where interventions would
have the greatest impact to address both systemic and
care delivery issues to improve maternal and child health
outcomes.
Assessment of maternal and new-born services and quality
of care in the global context and India
Globally, several standardized facility assessment tools
exist to comprehensively assess maternal, newborn and
child health. However, their objective and structure vary
signicantly. As example – the Service Delivery Indica-
tors (SDI) initiative of the World Bank aims to provide
benchmarking of service standard [14], Service Availabil-
ity and Readiness Assessment (SARA) developed by the
World Health Organization (WHO) monitors indicators
related to the continuum of care [15], and lastly Service
Provision Assessment (SPA) spearheaded by Demo-
graphic and Health Survey Program (DHS) includes sev-
eral quality of care indicators – related to antenatal care,
family planning, and sick child care – but not related to
prenatal care during childbirth [16]. Recently, WHO
led the development of the Harmonized Health Facil-
ity Assessment (HHFA) through a collaborative, multi-
stakeholder process. e HHFA provides modules and
tools for a comprehensive, standardized assessment of
health facility services, including quality of care through
record reviews, to generate evidence to strengthen health
systems [17]. However, prominent assessment methods
specically for the quality of maternity and newborn care
in health facilities used globally include WHO’s Stan-
dards for enhancing the quality of maternal and newborn
care [18], a toolkit developed by JHPIEGO for site assess-
ment and strengthening of maternal and newborn health
programs [19], and the Maternal and Child Health Inte-
grated Program Health Facility Survey Toolkit by USAID
[20]. Among these, the WHO framework is widely used
and considered the only unied global tool with a com-
prehensive set of indicators for maternal and newborn
health [21].
In India, women can access maternal health services at
dierent levels, ranging from community to the highest
tier of healthcare facilities, encompassing both the public
and private health systems. In the public health system,
Sub-Centres Health and Wellness Centre (SC-HWCs) at
3000–5000 population, serve as the primary level facili-
ties for basic maternal health services, managed by a
trained Community Health Ocer, at least one or two
female multi-purpose workers and 4–5 ASHAs (Com-
munity Health Workers) who conduct outreach services
for pregnancy registration, antenatal and postnatal care,
and family planning. Primary Health Centres-HWC
(PHC-HWC) at 20,000–30,000 in rural and for minimum
50,000 population in urban areas act as women’s initial
point of contact with physicians, oering more expanded
services and with a longer time or 24-hour availability of
services.
e rst tier of secondary care facilities is 50–100
bedded Community Health Centres (CHCs) at the
harmful labor practices, mistreatment of mothers or newborns, childbirth support, and eective clinical leadership
and supervision.
Conclusion LaQshya is a powerful model for evaluating quality of care, surpassing other global assessment tools. To
achieve its maximum potential, we suggest strengthening district governance structures and oering tailored training
programs for RMC and other new quality processes. Furthermore, expanding its quality measurement metrics to
eectively assess provider accountability, patient outcomes, rights, sta supervision, and health facility leadership will
increase its ability to assess quality improvements.
Keywords Maternal and newborn care, Intrapartum care, Quality improvement, Quality of care assessment, Maternal
and newborn care assessment
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
sub-district level. CHCs have specialists in obstetrics,
gynaecology, paediatrics, and anaesthesia, along with
trained nursing sta. CHC’s oer 24-hour delivery, refer-
rals for complications, postnatal care for 0 & 3rd day,
management of obstetric complications and Basic Emer-
gency Obstetric Care. CHCs designated as rst refer-
ral units (FRUs) can perform Caesarean sections and
have blood storage units. Sub-divisional (100 bedded) at
sub-districts and District hospitals (50–500 bedded) are
other secondary facilities, that provide normal delivery
care, Caesarean sections, manage complicated deliveries
that CHCs cannot handle, address associated maternal
and neonatal complications. SDHs are expected to have
2 specialists each in obstetrics and gynecology, pediat-
rics, and anesthesia, along with ve medical ocers and
adequately trained nursing sta to ensure the provision
of comprehensive maternity care services. While Dis-
trict Hospitals have larger number of specialists [2–6] for
obstetrics and gynecology, pediatrics, and anesthesia, an
adequate number of medical ocers and trained nursing
sta to deliver comprehensive maternity care services.
Government medical colleges and specialty hospitals,
tertiary facilities, handle the most complex maternal and
neonatal health conditions [22–25].
Over the last two decades, several programs have been
implemented to improve the quality of care in these
health facilities [26]. e Ministry of Health and Family
Welfare (MoHFW) has been implementing the National
Quality Assurance Program (NQAP) as the primary
means of quality assessment of health programs since
2013. As part of the NQAP, MoHFW has been using
National Quality Assurance Standards (NQAS), accred-
ited by the International Society for Quality in Health
Care (ISQUA), which further adapted measures based
on the three aspects of the Donabedian Model of Qual-
ity of Care– the Structure, Process, and the Outcome
[27]. Nonetheless, India’s record of ensuring high-quality
maternal and newborn care remained suboptimal [11,
28, 29]. Several factors contribute to suboptimal care
in health facilities, including delays in providing care to
intrapartum mothers, incomplete adherence to safe birth
protocols, a lack of organized preparation for birth, refer-
rals not resulting in treatment, low competence among
sta to manage obstetric complications, the absence of
skilled birth attendants, and instances of sta abuse and
neglect during delivery [30–33]. is underscored the
need to implement a robust facility-level quality assess-
ment program specically targeting maternity and new-
born care to improve health outcomes.
