A story with a beautiful ending: India’s path to promoting respectful maternal care

Dr. Dinesh Baswal remembers the exact moment he glimpsed the future.

He and his colleagues from the Indian Ministry of Health and Family Welfare were visiting the Aurangabad Medical College in Maharashtra state. It was 2018, a time when Indian society, the government, and health leaders were deeply engaged in a dialogue about the rights of women and how women should be cared for during labor. The medical college assisted in about 18,000 births each year, making it one of India’s busiest labor wards. But when Dr. Baswal and his colleagues entered the 210-bed obstetric ward, it was orderly.

The hospital staff tried to ensure that each of the hundreds of women who delivered there each week knew their rights and felt supported and respected. From the moment they arrived, women in labor were provided with a detailed step-by-step explanation of the process, their rights, and options. The doctors and nurses knew their roles and responsibilities, and used checklists to make sure every woman was told, for example, what labor positions she could opt for, that she could bring in a birth companion for support, and even what was expected of this birth companion.

“They had a remarkable system. Everyone’s expectations were clear and aligned,” said Dr. Baswal, who at the time led the Ministry of Health and Family Welfare’s Labor Room Quality Improvement Initiative (LaQshya). “They even showed pictures to the women of the various positions they could assume during labor. Previously, in every labor room I had visited, women were told to deliver in a position that was convenient for the obstetrician, not what was most comfortable or preferable for the women patient.”

As a result, said Dr. Baswal, the women were less likely to have complications.

At a time when Dr. Baswal and his colleagues were working to improve the quality of care provided to women, the medical college offered a remarkable vision for what was possible. He quickly began sharing the checklists with health leaders and health facility administrators across the country.

These checklists, along with other reforms, have helped India transform its delivery of maternal care from one in which “disrespectful care was normalized and women often chose to give birth at home once they had experienced a delivery in a health facility,” said Dr. Baswal, to a leader in the movement to provide respectful care to women.

The percentage of Indian women who give birth in a health facility has increased from 41% in 2000 to about 89% today. This has helped transform the country’s health outcomes and supported a reduction in the maternal mortality ratio from 556 per 100,000 live births in 1990 to 97 in 2018-2020. There was a similar reduction in neonatal mortality rate from 88 per 100,000 live births to 20 over the same period. The country, once responsible for more than a quarter of maternal deaths globally each year, is now responsible for about 8% of global maternal mortality.

Dr. Baswal pinpoints the 2005 launch of the National Rural Health Mission as the start of India’s key reforms. The mission identified home births as a critical challenge. In response, authorities launched the Janani Suraksha Yojana, or Woman Protection Scheme, a conditional cash transfer of 1,400 rupees (today it has increased to 6,000 rupees, about US$73) aimed at encouraging women to deliver in a health facility. To meet the demand for care this would create, the government built and staffed more than 600 maternal and child health facilities and 250 new obstetric ICUs, including high dependency units. The government also incentivized traditional birth attendants to refer women to health facilities to give birth. And it converted some underused areas of primary health facilities in remote areas into birth waiting rooms, where women could safely and conveniently await labor in their final days of pregnancy.

Over the next decade, all of these reforms and initiatives helped. But there was still one tremendous hurdle: women were widely disrespected during labor. They were shouted at, smacked and pinched, and their privacy was violated, said Dr. Baswal.

“Disrespect was normalized,” he said. “Doctors didn’t think they were doing anything wrong. What they didn’t understand is that their poor behavior can slow the progress of labor. In fact, the natural flow of oxytocin is disrupted if the woman does not feel safe and secure.”

Elena Ateva, who worked with the White Ribbon Alliance on this issue, explained that the challenge of disrespectful care is not unique to India, “Many health facilities around the world are designed not for the convenience or needs of women, but for providers. We need to transform these systems to meet women’s needs and improve health outcomes,” added Ateva, “if we would like to see women go back to the facilities for their second birth or to immunize their children. This requires a profound shift in how we view women.”

