Introduction
The Respectful Maternity Care (RMC) pilot project, led by the American India Foundation in Haridwar district, Uttarakhand, aims to improve the quality, safety, and dignity of care in public labor and delivery facilities. The initiative focuses on strengthening the clinical skills of nursing staff, improving labor room infrastructure, and promoting respectful, patient-centered maternity care practices. To support implementation, AIF appointed two experienced nurse mentors in clinical supervision who oversee eight government hospitals across the district, conducting visits to each facility twice a month. As part of my AIF Professional Development Grant, I had the opportunity to visit a Community Health Centre (CHC) in Jwalapur, Haridwar, to observe the program and its impact firsthand.
Facility Evaluation Frameworks: LaQshya and OSCE
The RMC facility evaluations are structured around two key frameworks. The first is the LaQshya guidelines, a national quality improvement initiative launched by the Ministry of Health and Family Welfare in 2017 under the National Health Mission1. LaQshya focuses on improving the quality of care in labor rooms and maternity operation theatres to reduce preventable maternal and newborn deaths, particularly during labor and the immediate postpartum period. For facility certification, it draws on the National Quality Assurance Standards (NQAS), generating ratings across domains including service provision, patient rights, clinical care, infrastructure, and patient outcomes.
The second is the OSCE (Objective Structured Clinical Examination) framework, a standardized tool used to assess clinical competence. By breaking down clinical tasks into discrete, measurable steps, OSCE checklists allow nurse mentors to evaluate whether each component is performed correctly. The nurse mentors walked us through checklists completed during a recent facility visit — the granular level of detail captured across each domain reflects the precision required to uphold safe, hygienic, and high-quality maternity care.
In addition to assessing hospital conditions, the RMC program collects feedback from 30% of labor and delivery patients across seven domains, including communication, cleanliness, respectful care, and overall satisfaction. One 23-year-old ANC patient reported short wait times, clear communication, and respectful treatment, rating her experience 8/10, though she noted that cleanliness could improve. However, the reliability of this feedback may be limited, as patients may feel pressured to give positive responses while being observed by staff.
During the labor room tour, nurse mentors identified issues with equipment placement and organization, which would be reported to hospital staff. While resolving infrastructure and resource gaps is primarily the government’s responsibility, documenting these challenges helps highlight priority areas for intervention. We also observed that many best practices are difficult to implement in resource-constrained settings. For example, labor rooms meant to remain sterile are often also used for antenatal checkups due to limited space, compromising hygiene standards. Workforce shortages, delays, absenteeism, and shift cancellations further strain the delivery of consistent, high-quality maternal care.
Birth Simulations
In partnership with PRONTO International, AIF has introduced a birth simulation exercise to the RMC program.
PRONTO International extensively trains the nurse mentors and provides them with a simulation bag, called the PRONTOPack™, along with training manuals and instructional videos. The PRONTOPack™ is a portable simulation kit that includes low-cost training tools such as a wearable birth simulator (PartoPants™), a cloth baby and placenta, a simulated blood system, and basic supplies for practicing injections and IV care. It also contains scenario guides and simple monitoring tools (like a whiteboard) to support realistic obstetric and neonatal emergency exercises. The PRONTOPack allows low-resource environments to promote hands-on, continuous learning and skill improvement.
For each simulation, they solicit three staff volunteers: one to act as the patient, one as the patient’s companion, one as the delivery staff. A nurse mentor walks the volunteers through a specific delivery scenario, ranging from a normal delivery to one requiring complex treatment and/or referral to a higher treatment center. The nursing officers are assessed on their skills such as clinical accuracy, time management, and communication with patients. After the simulation, the nurse mentors and volunteers debrief what they learned, what was missed or done incorrectly, and any outstanding questions. During the debrief which we attended, the nurse mentors reinforced the positive behaviors displayed by the nursing officers while offering constructive criticism. The nurse mentors shared that although it is challenging to take time out of the hospital staff’s day for the simulations, it is a valuable exercise in quality improvement. After observing the simulation, I could clearly envision how this could be implemented and leveraged as a tool for continuous learning and improvement in other resource-constrained communities.
Public vs. Private: Perceptions of Maternal Care
Many women and their families are hesitant to deliver at public hospitals, driven by a combination of structural policies and perceived disadvantages. Mandatory 48-hour post-delivery stay requirements, for instance, stand in stark contrast to private facilities, which discharge new mothers as soon as 2–3 hours after birth. While the 48-hour requirement is not always enforced, government guidelines could strike a better balance between evidence-based health standards and the real-world needs of women and their families. Beyond policy, women are often steered toward private hospitals through the perception of higher quality, greater cleanliness, and seemingly affordable pricing. Concerningly, there are also reports of private hospitals paying ASHA workers to direct clients away from public facilities, raising serious ethical and regulatory questions about undue influence in maternal healthcare decision-making.
Programs such as Janani Suraksha Yojana (JSY), which offer monetary incentives to encourage deliveries in public facilities, represent meaningful steps forward. However, financial incentives alone are insufficient. To make further progress in reducing maternal and neonatal mortality, sustained investment in the capacity, quality, and infrastructure of public facilities — through programs like RMC — must be scaled across additional districts and states. When public hospitals are equipped to serve the communities that need them most, utilization will follow naturally, and the most vulnerable women will be the first to benefit.
References:
Ministry of Health and Family Welfare. (2017). LaQshya: Labour room quality improvement initiative – Guidelines. Government of India.
PRONTO International. (n.d.). About PRONTOPack. PRONTO International. https://prontointernational.org/our-resources/simulation-supplies/about-prontopack/