In response, the government launched the Labor
Room Quality Improvement Initiative (LaQshya) in
2017. LaQshya aims to reduce clinical complications
and improve outcomes by enhancing the quality of
maternal and newborn care. Its goals include decreasing
complications such as hemorrhage, retained placenta,
preterm birth, preeclampsia, obstructed labor, sepsis, and
asphyxia, etc. It also focuses on building capacities for
prompt stabilization of above complications, timely refer-
rals, and building an eective two-way follow-up system
through eective communication between health provid-
ers at dierent levels of the health care system. Extending
respectful maternity care (RMC) to all pregnant women
is another critical objective of LaQshya [34]. During its
conceptualization, measurement metrics, and processes
to assess the quality of intrapartum and immediate post-
partum care in LaQshya were drawn from NQAS.
Over the last six years since its launch, only a few stud-
ies have been conducted to examine LaQshya’s perfor-
mance, which indicated structural and process related
improvements in service delivery under LaQshya, includ-
ing infrastructure upgrades, new protocols, training pro-
grams, and infection control practices [35, 36].
However, these studies are limited in scope and depth,
providing insucient insights into the overall eective-
ness of LaQshya. Either they focus on a few aspects of
the program, such as RMC or adherence to guidelines, or
they report on changes experienced due to the program
from a single health facility. e studies lack a thorough
examination of LaQshya’s implementation experience
that can help in identifying bottlenecks faced with the
program and specic areas of improvement to strengthen
the program.
Furthermore, to date, no comparative analysis has been
conducted to evaluate LaQshya against global standards,
such as the framework outlined by the WHO [18]. Such
an analysis could provide valuable insights into how
LaQshya aligns with established international bench-
marks for maternal and newborn healthcare.
is paper aims to address these knowledge gaps and
appraise LaQshya’s potential in measuring the quality
of care for mothers and newborns. We begin by oer-
ing a descriptive case analysis of LaQshya’s operational
elements, strengths, implementation experience, and
challenges. Next, we compare LaQshya’s measurement
metrics and facility assessment tools with the WHO’s
Standards for Improving Quality of Maternity and
Newborn Care in health facilities. rough the descrip-
tive case analysis and comparative assessment, we draw
insights into LaQshya’s capacity to measure the quality
of intrapartum care for mothers and newborns in public
health facilities.
Methods
We implemented a “Descriptive Case Design” to review
the structure of LaQshya and compare it with WHO’s
Standards for Improving Quality of Maternity and New-
born Care. ere are inherent challenges for appraising
any new quality improvement programs like LaQshya
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
due to the contextual dependencies and interconnected
activities that are implemented at varying times and
scales within the health systems, in addition to the lack of
standardized evaluation frameworks [37]. A descriptive
case design is the most relevant method in this context
for an in-depth, detailed examination of the components,
implementation strategies, strengths, and weaknesses of
the program rather than the program outcomes. Further-
more, comparing and contrasting with the WHO stan-
dards through a descriptive case design will provide a
rich, contextual understanding of similarities and dier-
ences between the two quality improvement frameworks
[38].
In our analytical approach, we rst conducted a
document review to obtain information and insights
about LaQshya’s strategy, operational plan, and imple-
mentation experience. A combination of searches on
the Internet and PubMed were used to collect rel-
evant materials. PubMed searches were conducted
using the following search query “LaQshya“[All Fields]
AND ((((“Maternal Health“[MeSH Terms] OR “Mater-
nal Health“[All Fields] OR “Infant Health“[MeSH
Terms] OR “Infant Health“[All Fields]) AND “Or“[All
Fields]) AND “Neonatal Health“[All Fields]) OR “labor,
obstetric“[MeSH Terms] OR “labour“[All Fields])
AND (“quality improvement“[MeSH Terms] OR “qual-
ity assurance, health care“[MeSH Terms] OR “quality
improvement*“[All Fields] OR “Quality Assurance“[All
Fields] OR “Quality Monitoring“[All Fields]) AND
(“India“[MeSH Terms] OR “India“[All Fields]) AND
2017/01/01:2024/02/29[Date - Publication] AND
“english“[Language]. As LaQshya program was launched
in 2017 we considered articles published after 2017.
Only one study was found pertaining to the program
and was included in the documents review (Supplemen-
tary File 1 for detailed search strategy). An aadditional
nine documents including LaQshya-related published
peer-reviewed articles, and other grey literature - such as
program guidelines, program updates, process documen-
tation, technical resource group reports, and meeting
reports - were obtained through internet searches using
key terms LaQshya Program, LaQshya Initiative India,
Labor Room Quality Improvement Initiative in India. We
used the identied set of ten documents and conducted
a detailed content review (See Fig. 1 for distribution of
documents used).
Fig. 1 Types of documents reviewed
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
A data charting form was used to extract the evidence
from the documents for thematic exploration to prepare
the descriptive case analysis (Supplementary File 2).
