1District Hospital, Mulugu, Telangana, India
2Ganodaya College & Institute of Nursing, T. Narasipura, Mysuru, India
Reducing preventable maternal and new-born mortality is critical under the Sustainable Development Goals (SDG 3.1 & 3.2). In India, the Ministry of Health launched the LaQshya (Labour Room Quality Improvement Initiative) in 2017 to elevate the Quality of Care (QoC) through standardization based on National Quality Assurance Standards (NQAS). This study aimed to evaluate LaQshya implementation at the District Hospital, Mulugu, Telangana, and assess staff knowledge of continuous quality cycles (CQI), documentation, and Respectful Maternity Care (RMC) principles. A descriptive, cross-sectional, mixed-methods design was employed at the District Hospital, Mulugu. Data were collected from a convenience sample (N=30) of healthcare professionals (HCPs). The methodology utilized a validated observational checklist and a semi-structured interview schedule to capture both practice and programmatic awareness. Staff demonstrated high clinical experience (36.7% with ?10 years in labour room) and high awareness of core clinical protocols, such as Active Management of Third Stage of Labour (AMTSL) (96.7% to 100% awareness). However, a significant programmatic knowledge deficit was found: only 23.3% were fully aware of the six required CQI cycles, and just 16.7% fully aware of strengthened documentation procedures. RMC awareness was moderate (20.0% reporting full awareness). LaQshya implementation at the District Hospital, Mulugu, faces a critical barrier, a disconnect between high clinical competency and low programmatic awareness regarding CQI and documentation. Achieving LaQshya's objectives requires actionable, evidence-based interventions focusing on system-level training and governance to bridge this gap and ensure high-quality maternal and new-born care.
Maternal and new-born health remains one of the most significant and pressing public health challenges globally, with disparities sharply defined across economic and geographic boundaries. Despite concerted international and national efforts, including the push toward the Sustainable Development Goals (SDG 3.1 and 3.2), India carries a disproportionately high share of the global burden of maternal and new-born mortality [1]. Effective policies must target the crucial period of intrapartum and immediate postpartum care, as the majority of preventable maternal and neonatal deaths occur due to complications during delivery and the first 24 hours of life[2]. A consistent finding in implementation research is that these adverse outcomes are often linked not just to a lack of resources, but to suboptimal quality of care (QoC) and system inefficiencies within facilities [3]. To address this critical gap in quality, the Ministry of Health and Family Welfare, Government of India, launched the LaQshya (Labour Room Quality Improvement Initiative) program. This ambitious, national-level initiative operates on a time-bound, multi-pronged framework designed to ensure sustained improvement in the quality of care provided in all public health labour rooms and maternity operation theatres. The core objective of LaQshya is to reduce preventable maternal and new-born mortality and morbidity by standardizing services across three interconnected pillars: Infrastructure and Equipment, Clinical Processes and Protocols, and Human Resources and Capacity [4]. Previous studies evaluating national quality improvement initiatives have consistently highlighted that successful implementation hinges on factors assessed in this research, including:
The current study focuses on the District Hospital, Mulugu, Telangana, India, which serves as the sole tertiary-level public healthcare provider for a vast, newly formed district. This region is characterized by a significant rural and historically marginalized tribal population, creating specific public health challenges related to geographical accessibility, cultural sensitivity, and resource allocation [8]. Operating as a 24/7, 220-bed capacity facility with high-risk specialized units, including a dedicated Labour Room, Maternity Operation Theatre, and Special New-born Care Unit (SNCU), the hospital represents a high-volume, resource-constrained environment where the gap between policy intent and operational reality can be most pronounced. Given the complex interplay between national policy, facility characteristics, and staff competency, a systematic, localized evaluation is essential. Existing literature often relies on audit data or focuses on metropolitan centres, leaving a significant gap regarding the practical challenges, implementation fidelity, and specific staff perceptions in rural district hospitals like Mulugu. This study aimed to systematically evaluate LaQshya implementation at the District Hospital, Mulugu, Telangana, and assess staff knowledge, skills, and adherence to standardized maternal and new-born care protocols.
METHODOLOGY
Study Design and Setting
This research employed a descriptive, cross-sectional, mixed-methods design to systematically evaluate the implementation status of the LaQshya initiative. Data were collected at a single point in time across a three-month period (April to June 2025) in the Labour Room of the District Hospital, Mulugu, Telangana, India. This hospital serves as the primary referral centre for a high-volume, resource-constrained district.
Study Population and Sampling
The study population comprised all healthcare professionals (HCPs) directly involved in Labour Room care, including Medical Officers and Staff Nurses. A convenience sample of N=30 was selected for in-depth data collection.
