Does Quality Certification Work? An Assessment of Manyata, a Childbirth Quality Program in India’s Private Sector

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FIGURE 1
Manyata Theory of Change
Abbreviations: LR, labor room; MNH, maternal and neonatal health; MPR, monthly progress report.
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FIGURE 2
Manyata Project States in India
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FIGURE 3
Flow Chart of Manyata-Enrolled Facilities in Jharkhand, Maharashtra, and Uttar Pradesh States, India
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FIGURE 4
Facilities’ Adherence to Manyata Quality Standards at Baseline and Endline in Jharkhand, Maharashtra, and Uttar Pradesh States, India
Abbreviations: AMTSL, active management of third stage of labor; ANC, antenatal care; PP, postpartum; PPH, postpartum hemorrhage.
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FIGURE 5
Estimated Change in Specific Health Outcomes With Each Month of Manyata in Jharkhand, Maharashtra, and Uttar Pradesh States, India

TABLE 1.

Manyata Clinical Standards for Maternity Care in India

Standard No.	Manyata Clinical Standards
Antenatal care
1	Provider screens for key clinical conditions that may lead to complications during pregnancy (to be verified only among booked cases).
At admission
2	Provider prepares for safe care during delivery (to be checked every day).
3	Provider assesses all pregnant women at admission.
4	Provider conducts pelvic examination appropriately.
5	Provider monitors the progress of labor appropriately.
6	Provider ensures respectful and supportive care.
At delivery
7	Provider assists the pregnant woman to have a safe and clean birth.
8	Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried immediately).
9	Provider performs active management of third stage of labor.
10	Provider identifies and manages postpartum hemorrhage.
11	Provider identifies and manages severe preeclampsia/eclampsia.
12	Provider performs newborn resuscitation if baby does not cry immediately after birth.
13	Provider ensures care of newborn with small size at birth.
Beyond delivery
14	Facility adheres to universal infection prevention protocols.
15	Provider ensures adequate postpartum care package is offered to the mother and baby at discharge.
Cesarean standard
16	Provider reviews clinical practices related to cesarean delivery at regular intervals.

TABLE 2.

Maternal Outcomes for Modeling in Manyata Facilities in Jharkhand, Maharashtra, and Uttar Pradesh States, India

	Modeling Change Over Time (Patient-Level)
Outcome	In Absolute Rates: N Events/ N Births	In Referral Rates: N Referrals/ N Events
Morbidities
Hemorrhage	Y	Y
Eclampsia or preeclampsia (pooled)	Y	Y
Obstructed labor	Y	Y
Asphyxia	Y	Y
Maternal sepsis	Y	Y
Newborn sepsis	Y	Y
Prematurity	Y	Y
Mortality
Intrauterine death	Y	N/A
Any neonatal death	Y	N/A
Process measure
Cesarean delivery	Y	Not recorded

TABLE 3.

Characteristics of Manyata Facilities in Jharkhand, Maharashtra, and Uttar Pradesh States, India

Characteristics	Facilities, No. (%) (N=466)
State
Jharkhand	103 (22.1)
Maharashtra	134 (28.8)
Uttar Pradesh	229 (49.1)
Size of facility, beds^a
≤20	208 (44.6)
>20	206 (44.2)
Missing	52 (11.2)
Number of staff^a
≤15	172 (36.9)
16–30	160 (34.3)
>30	82 (17.6)
Missing	52 (11.2)
Time between baseline and endline assessments, months^a
≤3	83 (17.8)
4–6	174 (37.3)
7–9	90 (19.3)
≥10	32 (6.9)
Missing	87 (18.7)
Type of facility^a
Exclusive maternity hospital	186 (39.9)
Multispecialty hospital	202 (43.4)
Others	1 (0.2)
Missing	77 (16.5)
Average monthly delivery load^a
1–10	70 (15.0)
11–20	117 (25.1)
21–30	86 (18.5)
≥31	112 (24.0)
Missing	81 (17.4)

↵^a These characteristics have more than 10% missing data, and thus should be interpreted with caution.

TABLE 4.

Knowledge and Skills Assessments for Nurses Participating in Manyata in Jharkhand, Maharashtra, and Uttar Pradesh States, India

	Total Nurses, No.	Average Prescore/ Max Score (%)	95% CI	Average Postscore/Max Score (%)	95% CI
Knowledge assessment
Knowledge test scores^a	912	6.3/20 (31.5)	6.1, 6.5	13.2/20 (66.0)	12.9, 13.4
OSCE assessment
Overall^a	878	8.0/46 (17.4)	7.6, 8.3	34.3/46 (74.6)	34.1, 34.6
AMSTL (passed=8 or higher)	888	1.5/10 (15.0)	1.4, 1.7	9.1/10 (91.0^b)	9.1, 9.2
Antenatal complications (passed=6 or higher)	882	1.3/8 (16.3)	1.2, 1.4	6.1/8 (76.3^b)	6.0, 6.3
Newborn resuscitation (passed=12 or higher)	890	1.4/16 (8.8)	1.3, 1.5	10.5/16 (65.6^c)	10.4, 10.6
Postnatal complications (passed=9 or higher)	880	3.8/12 (31.7)	3.6, 4.0	8.5/12 (70.8^c)	8.4, 8.7

Abbreviations: AMSTL, active management of third stage of labor; CI, confidence interval; OSCE, objective structured clinical examinations.
↵^a Passing score not specified.
↵^b Average postscore was above the “passing” level (>75%).
↵^cAverage postscore was below the “passing” level (<75%).

TABLE 5.

Monthly Changes in Referral Practices for Specific Complications During Manyata in Jharkhand, Maharashtra, and Uttar Pradesh States, India

Outcome	Parameter Estimate	P Value	Odds Ratio	95%Confidence Interval
Hemorrhage	0.15	.08	1.17	0.98, 1.39
Eclampsia or preeclampsia (pooled)	−0.14	.04	0.87	0.75, 0.99
Obstructed labor	−0.06	.46	0.94	0.80, 1.11
Asphyxia	−0.07	.37	0.93	0.80, 1.09
Maternal sepsis	−0.19	.07	0.83	0.67, 1.01
Newborn sepsis	−0.27	.04	0.76	0.60, 0.98
Premature	−0.07	.32	0.93	0.81, 1.07