Next, we compared the LaQshya quality measurement
system with the WHO’s Standards [18]. e WHO stan-
dards adopt a health systems framework and include
eight standards of quality of care to assess, improve, and
monitor services being received by pregnant women and
newborns during childbirth in health facilities. Each stan-
dard embodies a certain number of quality statements,
which are further linked with specic indicators or mea-
sures. e eight standards provide a clear and broad out-
line of the necessary requirements to attain high-quality
care during childbirth, and quality statements linked
to each standard were formulated to drive measurable
improvements in the quality of care. e measures were
established as the actual criteria used to assess and moni-
tor the quality of care linked to each specied in the qual-
ity statements [18]. ere are a total of 352 indicators or
measures, which include 164 input, 110 output/process,
and 78 outcome measures [18]. ese standards, quality
statements, and measures have been referred to widely in
the LMIC settings, used as guidelines to understand qual-
ity gaps [31, 32], and used to assess the ability of existing
tools to optimally capture quality of care indicators [33].
We believed that comparing LaQshya against the WHO
standards would provide valuable insights into how
LaQshya’s measurement criteria compare with estab-
lished global standards to assess the quality of maternity
and new-born care. For additional information on the
WHO’s Standards, please review https://www.who.int/
publications/i/item/9789241511216.
e LaQshya quality measurement system drawn from
NQAS includes slightly dierent elements which are
structured into areas of concern, standards, measurable
elements, and checkpoints. ese elements are linked
to two dierent checklists to assess the quality of care
in labour rooms and maternity operation theatres (OT),
respectively. Each of these checklists includes eight areas
of concern – inputs, service provision, support services,
patient rights, clinical services, quality measurement
systems, infection control, and outcomes [34]. Combin-
ing both the labour room and maternity OT checklists,
LaQshya embodies- a total of 58 standards, 181 mea-
surable elements, and 429 checkpoints to monitor the
eight areas of concern. Among these, 8 standards, 50
measurable elements, and 269 checkpoints are unique
to either of the checklists, with the remaining elements
common to both. Like the WHO’s framework, standards
in LaQshya are also “statement of requirements of a par-
ticular aspect of quality” and measurable elements are
specic attributes of a standard that need to be reviewed
for assessing the adherence to a particular standard.
Lastly, checkpoints are the tangible elements that can be
recorded, scored, and objectively observed [39], which is
very similar to the WHO measures.
We adapted the method presented by Brizuela and
colleagues [40] as our analytical approach, where the
authors equated quality standards proposed by WHO
with other facility-level assessment tools [40].
Our comparative analysis specically focused on mea-
sures from WHO standards and measureable elements/
checkpoints in LaQshya’s framework. We initially devel-
oped a comparison matrix in Excel with WHO standards,
the corresponding quality statements, and measures. Uti-
lizing the keywords from WHO measures, we conducted
a comprehensive search for measurable elements and
checkpoints in the LaQshya checklists for labour room
and maternity OTs [41]. e matching measurable ele-
ments and checkpoints were then added to the matrix
against the WHO measure being compared. We labeled
the WHO measures for which no matching results were
found in the LaQshya checklists as “Not covered” in the
comparison matrix (Supplementary File 3). Once all
WHO measures were thoroughly assessed to determine
their coverage, a score of 1 was assigned to each measure
covered, and 0 for those Not covered. Using descrip-
tive statistics, we calculated how many quality measures
could be assessed using the LaQshya checklist.
Results
e study’s results are presented in three sections. Part
A details the Organization of LaQshya, focusing on its
strategy, enablers, and innovations. Part B provides a
summary of LaQshya’s comparative assessment with
WHO standards, and Part C reports on LaQshya’s imple-
mentation experience, program progress, and challenges.
Organization of LaQshya
Strategy
LaQshya adopts a multipronged approach to improve
the quality of intrapartum and immediate post-natal care
for mothers and newborns in government-funded (pub-
lic) health facilities. It targets three key strategic levers-
(a) remodeled and standardized labor rooms (LRs) and
maternity operation theatres (OTs) (b) protocol-based
care around childbirth, and (c) enhanced client satisfac-
tion through “respectful maternity care” (RMC). It is
a voluntary program for the health facilities to partici-
pate. And once registered, the facilities must follow ten
sequential steps to get certied (Fig.2).
e LaQshya program is implemented as a “facilitated
process”, wherein both central and state governments
provide additional resources to aid the assessment and
accreditation process. After registration, health facili-
ties are required to submit their action plan, the govern-
ment provides extra funding, workforce, and resources
to support the attainment of LaQshya’s quality of care
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
Fig. 2 Ten Steps towards LaQshya Certication
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Page 7 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
enhancements. LaQshya’s mentoring structure comprises
program ocers, representatives from medical colleges,
development partners, quality of care experts, nurse
mentors, etc. e groups enhance the program support
by preparing implementation plans, oering on-site sup-
port, conducting training, identifying best practices and
innovations, and overseeing maternal and infant death
surveillance along with Quality Circles (QC) monitor-
ing. e QC is the facility-level structure that executes
all LaQshya interventions, clinical protocols, and tools
in the labor room and maternity OT with support from
the hospital quality team. ese QC use standard qual-
ity improvement methodology: incorporate six Rapid
Improvement Cycles (thematic campaigns implemented
every two months for phased learning), evaluation, feed-
back, and mastering quality protocols for sustainabil-
ity. QC records gaps related to the selected theme, and
for process improvement, use Plan – DO – Check –Act
(PDCA) cycles.
