Research Proposal on

Challenges in implementing LaQshya in Government health

care facilities in Tamil Nadu.

Submitted by:
Dr. J. Sathya, MD, DCH., MPH.,
Principal, Health and Family Welfare Training Centre,
The Gandhigram Institute of Rural Health and Family Welfare Trust,
Gandhigram, Dindigul Dist, Tamil Nadu- 624301

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 INDEX

S.No. PARTICULARS PAGE NO

1 BRIEF INTRODUCTION 3

EXPLANATION ABOUT THE PROBLEM

2 4
STATEMENT
PROBLEM STATEMENT AND NEED
3 6
FOR THE STUDY

4 APPROACH AND METHODOLOGY 7

5 PROPOSED PROJECT TEAM 15

6 TIME LINE – IMPLEMENTATION PLAN 15

7 DURATION OF THE PROJECT 15

8 REFERENCES 16

9 BUDGET OUTLINE 17

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Brief introduction about GIRH & FWT, Gandhigram:

The Gandhigram Institute of Rural Health and Family Welfare Trust (GIRH&FWT) is an
autonomous body under Ministry of Health and Family Welfare, Government of India. This
institute is supporting for conducting training, research and services in the field of Health
and family welfare as per the guidance of the Government of India and Tamil Nadu.

Health and Family Welfare Training Centre (HFWTC) is one among 47 centers in
Government of India for conducting NHM training programmes like DHAKSHADA,
RMNCH+A, MCH SKILL LAB, LaQshya and other twining for health care providers
working in the government health facilities under DME, DMS and DPH&PM from six
health unit districts in the southern part of Tamil Nadu. LaQshya reginal consultant is
working in the HFWTC, Gandhigram by covering 6 health unit district for Laqshya quality
assurance certification.

Reginal Health Teachers Training Institute (one among 6 RHTTIs in Government of

India) and the Department of Health Promotion Education (one among three institute
in India) are conducting long term courses for in-service candidates from health
department though out the country and other countries.

Central Training Institute (one among 6 CTIs in Government of India) of our institute is
organizing in-service training at regional level for health functionaries from southern
states and other sectors like railways, corporation and municipalities etc.

Population Research Centre (one among 18 PRCs in India) of our institute is taking part
in conducting NFHS surveys and other national level research activities on maternal and
child health care.

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 1. Explanation of the problem statement:

Maternal, stillbirth, and newborn mortality rates remain a critical global health concern, as
evidenced by a recent joint report from the World Health Organization (WHO), the United
Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA).
The years 2020-2021 witnessed a distressing total of 4.5 million deaths attributed to these
causes, with India emerging as a significant contributor, responsible for 60% of these
tragic occurrences. (1) Particularly alarming is the situation in Tamil Nadu, where maternal
mortality stands at a staggering 54 deaths per one thousand live births. This grim reality
underscores the urgent need to address the challenges associated with childbirth,
especially during labor and delivery, where these losses occur due to a complex interplay
of maternal and fetal factors.

In response to these pressing challenges, India has launched various initiatives, among
them the LaQshya program. Commencing in 2017 under the National Health Mission,
LaQshya is designed to enhance the quality of care provided in labor rooms and maternity
operation theaters within public health facilities. The program seeks to establish quality
assurance standards tailored to different healthcare facility levels, with a central mission
of reducing maternal and newborn mortality, improving the quality of care during childbirth
and postpartum periods, and ensuring dignified maternity care. Innovative measures such
as standardization guidelines and a maternal and newborn health toolkit have been
introduced to support these objectives.