Data Collection Tools
Two primary instruments, based on National Quality Assurance Standards (NQAS) and LaQshya guidelines, were used:
Both tools underwent pre-testing and content validation by subject-matter experts to ensure clarity and scientific alignment with the study objectives.
Data Analysis
Quantitative data (from the checklist and closed-ended questions) were analysed using descriptive statistics (frequencies, percentages) using statistical software MS-Excel.
RESULTS
This descriptive cross-sectional study was conducted to evaluate the baseline implementation status of the LaQshya quality improvement initiative by surveying N=30 healthcare providers (HCPs) at the Labour Room of the District Hospital, Mulugu, Telangana. The participant cohort included 18 doctors (60.0%) and 12 nursing staff (40.0%).
Table 1: Demographic Characteristics of Participants
|
S. NO. |
characteristics |
Variables |
Doctors (n=18) |
Nursing Staff (n=12) |
Total (N=30) |
|
1 |
Age (Years) |
20-29 |
2 |
7 |
9 |
|
30-39 |
8 |
3 |
11 |
||
|
40-49 |
2 |
1 |
3 |
||
|
50-59 |
6 |
1 |
7 |
||
|
2 |
Gender |
Male |
6 |
- |
6 |
|
Female |
12 |
12 |
24 |
||
|
3 |
Marital Status |
Single |
1 |
2 |
3 |
|
Married |
17 |
10 |
27 |
||
|
4 |
Religion |
Hindu |
15 |
7 |
22 |
|
Muslim |
1 |
- |
1 |
||
|
Christian |
2 |
5 |
7 |
||
|
5 |
Years of experience in Labour room |
<1 year |
1 |
1 |
2 |
|
1-5 years |
3 |
- |
3 |
||
|
6-10 years |
6 |
- |
6 |
||
|
>10 years |
8 |
3 |
11 |
The study population demonstrated a relatively mature and experienced composition, with the largest age group being 30–39 years, comprising 36.7% (n=11) of the total sample. A significant portion of the staff (23.3%, n=7) were senior professionals aged 50–59 years, signalling a substantial presence of long-tenured personnel. The staff composition was overwhelmingly female (n=24, 80.0%), with all nursing staff being female and two-thirds of the doctors being female. reflecting typical gender ratios in the maternal and nursing workforce. Hindu participants formed the dominant group, representing 73.3% (n=22) of the sample. Christian participants accounted for 23.3% (n=7), with a single Muslim participant making up the remaining 3.3% (n=1). The collective tenure within the labour room was high. The staff exhibited deep institutional knowledge, with the largest segment, 36.7% (n=11), reporting more than 10 years of experience in the labour room. This highly experienced group was predominantly composed of doctors (n=8). Furthermore, 20.0% (n=6) reported 6-10 years of experience, all of whom were doctors. Only 6.7% (n=2) reported less than one year of experience, indicating high tenure and low recent turnover within the specialized labour room setting which suggests a high level of collective stability and clinical expertise in the department.
Figure 1: Staff Composition
Figure 1 shows the distribution of specialised roles confirms the multidisciplinary nature of the labour room team. The doctor cohort was led by Gynaecologists, who constituted 55.6% (n=10) of the medical team, reflecting the primary clinical focus. Anaesthetists comprised 27.8% (n=5), crucial for pain management and emergency surgical interventions, while Paediatricians accounted for 16.7%(n=3), ensuring immediate expertise in new-born care and resuscitation. The nursing team was primarily composed of Nursing Officers (50.0%,n=6) and Midwives (41.7%,n=5), who are the frontline providers of continuous labour support and delivery care. One individual served in the supervisory capacity of Head Nurse (8.3%, n=1)
Table 2: Factors Related to Knowledge of the Staff
|
Question |
Response Category |
Frequency (n) |
Percentage (%) |
|
Fully Aware |
7 |
23.3% |
|
Partially Aware |
16 |
53.3% |
|
|
Not Aware |
7 |
23.3% |
|
|
Fully Aware |
5 |
16.7% |
|
Partially Aware |
13 |
43.3% |
|
|
Not Aware |
12 |
40.0% |
|
|
Fully Aware |
6 |
20.0% |
|
Partially Aware |
19 |
63.3% |
|
|
Not Aware |
5 |
16.7% |
|
|
Fully Aware |
9 |
30.0% |
|
Partially Aware |
20 |
66.7% |
|
|
Not Aware |
1 |
3.3% |
|
|
Fully Aware |
13 |
43.3% |
|
Partially Aware |
17 |
56.7% |
|
|
Not Aware |
0 |
0.0% |
|
|
Fully Aware |
8 |
26.7% |
|
Partially Aware |
22 |
73.3% |
|
|
Not Aware |
0 |
0.0% |
Baseline knowledge regarding core life-saving clinical protocols was robust, with 100% of respondents reporting awareness (Fully or Partially) of the essential and emergency care components for new-borns, infection prevention, and Biomedical Waste (BMW) management. Similarly, 96.7% (n=29) were aware of key labour management practices, such as Active Management of Third Stage of Labour (AMTSL) and the rational use of uterotonics. However, a critical and widespread deficit was identified in knowledge specific to the LaQshya programmatic framework. Only 7 participants (23.3%) reported being "Fully Aware" of the 6 quality cycles of the LaQshya initiative. A substantial majority (53.3%, n=16) reported being "Partially Aware," and 23.3% (n=7) were completely "Not Aware." This gap extended to program monitoring: 40.0% (n=12) were "Not Aware" of the specific documentation procedures required for program strengthening and external monitoring to be strengthened under the initiative.