e full suite of LaQshya interventions is to be imple-
mented over a period of 18 months across four dier-
ent phases - preparatory, assessment, improvement,
and evaluation. At the end of 18 months quality of care
evaluation of labor room and maternity OTs is under-
taken by external assessors. At the national and sub-
national, the government has been developing extensive
programatic and institutional structures to support
health facilities to achieve LaQshya certication. e
existing Quality Assurance committees established at
national and sub-national levels for the NQAS are sup-
porting LaQshya-specic mentoring activities. is also
includes experts empaneled by the National Health Sys-
tems Resource Centre - the Technical Secretariat for the
LaQshya program at the national level. Assessors review
the quality of care as per the standard quality mea-
surement tool - the LaQshya checklists [41]. State and
national level teams of quality assessors’ complete assess-
ment for accreditation in two rounds, respectively, and
certify the health facility. ereafter, performance is mea-
sured on a set of 20 pre-specied structure, process, and
outcome measures listed in Fig.3 [34].
e information generated through the quality
improvement process enables performance tracking to
disburse incentives to health facilities. Incentives are
released on achievement of quality certication of labor
room and/or OT, attainment of at least 75% of commen-
surate facility level targets for indicators listed in Fig.2,
its verication by the State Quality Assurance Commit-
tee, and on achieving 80% of the beneciary satisfaction
rate.
Enablers and innovations
From our review, we identied four key drivers for
LaQshya’s progress, particularly observed in the states
that demonstrated good progress. First, eective leader-
ship and commitment across all levels drive change [34].
Second, proactive and comprehensive actions to address
infrastructure, human resources, and quality of care gaps,
Fig. 3 Indicators for health facility performance measurement and incentive disbursal after LaQshya certication
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
as observed in MP and Gujarat, are critical to advancing
the program. Next, systems of weekly progress reviews
and on-the-job training of clinical providers by master
trainers, exemplied in Chandigarh, are necessary. Lastly,
proactive collaboration and stakeholder engagement
through experience sharing by certied facilities, seen in
Tamil Nadu, helps in overcoming challenges (such as sta
reluctance), towards the implementation of extensive and
new program activities under LaQshya [42].
During implementation of LaQshya, several digital
innovations for training, program monitoring and certi-
cation process have also evolved. SaQsham (Strengthen-
ing Quality and Safety of Health Facility Assessments),
a web platform, has been developed to document and
review all the tasks related to LaQshya certication in the
country. is is expected to support the program manag-
ers in the intensive certication process, through system-
atically organizing the exhaustive information required
for the assessment process. is platform also assists in
data storage for tracking quality improvement changes,
maintains transparency, reduces variability, ensures time
eciency, and acts as a digital backup system for the data
[43].
In recent years, additional digital tools have been devel-
oped in collaboration with development partners to
support implementation of LaQshya [44]. For example,
a mobile Integrated Safe Delivery App is being used to
enhance healthcare providers’ skills in safe delivery and
newborn care through self-learning. Various program
monitoring tools, including oine scorecards, action
plan templates, LaQshya MIS/dashboards, and online
outcome indicators tools, have been developed. Mera
Aspatal, a Ministry of Health client satisfaction tool, has
been adapted to gather client perceptions on care in labor
rooms and maternity OTs [44]. LaQshya assessments had
to be re-oriented due to COVID-19 restrictions, and vir-
tual platforms for training, mentoring, and assessments
served as key enablers to maintain program continuity.
Comparative analysis of Laqshya with the WHO standards
Our comparative analysis reveals that out of the 352
WHO quality measures, the LaQshya checklists cover
and assess 269 (76%) measures. Figure4 depicts the num-
ber of WHO standards, statements, and measures under
review and measures assessed by the LaQshya checklists.
e extent of overlap in the LaQshya checklist is high-
est for input measures (80%), followed by outcome mea-
sures (74%) and is lowest for process measures (72%).
ere is signicant variation observed in the extent to
which LaQshya checklists can measure each of the eight
WHO standards (Figure: 5) While all standards are par-
tially assessed, the tool excels in evaluating standard 3,
pertaining to referrals for conditions that cannot be ade-
quately addressed using the available resources, coverage
of up to 96% WHO quality measures.
It also has a moderate capacity (about 74–82%) to
assess evidence-based care and management of com-
plications (standard 1), use of health information
Fig. 4 WHO measures under review and assessed by LaQshya checklists
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
system (standard 2), eective communication (standard
4), women and newborns receiving care with respect and
dignity (standard 5).and appropriate physical environ-
ment, medicines, supplies (standard 8). A relatively lower
capacity (60–68%) is observed to measure provision of
emotional support to mothers and families (standard 6)
and availability of competent, motivated sta (standard
7).
Table1 summarizes the ability of LaQshya checklist to
measure each of the 32 WHO quality statements. Col-
umns report proportion of input, process and outcome
measures within the quality statement that are captured
by the LaQshya. Albeit partially, LaQshya checklist can
assess all quality statements from the WHO framework.
It assesses all 100% measures for seven quality statements
(1.2, 3.1,3.3, 4.2,5.1, 6.1, 7.1). For 16 quality statements
(1.1a/b, 1.3, 1.4, 1.5, 1.6a/b, 1.7b, 1.8, 2.1, 2.2, 3.1, 3.2,
5.3, 8.1 to 8.3), LaQshya can capture a signicant sub-
set (more than 70%) of the quality measures. e quality
statements which have 60% or less coverage in LaQshya
are those related to- prevention of unnecessary or harm-
ful practices during labor and postnatal period (1.9);
elimination of mistreatment towards women and new-
borns (5.2); support for women during childbirth (6.2)
and availability of competent skilled birth attendants and
support sta (7.2) and presence of managerial and clini-
cal leadership to foster an environment that supports
facility sta in continuous quality improvement.