Despite the LaQshya program's ambitious goals, its implementation within government
health facilities in Tamil Nadu faces several challenges. These include an increase in
institutional deliveries, limited research on labor room quality assessment, and various
operational complexities. A retrospective review of the LaQshya program's
implementation demonstrates significant achievements but also highlights persistent
challenges. These challenges encompass ongoing construction activities within
healthcare premises, the need for comprehensive training and rigorous supervision, and
the issue of staff turnover. (2)

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Furthermore, an assessment of the implementation of the WHO Labour Care Guide in
Indian hospitals reveals alignment with the LaQshya initiative and the principles of
respectful maternity care advocated by the WHO. However, variations in obstetric
intervention rates and risk profiles could influence the effectiveness of the LCG strategy.
Thus, further trials in diverse healthcare settings are imperative to comprehensively
assess its impact (3)

A facility-based cross-sectional study offers recommendations for enhancing the practice

of Birth Companions during childbirth. These recommendations encompass educational
interventions, sensitization of healthcare staff, informed decision-making for pregnant
women, infrastructure improvements, and adherence to quality assurance standards. (4)
Finally, a comprehensive study conducted in District Hospital Sitamarhi, Bihar,
underscores significant challenges affecting maternal and newborn healthcare services.
These challenges include human resource shortages, the absence of standardized
operating procedures, deficiencies in organizational quality frameworks, prolonged
patient stays, and issues related to equipment and instrument calibration. Addressing
these issues necessitates the establishment of a quality circle, convergence between
healthcare levels, patient satisfaction surveys, and comprehensive training and support.
(5)

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Problem statement and Need for the study

Dakshata trainees – low hanging fruit discussion – Encouraged us to submit the proposal
to improve challenges faced by them in 6 districts served by HFWTC, GIRH & FWT,
Gandhigram.

This research proposal seeks to systematically investigate the underlying causes of these
challenges and propose effective solutions. The ultimate aim is to optimize the impact of
the LaQshya initiative and enhance maternal and neonatal healthcare outcomes in Tamil
Nadu.

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2.Approach and Methodology:

a. Primary objective:
To assess and understand the functionality of labour room in implementing LaQshya
standard guidelines in government health facilities in Tamil Nadu.

b. Specific objectives include:

1. To assess the existing labour room infrastructure, availability of human resource
and essential equipments and consumables.
2. To evaluate the knowledge of health care providers in terms of labour room
practice and capacity-building programs available for healthcare staff.
3. To explore the facility parameters associated with its delivery load taking the facility
as a unit of analysis.
4. To analyze data management and reporting practices related to LaQshya.
5. To gauge community awareness and participation in LaQshya initiatives.
6. To develop recommendations for addressing identified challenges.

c. Research Design:

A cross sectional Analytical research design with mixed-method approach combining

quantitative and qualitative research methods.

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d. Study population and Sampling:

Health statistics
District Name Tamil Dind- Tiru- Ten-
S. No Theni Karur Tuticorin Source
Indicators Nadu igul nelveli kasi

Mid-Year Population 7.61

1 22.2 13.5 11.1 18.8 18.6 15.7 CRS 2020
( in Lakhs) Cr.
Total Reported Births
2 9.3L 0.26L 0.17L 0.12L 0.23L 0.44L CRS 2020
(in Lakhs)
3 Birth Rate 12.3 11.5 12.3 11.3 12 14.1 CRS 2020
4 Death Rate 9.0 9.0 9.4 9.4 8.7 10.5 CRS 2020
NFHS-5 19-21
5 Maternal Anemia % 48.3 34.6 36.6 48.4# - - #NFHS-4 15-
16
6 Low Birth Weight % 17.0 15.6 13.4 15.9 16.0 15.2 NFHS-5 19-21

Maternal Mortality
7 71.1 58.4 96.2 55.6 48.6 82.7 CRS 2020
Ratio

8 Still birth rate 6.4 11.3 12.7 5.6 6.7 7.5 CRS 2020
9 Infant Mortality Rate 9.4 10.2 12.7 12.7 8.6 8.3 CRS 2020
Estimate of
CRS 2020
Neo-Natal Mortality
10 6.4 7.0 8.7 8.7 5.9 5.7 @68.3%IMR
Rate
as per NFHS
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11 Under 5 Mortality Rate 22.0 - - - - - NFHS 5 19-21
Government Health
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Facilities:
Primary Health
13 2267 73 41 29.0 60 52 52
centres
State and
14 Sub- Centres 8713 338 190 168 253 253 177
District
Govt. Hospitals Statistical
15 (*including ESI 366* 13 5 5 11 8 9 Books 2021-
Hospital) 22
Govt. Medical College
16 Hospitals
37 1 1 1 1 1 0