A 2010 landmark USAID report by Diana Bowser and Kathleen Hill documented examples from around the world of neglect, disrespect, and abuse of women in labor across low, middle, and high-income countries, often as a result of overburdened staff struggling to keep women and their newborns safe. Bowser and Hill concluded that “disrespect and abuse may sometimes act as more powerful deterrents to skilled birth care utilization than other more commonly recognized deterrents such as geographic and financial obstacles.”

In India and many other countries, the report proved a catalyst for remarkable national conversations about women’s rights, power in the medical system, and the treatment of women in labor, and built momentum for further reforms. It was this national conversation that eventually led Dr. Baswal and his colleagues to the Aurangabad Medical College in 2018.

They were drawn by the checklists and protocols Dr. Shrinivas Gadappa had developed and adopted for maternal care in 2016. The checklists, said Dr. Gadappa, helped medical staff recognize the needs of women and ensured clear communication.

“From the moment of admission through to the labor room, there were checklists,” said Dr. Gadappa. “We developed consent forms for everything from abortion, preterm labor, anemia, fetal distress, to preeclampsia. Each consent form was carefully prepared so that women were well-informed, and their equal participation was considered.”

“We also developed standard protocols for the treatment of various conditions, like pre-eclampsia, eclampsia, premature rupture of membranes, so that uniformity is maintained, and the work is carried out effectively,” he added.

Initially, Dr. Gadappa recalls, there was resistance to the use of checklists among his staff because his colleagues were worried it would create a lot of paperwork. “But in reality, the checklists we developed made the work drastically easier,” said Dr. Gadappa. “What we realized is that a systematic and procedural use of checklist helps to maintain harmony … the checklist proved very beneficial for both staff and patients. It is rightly said that change is hard at first, messy in the middle, and beautiful in the end."

“Over time,” added Dr. Gadappa, “the checklists created wonders by improving the standard of care, reducing healthcare errors, systematizing routine practices, and improving communication between healthcare professionals, reducing complications and hospitalization time.”

Outcomes at his hospital were transformed, he said. For example, the need to perform an episiotomy fell from about 80% to 90%, to about 30%. The rates of caesarean sections dropped from 40% to 27%.

The hospital also ensured all women were interviewed as they left the facility to solicit feedback. A complaint box was established in every ward. Opened every Wednesday, the complaints were taken “very seriously,” said Dr. Gadappa. The White Ribbon Alliance, India, which had launched the Hamara Swasthya Hamari Awaaz (Our Health, Our Voice) campaign in 2016 to advocate for respectful care in the country, partnered with Dr. Gadappa’s facility to support the transformation.

The White Ribbon Alliance, India, signed an MoU with the health facility and conducted a baseline evaluation of the facility. What followed was an intervention that included training of all providers in the protocols and checklists. The training emphasized their unequivocal utilization by all staff at all levels, including doctors, nurses, and support staff. The alliance also provided mentoring, information, education, and communications material support.

The Our Health Our Voice campaign was part of the White Ribbon Alliance’s global effort to promote the Respectful Maternity Care Charter, which outlines the rights of women and newborns and provides recommendations and guidelines to support the delivery of high-quality, respectful maternity care. Over the next few years, the successful campaign helped accelerate and inform a cascade of policy, guidelines, and curriculum changes in India led by Dr. Baswal and his colleagues at the Labor Room Quality Improvement Initiative.

These included new National Midwifery Guidelines in 2018 and the Surashit Matritva Aashwasan – Suman Program – launched in 2020. The Suman Program provides all pregnant Indian women with an assurance of services that includes free ambulance services, at least four antenatal check-ups, delivery services, postpartum care, and lab tests. It emphasizes the provision of respectful care and details a step-by-step process for facilities to follow to achieve the program’s goals and standards of care.

“A lot of countries can learn from what we’ve done,” said Dr. Baswal. “We simultaneously incentivized women and frontline health providers. We built labor rooms, set standards, trained the staff, and tried to continuously improve.”