Table 3: Knowledge Regarding Respectful Maternity Care (RMC)
|
Question |
Response |
Frequency (n) |
Percentage (%) |
|
Are you aware of the meaning of respectful maternity care? |
Yes |
29 |
96.7% |
|
No |
1 |
3.3% |
|
|
Are you aware of the purpose of respectful maternity care? |
Yes |
18 |
60.0% |
|
No |
12 |
40.0% |
|
|
Are you aware of the LDR (Labour/Delivery/Recovery) concept in the labour room? |
Yes |
16 |
53.3% |
|
No |
14 |
46.7% |
Awareness of the ethical and patient-centric dimensions of care was notably strong, with 96.7% (n=29) aware of the meaning and principles of Respectful Maternity Care (RMC). Practice aligned with this, as 100% of the respondents confirmed that a birth companion is permitted, meeting a fundamental RMC standard. In contrast, knowledge regarding the Labour/Delivery/Recovery (LDR) concept was significantly limited, with only 53.3% (n=16) reporting awareness.
Table 4: Factors Related to Healthcare Policy and Management (N=30)
|
Question |
Response Category |
Frequency (n) |
Percentage (%) |
|
Yes |
22 |
73.3% |
|
No |
8 |
26.7% |
|
|
Yes |
30 |
100.0% |
|
No |
0 |
0.0% |
|
|
Yes |
22 |
73.3% |
|
No |
8 |
26.7% |
|
|
Yes |
9 |
30.0% |
|
No |
21 |
70.0% |
Institutional commitment to the quality program was unanimous, with all 30 participants (100.0%) confirming that the hospital leadership actively supports the LaQshya initiative. This commitment is translated into policy, with 73.3% (n=22) reporting the existence of a formal policy regarding implementation.
Regular program-related training was reported by a high percentage of staff (73.3%, n=22). When asked about overall staffing adequacy, a majority (70.0%, n=21) did not perceive a general staff shortage for the proper implementation of the initiative. Only 30.0% (n=9) reported a perceived shortage.
Table 5: Factors Related to the Hospital Characteristics (N=30)
|
Question |
Response Category |
Frequency (n) |
Percentage (%) |
|
Yes |
18 |
60.0% |
|
No |
12 |
40.0% |
|
|
Yes |
26 |
86.7% |
|
No |
4 |
13.3% |
|
|
Yes |
21 |
70.0% |
|
No |
9 |
30.0% |
|
|
Yes |
17 |
56.7% |
|
No |
13 |
43.3% |
|
|
Yes |
12 |
40.0% |
|
No |
18 |
60.0% |
|
|
Yes |
26 |
86.7% |
|
No |
4 |
13.3% |
|
|
Yes |
30 |
100.0% |
|
No |
0 |
0.0% |
This section indicates general satisfaction with infrastructure, supplies, and dedicated staff, though perceived patient load is split almost evenly. Institutional support for the program was unanimously reported, with all participants (n=30, 100%) agreeing that hospital leadership supports LaQshya implementation. A large majority of staff reported that the hospital had drafted and implemented a policy (n=22, 73.3%) and that they were being provided with regular training (n=22, 73.3%). A dedicated Quality Control team for monitoring was also confirmed by 26 respondents (86.7%). In terms of logistics, 26 respondents (86.7%) reported a regular and adequate supply of consumables. Adequate equipment and physical infrastructure were reported by 21 (70.0%) and 18 (60.0%) staff members, respectively. While a majority (n=21, 70.0%) did not perceive a staff shortage, opinion was divided on patient load, with 12 staff members (40.0%) indicating a high patient load that affects the proper implementation of LaQshya. Furthermore, 13 staff members (43.3%) indicated that the hospital does not have dedicated staff (Doctors & Nurses) for the labour room.