Six Health Unit districts covered by Reginal Quality Assurance Unit undertaking LaQshya
Quality assurance namely Dindigul, Theni, Karur, Thoothukudi, Tenkasi and Tirunelveli
Districts. These districts covers 1685 no of government health facilities includes 5 medical
college hospitals, 51 Government hospitals and 307 Primary Health centres are
conducting deliveries.

Sampling

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Stratified sampling technique. The health facilities will be stratified according to the
number of deliveries performed.

The data regarding number of deliveries will be obtained from the National Health Mission
(HMIS). The LaQshya and health facilities will be listed according to the number of
deliveries. The geographical locations as Rural, Urban and Tribal will be indicated.
Strategic sampling technique will be applied to all the facilities in each district and the
facilities will be finalized.

All the healthcare providers who have role in management of labour will be included in
the study. In the Medical College and District Hospitals, the Head of the Department,
Specialist, Resident Medical Officer, Staff Nurse, ANMs, Quality Managers; in the Primary
Health Centres (PHCs) Medical Officers / in-charge (MO i/c), Staff Nurse and Sanitary
team will be included in the In-depth Interview (IDI), Focus Group Discussions (FGDs).
The health persons will be required to fill in the knowledge questionnaire.

The LaQshya Quality Team will perform the structural capacity assessment.

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 e. Data Collection Methods:
S.NO Data collection method
1 Survey- Questionnaire
Data collection tools Target group
 WHO Standards for
Improving Quality of
Maternal and A.Health facility
Newborn Care in Parts in Questionnaire
Health Facilities, Part 1- Information on the
infrastructure of the
 Labour Room
health facility,
Quality
Part 2- Information on the
Improvement
availability of essential
Initiative (LaQshya),
equipment and
 MNH Toolkit,
consumables,
 Guidelines for Part 3-Availability of
Standardisation of healthcare providers at
Labour Rooms at the facility.
Delivery Points,
 DAKSHTA
B.Health care provider

Knowledge of healthcare
providers on topics like
Partograph,
Active management of
the third stage of labour
(AMTSL) and
Post-partum
haemorrhage (PPH).
In-depth interview guide -
Key stakeholders (Health Insight in to challenges
2 In-depth interviews
care providers and health and solutions
administrators)
health care practice,
Labour room Observation
3 Observations infrastructure, resources
check list
etc
Checklist to assess
Relevent LaQshya implementation
4 Document Review
documents,reports and process
records.

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f. Data Collection:

The data will be collected using two types of questionnaires; one for assessing the health
facility and the other for assessing healthcare providers. The questionnaire will be
developed by reviewing literature from the WHO Standards for Improving Quality of
Maternal and Newborn Care in Health Facilities, Labour Room Quality Improvement
Initiative (LaQshya), MNH Toolkit, Guidelines for Standardization of Labour Rooms at
Delivery Points, DAKSHTA and other various studies conducted in the different states of
India. The health facility questionnaire will be covering three main categories, The first
part collected information on the infrastructure of the health facility, availability of
equipment and consumable, the second will assess the availability of health care team
and sanitation team as per the recommendation. The closed-ended questions will be used
to assess the knowledge of labour room health care provider on topics like partograph,
active management of the third stage of labour (AMTSL) and post-partum hemorrhage
(PPH).

All the questionnaire of healthcare providers will be translated into the local language. In
order to ensure that both the questionnaires, local language and English to be
conceptually equivalent, forward translation and back translation methods will be
implemented. The validated questionnaires will be used in the pilot study by assessing
five health facilities and healthcare providers appointed in those facilities.

g. Data Analysis

The labour room readiness will be assessed based on categories such as (1) knowledge
of health care team, (2) manpower capacity and (3) structural capacity and sanitation
facilities.