In absolute terms, out of 83 (24%) unassessed quality
measures in LaQshya, the highest number [37] is from
WHO Standard 1, focusing on care during labor, child-
birth, and postnatal period. Standard 7, dealing with
available sta for care, follows with 22 measures. e
remaining standards have 3 to 13 missing measures in
LaQshya (See Supplementary File 4 for details).
LaQshya falls short in assessing important input mea-
sures, such as those related to the supportive supervision
of the health facility sta for- evidence based care, com-
munication with mother and families, leadership, and
management skills. Critical inputs specied by WHO to
assess standard 5 on accountability mechanisms and pro-
tocols to ensure care of mothers with respect and dignity
are also missing.
Amongst the WHO process measures, LaQshya
includes all for physical environment and supplies (stan-
dard 8), but it lacks multiple process assessments for
evidence-based care (standard 1). ese omissions span
various aspects such as providing women pain relief
options, specic procedures such as adherence to Rob-
son classication for C sections, antibiotic administra-
tion for perineal tears, newborn infections etc. Moreover,
LaQshya doesn’t cover essential parameters like proto-
cols of newborn referrals, sta communication, grievance
redressal, women’s rights, and measures to review com-
petence, mentoring and supervision of sta to support
quality improvement activities.
Fig. 5 Standard wise proportion of measures in WHO standards assessed by LaQshya
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
WHO
Quality
Statement
WHO Quality Statement Input
(%)
Pro-
cess
(%)
Out-
come
(%)
Over-
all
(%)
1.1a Women are assessed routinely on admission and during labour and childbirth and are given timely,
appropriate care.
100 60 100 83
1.1b Newborns receive routine care immediately after birth. 100 80 100 92
1.1c Mothers and newborns receive routine postnatal care. 63 56 100 63
1.2 Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO
guidelines.
100 100 100 100
1.3 Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO
guidelines.
100 50 60 73
1.4 Women with delay in labour or whose labour is obstructed receive appropriate interventions, according
to WHO guidelines.
100 86 50 81
1.5 Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with
a bag-and-mask within 1min of birth, according to WHO guidelines.
100 100 50 89
1.6a Women in preterm labour receive appropriate interventions for both themselves and their babies, ac-
cording to WHO guidelines.
75 100 100 90
1.6b Preterm and small babies receive appropriate care, according to WHO guidelines. 100 100 50 82
1.7a Women with or at risk for infection during labour, childbirth or the early postnatal period promptly
receive appropriate interventions, according to WHO guidelines.
100 80 0 70
1.7b Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment,
according to WHO guidelines.
100 0 100 78
1.8 All women and newborns receive care according to standard precautions for preventing hospital-
acquired infections.
100 75 67 86
1.9 No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and
the early postnatal period.
50 43 NA 46
2.1 Every woman and newborn has a complete, accurate, standardized medical record during labour, child-
birth and the early postnatal period.
33 100 NA 67
2.2 Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for
monitoring and improving performance around the time of childbirth.
100 67 100 91
3.1 Every woman and newborn is appropriately assessed on admission, during labour and in the early post-
natal period to determine whether referral is required, and the decision to refer is made without delay.
100 100 100 100
3.2 For every woman and newborn who requires referral, the referral follows a pre-established plan that can
be implemented without delay at any time.
100 100 67 90
3.3 For every woman and newborn referred within or between health facilities, there is appropriate informa-
tion exchange and feedback to relevant health care sta.
100 100 NA 100
4.1 All women and their families receive information about the care and have eective interactions with
sta.
50 67 75 64
4.2 All women and their families experience coordinated care, with clear, accurate information exchange
between relevant health and social care professionals
100 100 100 100
5.1 All women and newborns have privacy around the time of labour and childbirth, and their condential-
ity is respected.
100 100 100 100
5.2 No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimi-
nation, neglect, detainment, extortion or denial of services
63 60 33 56
5.3 All women have informed choices in the services they receive, and the reasons for interventions or
outcomes are clearly explained.
100 67 67 80
6.1 Every woman is oered the option to experience labour and childbirth with the companion of her
choice.
100 100 100 100
6.2 Every woman receives support to strengthen her capability during childbirth. 50 25 75 50
7.1 Every woman and child has access at all times to at least one skilled birth attendant and support sta for
routine care and management of complications.
100 100 100 100
7.2 The skilled birth attendants and support sta have appropriate competence and skills mix to meet the
requirements of labour, childbirth, and the early postnatal period.
33 43 40 39
7.3 Every health facility has managerial and clinical leadership that is collectively responsible for develop-
ing and implementing appropriate policies and fosters an environment that supports facility sta in
continuous quality improvement.
50 50 100 57
8.1 Water, energy, sanitation, hand hygiene and waste disposal facilities are functional, reliable, safe and suf-
cient to meet the needs of sta, women and their families.
64 NA 100 71
Table 1 Performance of LaQshya checklist under review according to WHO quality statements
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Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
Several WHO outcome measures such as those assess-
ing- management of complications during labour/
childbirth and the early postnatal period and eective
communication by providers with women and families
are missing in LaQshya. Additionally, it doesn’t incor-
porate patient-reported outcomes, respectful treatment,
patient rights, and sta satisfaction.
