Q&A: 'Manyata is not just about a checklist': Experts weigh in on a maternal health initiative

Nurse Jessy Clement (right), a health care worker in Navi Mumbai, Maharashtra, at a Manyata training. Photo by: Armando Gallardo / Devex

The majority of women in India give birth in health care facilities — over a third in private facilities. The private sector plays a significant role in providing labor and delivery services. Ensuring that private health care workers in this sector have the skills and tools they need to offer quality care is key to ensuring all women in India can access quality care.

Manyata, a quality improvement and certification initiative, aims to ensure all private facilities are able to meet quality standards, by building health workers’ capacity to meet standards and awarding certification to facilities that demonstrate adherence to standards during a third-party assessment. These quality standards are nationally endorsed and align with WHO standards.

“Until now, nurses were used to being dictated by the obstetrician-gynecologists in terms of what they should do. Even if there were complications.”

— Dr. Samita Bhardwaj, head of national program management, FOGSI

To understand how the initiative plans to scale, and the needs and demands for a program like this, Devex spoke with two experts who have played a key role in its implementation.

As the head of the national program management unit under the Federation of Obstetric and Gynaecological Societies of India, or FOGSI, Dr. Samita Bhardwaj manages the unit that looks after the nation-wide implementation of the program.

There are three different components to the initiative, which seeks to implement a total of 16 clinical standards, Bhardwaj said, and 10 facility standards. This includes training for nurses and health care providers from the registered facilities, which is followed by quality checks to ensure that the standards are followed, and quality assurance where FOGSI lead assessors — who are trained senior gynecologists — visit the facilities and conduct an assessment.

However, “Manyata is not just about a checklist, it’s about building clinical skills of private maternity providers and ensuring that they’re able to identify complications and act upon them,” Bhardwaj said.

Dr. Sucheta Kinjawadekar, an obstetrician at the Kamalesh Mother & Child Hospital in Navi Mumbai, a suburb of Mumbai, is one of Manyata’s earliest proponents. She stresses the importance of the mentoring that nurses receive as part of the program.

Due to the Manyata training she went through in 2018, Shital Abhary, a nurse at Gupte Hospital in Pune, Maharashtra, was able to assist a patient who had gone into postpartum hemorrhage until the doctor arrived. Photo by: Armando Gallardo / Devex

“Mentorship is a key aspect of the program … Manyata includes teaching extensively for three days, followed by periodic intervals of hands-on drills, which is very helpful. This has boosted the nurses’ confidence”, Kinjawadekar said.

Both Bhardwaj and Kinjawadekar said that since the Manyata initiative focuses on knowledge and skills rather than only on infrastructure, it is applicable across the private sector — no matter what size the facility — to ensure quality care.

This conversation has been edited for length and clarity.

How would you describe the need for a program like Manyata?

Bhardwaj: The private sector in India was highly fragmented and there was no standard treatment of care. With a high number of deliveries happening in private hospitals, there was a need to standardize it. There are a set of standards for government hospitals called LaQshya, but that set is more comprehensive and includes infrastructure, ensuring supplies of medicines etc. Since FOGSI is a group of 35,000 gynecologists with the forte of clinical excellence, we decided to take up Manyata.

Kinjawadekar: As doctors, we are trained at different medical colleges with different schools of thought — and sometimes in the process, some not-so-right practices get inculcated and then we continue with those. Similarly, when nurses come to us, they are also trained with different standards.

In day-to-day practice, we teach and train our staff nurses when there is an opportunity. For example, if there is a PPH [post-partum hemorrhage] case, then we teach them about it. But by that time, if there is another case, they might have forgotten [how to deal with it]. And only those nurses who are present in the operation theater learn about it, and others miss out on the opportunity. [This is why] I was looking for a continued-education training program that would impart standardized maternal care practices. When Manyata was introduced, I immediately enrolled in it.

What are the main aims of the Manyata initiative?

Bhardwaj: We’re trying to focus on the need to standardize intrapartum care in labor room settings. It begins from ... the time the patient walks into your hospital to initial care and treatment of the patient — when she is going into active labor, the way of managing and tracking the progress of labor. [Followed by that, the standards focus on] how to provide proper delivery, and then managing the complications of labor if the patient gets into eclampsia — and ensuring resuscitation and care.

What are the challenges in implementing an ambitious program like Manyata?

Bhardwaj: Because it’s a FOGSI-led initiative, which is a premier organization of leading practitioners in India, it wasn’t difficult at all to find takers. We have requests even from nonimplementing states in the country [currently, the program runs in Maharashtra, Uttar Pradesh, Karnataka, Rajasthan, and Jharkhand.] We find that the requirement is at an all-time high. The challenge before us now is to figure out how to service this demand.

From your perspective, how has Manyata made a difference in the maternal care sector?

Bhardwaj: The stories from the ground are the best indicators of the difference Manyata has made. Whenever you meet doctors, they will tell you. The nurses are now able to identify problems and act on them, even without the presence of a gynecologist — which is immensely useful in resource-poor settings. It is making a difference in saving lives. Doctors have been telling us about their positive experiences where the nurses have started being pro-active and want to use what they’ve learnt in the trainings.

Kinjawadekar: Because of Manyata, we’ve been able to implement a few new concepts in our facility: one of them is that of a birth companion. [Before], nurses had an inhibition about [a patient’s] husband being present in the labor room. But this has changed in part due to the training. Because of Manyata, the nurses were able to see a change in the attitude of relatives [of the patient] towards the nurses. Nurses can now see that respect is reciprocal.

Could you say a little more about the mentoring aspect?

Bhardwaj: Until now, nurses were used to being dictated by the obstetrician-gynecologists in terms of what they should do. Even if there were complications, the nurses weren’t empowered to make their own decision. With Manyata, nurses feel confident and empowered to take steps on their own to avoid complications and act upon them in order to ensure the best care for mothers and children.

Kinjawadekar: Mentorship is a key aspect of the program. The folks from Jhpiego [an organization specializing in reproductive health training and implementing partner of Manyata] conduct regular mentorship visits. Teaching is like preaching for [a] day, and then people forget what was said, which is of no use. But Manyata includes teaching extensively for three days, followed by periodic intervals of hands-on drills which is very helpful. This has boosted the nurses’ confidence.

The Maternity Matters series is sponsored by MSD for Mothers, MSD’s $500 million initiative to help create a world where no woman has to die giving life. The content of this article is the responsibility of the author(s) and does not necessarily represent the official views of MSD. MSD for Mothers is an initiative of Merck & Co., Inc. Kenilworth, N.J., U.S.A.

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