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Knowledge of health care team
The health care provider’s knowledge regarding Partograph, Active Management of Third
Stage of Labour (AMTSL), Postpartum Haemorrhage (PPH) will be assessed by the years
of experience and trainings attended within previous 3 years and any reinforcement
training to the skills. Score will be calculated for each facility based on the assessment
of the knowledge of health team in each health facility and the calculation of the same will
be done and analysed.

Manpower capacity
The number of healthcare providers available will be assessed versus required healthcare
team per facility. The information on the number of the healthcare workers available in
the facility will be collected from the Dean (Government Medical College Hospital),
Medical Officer (Government Primary Health Centre) and Medical Superintendent
(Government Hospital).The required number of healthcare workers will be calculated
based on labour room quality improvement initiative and MNH. Using the information
obtained, the staffing index will be calculated for each facility.

Structural capacity analysis

Structural infrastructural parameters of all the labour rooms will be evaluated under four
broad headings:
i) Basic amenities & essential structural components in the health facilities
ii) Basic amenities & essential structural components in the health facilities in
terms of spacing, lighting, etc.
iii) Sanitation and hygiene component of the labour room
iv) Infant care parameters  facilities for newborn care
 immediate KMC support
 neonatal transport
Under these headings, infrastructure score will be computed and the calculation of the
scores for each component will be analysed.

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Essential equipment and consumables
To assess the availability of essential equipment and consumables, the Labour Ward i/c
Nurse, Pharmacist i/c, Equipment Stores i/c will be enquired along with the direct
visualization of each item in the checklist.

The assessment will be done under the following headings:

i) Protective equipments
ii) Instruments for examination & monitoring
iii) Diagnostic instruments
iv) Newborn care equipments
v) Trays, Records

The supply chain management, challenges and barriers for easy availability of the
equipment will be assessed using Focus Group Discussion (FGD).The FGD among
healthcare workers will be used to assess the barriers and facilities for adequate supply
of equipment, drugs for good sanitation practices. Suggestions from the team will be
conducted using FGD guidelines.

After the consent, the interview will be recorded in local regional language using audio
recorder.

The recordings will be transcribed and coding will be done using the NVIVO software.

The final analysis will address the following main things:

 Knowledge of health team
 Availability of essential equipments and consumables
 Infrastructure parameters
 Staffing strength
 Sanitation and hygiene
 Facility for newborn care

The percentage score will be calculated for the above 6 parameters.

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The final facility score for individual facility will be calculated for Medical College
Hospital/Government Hospital/Primary Health Centre.

The final score will be graded as …

Poor : 0 – 50%
Average : 51 – 75%
Good : 76 – 100%

Statistical Analysis
The collected forms will be checked for completeness and quality and the data will be
entered in MS Excel. The data will be re-checked and any inconsistency in the data will
be checked by the respective Questionnaire and corrected. The data will be analysed
using SPSS (Statistical Package for Social Sciences, Version 29.0).

The availability of assessed components and knowledge of the healthcare providers will
be expressed in the form of proportions while the scores computed for all the components
were expressed in the form of mean + standard deviation and percentages

The collected forms will be checked for completeness and quality and the data will be
entered in MS office excel. The data will be rechecked and any inconsistency in the data
will be checked by the respective questionnaire and corrected. The data will be analyzed
using SPSS statistical software for calculating proportion, Mean, standard deviation,
proportions, correlation multivariate linear regression analysis etc.

The Qualitative data from interviews and observations will be analyzed thematically. The
findings will be triangulated to provide a comprehensive understanding of the challenges.

h. Ethical Considerations: The research will adhere to ethical guidelines, ensuring

informed consent from all participants. Data will be anonymized and stored securely to
protect confidentiality.

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3.Proposed Project Team:
Principal Inves gator:
Dr.J. Sathya, MD, DCH, MPH
Principal, HFWTC, Gandhigram

Co-Principal Inve gator:

Dr. Priya Vasanth Kumari, MD., OG,
State Nodal officer – Quality Programmes, NHM – TN.