Implementation experience
Progress
LaQshya has an ambitious target to accredit 2445 high
case load tertiary and secondary care public health facili-
ties across India. e program has been initiated across
all government medical college hospitals, district hos-
pitals & equivalent health facilities, all designated FRUs
and high case load CHCs.
Other than slow progress owing to pandemic-related
restrictions in 2020–2021, the number of LaQshya-cer-
tied health facilities has been steadily increasing since
its launch in 2017 [43]. As of December 2022, about 47%
of the targeted health facilities (644 labor rooms and 504
maternity OTs) have achieved national-level certication
[45]. A total of 122 labor rooms at Community health
Centers, 116 at sub-district hospitals, 360 at district
hospitals and 45 at medical colleges are quality certied
for LaQshya.504 maternity OTs have been certied for
LaQshya, and include 49 at CHCs, 96 at SDH, 317 at dis-
trict hospitals, and 42 at medical colleges. However, this
progress is not uniform across India. State of Madhya
Pradesh (MP) has the highest number of certied labor
rooms and maternity operation theatres (144, 91LR,
53MOT), closely followed by Maharashtra (143, 72LR,
71MOT), Karnataka (122, 62LR, 60MOT), Gujarat (106,
58LR, 48MOT), Andhra Pradesh (76, 34LR, 43MOT) and
Tamil Nadu (76, 38LR, 38MOT). Progress is slow in other
states, while, the state of Meghalaya is yet to initiate the
certication process under LaQshya [43].
Challenges
Our review highlighted various barriers for LaQshya [35,
44, 46, 47]; in both, its implementation within health
facilities and program management. Most challenges
evolve from issues surrounding governance or inter-
connected factors of understang and limited program
support. Frequent changes in administrative leadership
and limited availability of both clinical and manage-
rial manpower adversely impact the program. At times,
program or hospital leaders lack clarity about LaQshya’s
requirements [44, 48], resulting in resource and infra-
structure constraints. Flawed prioritization of hospital
management also leads to a lack of program clarity, as the
focus often remains on the certication process, neglect-
ing the reviews and planning needed to improve clinical
protocols crucial for sustained quality improvements.
Most of these challenges can be resolved through sup-
portive supervision and mentoring by institutional struc-
tures - the State Mentoring Group (SMGs) or the District
Coaching Teams (DCTs) for LaQshya. ese were not
yet fully functional, at least in the seven states for which
process documentation is available [44]. In certain other
states, understang and sta orientation issues within
State and District Quality Assurance Units are seen to
be hindering the eective management of LaQshya [48].
Barriers are also observed due to inadequate competen-
cies of clinical providers, a critical prerequisite for high-
quality care. Trainings in intrapartum protocols have
either not been conducted previously, or there is inad-
equate support to refresh skills by quality circles, or men-
toring team visits, as originally anticipated in LaQshya
guidelines [44, 49].
Eectively tracking LaQshya’s quality measures
demands robust data collection, synthesis, and analysis.
However, multiple documentation needs, inadequate
integration of LaQshya data into routine health infor-
mation systems, and facility managers’ limited famil-
iarity with digital measurement tools hamper data
management. Data-related concerns also impede cli-
ent satisfaction assessment, it’s not fully operationalized
as the updated version of the digital application- Mera
Aspatal is not being utilized [44].
Implementing new LaQshya-specic processes such as
rapid improvement cycles, respectful maternity care, and
birth companions for delivery support has been particu-
larly dicult for health facilities [50]. QCs that ensure
these processes are not functional everywhere [39], and
there is an issue of awed perceptions and limited buy-in
from the providers related to these changes [46]. Quan-
tum of incentives for the health facility is perceived to be
WHO
Quality
Statement
WHO Quality Statement Input
(%)
Pro-
cess
(%)
Out-
come
(%)
Over-
all
(%)
8.2 Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every
woman and newborn can be cared for according to their needs in private, to facilitate the continuity of
care.
88 100 100 90
8.3 An adequate stock of medicines, supplies and equipment is available for routine care and management
of complications.
85 67 50 78
*NA = For these varia bles, the denominator is 0 , there was no input/outpu t/outcome listed in the WHO St andards for the Qualit y Statements
Table 1 (continued)
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Page 12 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
low to maintain sta motivation for LaQshya, and there
are no mechanisms to reward health providers who dem-
onstrate creativity and innovative change ideas for qual-
ity improvement. Finally, there is limited community
participation to enable joint accountability and owner-
ship of quality processes.
Discussion
is descriptive case analysis of the LaQshya program
reveals several key insights into its ability to assess the
quality of intrapartum care for mothers and newborns in
India.
First, LaQshya is envisioned as an integrated and
comprehensive strategy combining quality assurance
and quality improvement methods. e quality assur-
ance component, with external assessments and certi-
cation, enables benchmarking and accountability. e
quality improvement aspect, through mentoring sup-
port and internal reviews by quality circles, drives con-
tinuous enhancement [42, 44]. is dual approach allows
LaQshya to overcome the limitations of standalone other
Quality Assurance (QA) and Quality Improvement (QI)
methods. e assessments make judgments about care
quality at a moment in time, while the improvement pro-
cesses enable internal capability building for sustained
improvements [51].
Second, LaQshya operationalizes many recognized
enablers that catalyze its capacity for quality enhance-
ments and measurement. e program embodies strong
technical expertise, leverages a digital infrastructure,
provides performance incentives for providing high qual-
ity care, and utilizes quality improvement tools like the
PDCA cycles [42, 44, 46]. Leadership and governance
mechanisms have also been established in the form of
quality assurance committees and mentoring groups.