DISCUSSION
This study provides a critical baseline evaluation of LaQshya implementation at District Hospital, Mulugu, highlighting a paradoxical finding: high clinical competency coupled with low programmatic fidelity. The demographic analysis shows an experienced workforce (36.7% with ≥10 years of labour room experience), which ensures strong clinical competency—a non-negotiable for acute care. However, high tenure and clinical autonomy may create inertia against adopting new systemic quality assurance mandates, such as rigorous documentation and iterative audit cycles foundational to LaQshya’s model [9]. The multidisciplinary care team (Gynaecologists, Paediatricians, Nurses) aligns with WHO standards for obstetric and neonatal emergencies, but their effectiveness relies on a unified understanding of the LaQshya system [10]. The most profound structural weakness is the disparity between clinical and programmatic knowledge. Staff reported near-perfect awareness (96.7% to 100%) of life-saving protocols (e.g., AMTSL, emergency new-born care). Contrastingly, only 23.3% were "Fully Aware" of the six quality cycles, and a concerning 40.0% were "Not Aware" of specific documentation procedures required for program strengthening. This gap is a critical flaw in quality assurance infrastructure. LaQshya is fundamentally a systemic quality management program 11]. When staff are unaware of documentation standards, the ability to generate reliable data for internal audit, achieve external accreditation, and provide transparent public health monitoring data is severely compromised. In public health epidemiology, poor documentation directly leads to unreliable outcome data, potentially masking preventable causes of morbidity [12]. The high rate of reported training (73.3%) suggests content prioritizes clinical skills over the essential systemic and managerial components necessary for continuous quality monitoring. Despite these deficits, administrative commitment is exemplary: leadership support is unanimous (100%), and resource logistics are strong (e.g., 70.0% equipment availability). Universal adherence to the principle of Respectful Maternity Care (RMC), demonstrated by 100% allowance of a birth companion, is a cultural success that aligns the institution with global standards for dignified care [13]. Yet, this success is restricted by physical and conceptual limitations. A substantial 40.0% of staff reported inadequate physical infrastructure, and awareness of the Labour/Delivery/Recovery (LDR) concept was low (53.3%). The LDR model physically embodies the RMC philosophy, and a deficit here prevents the hospital from fully realizing RMC benefits, potentially compromising privacy and infection control standards in a high-volume setting [14]. Finally, the study highlights critical operational fragility related to human resources. While 70.0% did not perceive a general staff shortage, 43.3% reported a lack of dedicated labour room personnel. Non-dedicated staff are less effective in maintaining the high-fidelity protocol adherence required by LaQshya. This lack of specialization, coupled with the 40.0% perception of high patient load negatively affecting quality, creates a systemic risk factor [15]. High workload among non-dedicated staff is epidemiologically linked to fatigue and medical errors. To embed quality, management must prioritize the stable recruitment and deployment of dedicated, specialized personnel fully responsible for the labour room's quality mandate. In conclusion, while intent and resources are present, the current training and structural setup do not support the consistent, high-fidelity execution necessary for long-term accreditation and improved public health outcomes.
CONCLUSION
The LaQshya evaluation at District Hospital, Mulugu, reveals a critical disconnect: while staff clinical competency and leadership commitment are high, sustained quality assurance is undermined by systemic gaps. The primary barrier is a significant programmatic knowledge deficit, with a majority of staff unaware of the LaQshya quality cycles and required documentation. This is compounded by structural constraints, including inadequate physical infrastructure and lack of dedicated personnel. To achieve successful accreditation and high-fidelity care, focused interventions addressing these programmatic and resource deficiencies are essential.
LIMITATIONS
The study's findings are limited in generalizability due to its single-site nature and small sample size (N=30) restricted to one labour room's staff. Furthermore, the absence of objective outcome measures (e.g., direct observation) means the actual fidelity of protocol adherence is unknown.
Recommendations for Future studies
Future research should prioritize objective measurement, moving from knowledge assessment to quantifying actual protocol adherence via direct observation and clinical audits. Concurrently, qualitative studies are needed to uncover organizational and cultural barriers to adoption, particularly among experienced staff. Most importantly, follow-up epidemiological studies must link these programmatic deficits to critical maternal and neonatal health outcomes, such as delayed early and exclusive breastfeeding initiation rates.
ACKNOWLEDGEMENT
Authors would like to thank the District Hospital, Mulugu, Telangana, for the infrastructure provided.
Conflict of Interest
Authors declare no Conflict of Interest.
REFERENCE
K. Radha Kumari, G. Padmaraja*, Evaluation of the Implementation of Laqshya Initiative Programme In Labour Room at District Hospital, Mulugu, Telangana, Int. J. Sci. R. Tech., 2025, 2 (10), 458-465. https://doi.org/10.5281/zenodo.17454637
10.5281/zenodo.17454637