Project team consist of experts in public health working as a training faculty in the
Health and Family Welfare Training Center, Gandhigram includes public health
expert, Pediatrician, Medical officer, Maternal and child health officer, Sta s cian,
Social scien sts, Health Educa on Extension officer and Senior Sanitarian and
Reginal consultant for LaQshaya working under HFWTC, Gandhigram.
4.Timeline -implementa on plan (week wise /month-wise milestones)
Activities MONTHS (10 MONTHS)
1 2 3 4 5 6 7 8 9 &10
Preparation for project
1.Meeting state and district functionaries to
orient research activities
2.Tool development and pre testing
3.Recruitment of project staffa
4.Organising training for project staff
Survey- Infrastructural assessments
In-depth interview with health care
providers,administrators,mothers and
family
Labour room observation of health
practices
Review of documents
Data entry and analysis
Report writing and submission

5.Dura on of the project:10 months

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Reference:
1.The Times of INDIA, May 10, 2023https://timesofindia.indiatimes.com/city/chennai/key-health-
indicators-have-slowed-down-in-tn-former-health-minister/articleshow/99599632.cms?from=mdr
2. Mahalakshmi M et al(2023) “LaQshya- an uphill climb: a review of implementation of LaQshya
programme at a tertiary centre in Chennai” International Journal of Reproduction, Contraception,
Obstetrics and Gynecology Mar;12(3):785-793 DOI:https://dx.doi.org/10.18203/2320-
1770.ijrcog20230560
3. Joshua P. Vogel et.al 2022,” Implementing the WHO Labour Care Guide to reduce the use of
Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic,
stepped-wedge, cluster-randomized pilot trial” Research Square, DOI:
https://doi.org/10.21203/rs.3.rs-1591589/v1
4.Sarwal et al,2023 “Healthcare providers perceptions regarding the presence of Birth Companion
during childbirth at a tertiary care hospital in India” BMC Pregnancy and Childbirth 23:159
https://doi.org/10.1186/s12884-022-05327-1
5. Dhananjay D Mankar et al,2020 “A Study of Maternal and Newborn Healthcare Services at
District Hospital Sitamarhi, Bihar Journal of Research in Medical and Dental Science Volume 8,
Issue 5, Page No: 134-138 www.jrmds.in eISSN No.2347-2367: pISSN No.2347-254

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Research on Challenges in implementing LaQshya in Government health care
facilities in Tamil Nadu.
Budget outline
S. Unit cost Total Cost
Items/Activities Units
No. (Rs) (Rs)
Project orientation meeting with state and
1 6 25000 150000
district functionaries
2 Tool development and pre testing 1 75000 75000
3 Project Team Recruitment
a. Recruitment cost 1 40000 40000
b. Project co-ordinator salary (1 No) 30000*1 10 months 300000
c. Field Investigator salary (6 Nos.) 20000*6 6 months 720000
4 Project team capacity building 1 25000 25000
5 Survey – Infrastructural assessments
a. Survey tool cost 1 30000 30000
b. TA/DA for Project coordinator & Field
1 3000*7 staff 21000
Investigators
6 In-Depth Interviews
a. Tool cost (AV Equipment cost) 1 15000*6 90000
b. TA/DA for Project coordinator & Field
1 3000*7 staff 21000
Investigators
15000*6
7 Labour room observation & Data collection 1 90000
Districts
10000*6
8 Review of Documents 1 60000
Districts
9 Data entry and analysis
a. Data analysis tool – NVIVO software
1 150000 150000
cost
15000*7
b. Data analyst cost 1 105000
months
10 Report writing & Submission 1 100000 100000
11 Contingency & Unforeseen expenses Lumpsum 100000 100000
12 Overhead & Administrative cost 15 % 323000
13 Miscellaneous expenses Lumpsum 50000 100000
TOTAL 2500000

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