When optimally implemented, as seen in states like
Madhya Pradesh, these structures can enable LaQshya’s
objectives [42, 44, 52].
ird, LaQshya’s assessment checklists align signi-
cantly with WHO standards. e comparative analysis
shows its better capacity than other global tools in quality
assessment for maternal and newborn care. e check-
lists encompass a larger percentage (76%) of WHO’s 352
quality measures; is exceeds the coverage of other
tools such as the Service Provision Assessment (SPA)
designed for the Demographic and Health Surveys pro-
gram, the Service Availability and Readiness Assessment
by WHO, the Needs Assessment of Emergency Obstet-
ric and Newborn Care by the Averting Maternal Death
and Disability program at Columbia University, as well
as the World Bank’s Service Delivery Indicator (SDI) and
Impact Evaluation Toolkit for Results Based Financing in
Health, which range from 62% for the SPA to only 12%
for the SDI [53].
ese promising attributes have allowed Laqshya to
earn its recognition from the WHO as one of the lead-
ing successes in Southeast Asia’s Maternal and Child
Health Programs, establishing it as a notable model with
immense potential for assessing quality of care [8].
Finally, we found that specic gaps exist in LaQshya’s
ability for comprehensive quality assessments. It does
not comprehensively measure quality from the patient’s
perspective through assessments of rights, experience,
and mistreatment. Critical issues of harmful practices
and evidence- based care during labor, outcomes of refer-
rals and clinical leadership capabilities are a few other
missing elements. Incorporating dimensions around
accountability, eective supervision, and building sta
capabilities can strengthen LaQshya. Our analysis also
highlights variability in LaQshya’s implementation across
Indian states. Many challenges persist due to limitations
in leadership prioritization, data systems, provider skills,
and community engagement. Addressing these barriers
can maximize LaQshya’s potential for quality enhance-
ments [43, 44, 46].
Policy implications
is study’s ndings also shed light on specic concerns
that must be addressed to enhance both the implementa-
tion of LaQshya and the quality assessment checklists.
e emerging concerns in implementation are inter-
connected and multifaceted, spanning leadership misper-
ceptions, insucient sta training, clinical competency
gaps, sub-optimal data management, and coordination
issues and have been observed in other similar settings
[54]. ese issues aren’t standalone; they highlight the
need for improvements in governance structures sup-
porting LaQshya at the district level. Strengthening these
structures, establishing local networks with coaching and
quality improvement teams, and utilizing feedback for
better district supervision are crucial for driving quality
improvement initiatives in LMICs [55, 56] and can sig-
nicantly bolster LaQshya’s performance. Additionally,
promoting inter-facility collaboration [51], shared learn-
ing, and scalable practices through quality improvement
collaboratives [52] are promising approaches that could
be integrated into LaQshya by enhancing the role of dis-
trict governance structures.
e issue of low adoption of RMC in facilities imple-
menting LaQshya is reported owing to sta resistance
and unfavorable attitude of personnel who render care
during childbirth. Previous studies suggest that address-
ing abuse and promoting respect is a complex process
that lacks any quick, technical x to immediately change
individual attitudes, improve patient-provider relation-
ships, or challenge deeply rooted societal norms [57].
Other studies within India and other LMICs emphasize
that the barriers to providing RMC are multifaceted.
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Page 13 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
ese barriers could encompass health system factors,
such as the labor ward’s physical infrastructure, sta
shortages, resource limitations, motivational issues, hos-
pital policies, and suboptimal working conditions. Bar-
riers could also include health provider factors of health
providers personal beliefs, inadequate professional ori-
entation, and their limited collaboration. Additionally,
client-related factors involve women’s and their rela-
tives’ attitudes and unmet expectations [7, 13, 58–60]. A
deeper exploration to identify stakeholders’ issues with
RMC, utilizing those learnings to build transformational
training programs and interventions for RMC have been
suggested and could be examined for LaQshya too [57].
e ndings of this review indicate that the decien-
cies in the LaQshya assessment checklists for assessing
the quality of care align to a signicant extent with the
implementation or program level challenges discussed
above. For example, LaQshya fails to measure all criti-
cal issues of harmful practices and evidence- based care
during labor, mistreatment of mothers or newborns dur-
ing childbirth, support for women during childbirth, and
eective managerial and clinical leadership for continu-
ous quality improvement.
Lack of all measures to assess management of high-risk
cases and birth complications in mothers and newborns
is a concern. is could possibly limit LaQshya’s ability in
attaining its objectives of reducing maternal and neonatal
deaths on account of poor quality of care in health facili-
ties. It also does not include performance measures to
assess leadership, governance, and sta motivation. Eval-
uating leadership’s role in quality improvement becomes
more critical given the leadership and governance bar-
riers are already restraining LaQshya’s progress in many
states. ere is close interaction between leadership
and organization culture and senior leadership would
be vital for integrating innovations like LaQshya into an
organization’s vision and operations [54]. ey provide
direction, allocate resources, manage processes includ-
ing hospital sta capacities, and cultivate a performance-
driven environment for high performance in quality
initiatives [61].
LaQshya’s weaker capacity to assess standard 5 on
women and newborns receiving care with respect and
dignity and provision of emotional support to mothers
and families (standard 6) would also need to be addressed
more comprehensively if the program objectives of more
woman-centered, respectful maternity health-care ser-
vices are to be achieved in India.
Limitation
e key limitations of this analysis stem from the reli-
ance on secondary documents, the lack of primary data
collection, and the snapshot nature of the assessment.
While the analysis would have been enriched by visits
to facilities implementing LaQshya or interviews with
frontline health workers, we tried to mitigate this by
undertaking an extensive review of all available program
documents, reports, and scholarly literature. e com-
parison with WHO standards was also systematically
conducted using published tools to ensure standard-
ized and credible benchmarking. Additionally, while
the analysis provides insights into a particular time, the
focus on measurement frameworks and implementa-
tion structures evaluates the overarching capacity and
design of LaQshya. e knowledge generated through
document review and expert analysis still oers valu-
able insights into LaQshya’s strengths and weaknesses as
a quality measurement tool. e recommendations can
inform enhancements in LaQshya’s metrics, governance,
and implementation support. While primary data would
have added nuance, the analysis provides a robust initial
assessment to highlight areas for improving LaQshya’s
ability to measure and improve the quality of maternal
and newborn healthcare.
We used the WHO framework in entirety for our analy-
sis even though LaQshya is focused only on services pro-
vided in labor room and maternity OTs. is is because
segregating measures from WHO framework for labor
room and maternal OTs was not possible and LaQshya
checklists itself had some measures to assess care beyond
intrapartum period.
While this review provides valuable insights into
LaQshya’s capacity to assess quality of care, it is insu-
cient to make a conclusive judgment regarding the pro-
gram’s overall eectiveness, the limited existing studies
assessing program outcomes yield mixed results [36, 62,
63]. Only one study from the state of Tamil Nadu high-
light improvements in infrastructure, human resources,
equipment, supply chain, processes, and outcomes in
maternity care on account of LaQshya implementation.
ese enhancements also led to signicant reductions
in adverse events, improvements in breastfeeding rates,
and reductions in maternal and neonatal complications,
ultimately enhancing the quality of care [36]. Additional
research is needed to comprehensively grasp the eects
of LaQshya on improving the quality of care and its inu-
ence on maternal and newborn health outcomes.
Conclusion
In summary, the comprehensive and innovative design
of LaQshya positions it as a powerful model for evalu-
ating the quality of care, surpassing other global assess-
ment tools. To fully harness its potential, we propose
three specic actions. Firstly, strengthen the governance
structures at the district level to enhance program leader-
ship, mentoring, and supportive supervision for the qual-
ity of care. Secondly, gather input from clinical providers
to plan transformative training, support, and tailored
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Page 14 of 16
Singh et al. BMC Pregnancy and Childbirth (2024) 24:239
interventions for RMC and other new quality improve-
ment processes such as Rapid Improvement Cycles and
Quality Circles. Finally, expand the range of metrics used
to evaluate provider accountability, patient-reported out-
comes, RMC, patient rights, sta supervision, and lead-
ership in health facilities.
Abbreviations
MMR Maternal Mortality Ratio
NMR Neonatal Mortality Rate
SDI Service Delivery Indicators
SARA Service Availability and Readiness Assessment
SPA Service Provision Assessment
DHS Demographic and Health Survey Program
HHFA Harmonized Health Facility Assessment
LaQshya Labor Room Quality Improvement Initiative
NQAP National Quality Assurance Program
NQAS National Quality Assurance Standards
RMC Respectful maternity care
ISQUA International Society for Quality in Health Care
OT Operation theatres
LRs Labor rooms
QC Quality Circles
RIC Rapid Improvement Cycles
PDCA Plan – DO – Check –Act
SMGs State Mentoring Group DC Ts = District Coaching Teams
QA Quality Assurance
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12884-024-06450-x.
Supplementary Material 1
Supplementary Material 2
Supplementary Material 3
Supplementary Material 4
Acknowledgements
We would like to acknowledge Ms. Preetika Banerjee, Data Coordinator Lead
at the Fred Hutch Cancer Centre, Seattle, USA for her support in reviewing the
WHO-LaQshya comparative assessment. We are also thankful to Dr Anita Shet,
Director Johns Hopkins Maternal and Child Health India Centre for her support
and encouragement in taking this work forward.
Author contributions
SS, MH, and DS conceptualized the review; SS and DS developed the strategy
for documents review, and comparative analysis. SS conducted the searches
and extracted information for descriptive case analysis; AK, SS and DK together
completed the comparative analysis of the LaQshya checklists with the WHO
standards for quality of maternal and newborn care. SS and MH developed the
rst draft. JNS, DS, SG contributed to manuscript revision. All authors reviewed
and approved the manuscript for publication.
Funding
No funding was required for this review.
Data availability
The datasets or information generated and/or analysed for this paper are
available within supplementary les 1 and 2.
Declarations
Ethical approval
No ethical approval is required for the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that there is no conict of interest.
Author details
1Department of International Health, Johns Hopkins Bloomberg School of
Public Health, Baltimore, USA
2BRAC James P. Grant School of Public Health, BRAC University, Dhaka,
Bangladesh
3National Health Systems Resource Center, New Delhi, India
4Department of Epidemiology, Biostatistics and Informatics, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, USA
5Johns Hopkins India Pvt Limited, New Delhi, India
6The Global Fund, Geneva, Switzerland
Received: 29 November 2023 / Accepted: 26 March 2024
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