Maternity service would, perhaps be the most important service from public health point of view because an efficient maternal and infant health service are the very foundation of nation’s health. The quality of maternity services of a hospital must be of the highest order because: first, it affects two lives –that of the mother and the child and secondly unhealthy handicapped child not only deprives the nation of a healthy productive adult but also imposes a tremendous social and economic burden for the family.

Broad aims of the service would be three fold

First: to ensure a safe of the mother through pregnancy labor and the puerperium.

Second: to secure the birth of a healthy infant without any defects/diseases and with the best possible chances of survival and growth.

Third: ensuring that the mother, at the end of the lying in period enjoys as good or good even better health then she was in pregnancy.

Scope of services
Maternity services would generally include the following components:

1. Outpatient services for antenatal check up and post natal follow –up immunization, investigation and monitoring the progress.
2. In patient service: antenatal ward delivery room, to, post natal ward.
3. Obstetrical ICU department with more than 2000 deliveries /year may have an separate obstetrics ICU for patient with diabetes,RH incompatibility with complication, eclampsia, and severe PIH. Premature labour      (<33-34 weeks) for monitoring of physiological parameters of mother and the fetus very closely.
4. Out reach service through satellite clinics of individual doctors clinics or Hospital satellite clinics.

Role

1. Safe management of pregnancy
2. safe conduct of deliveries
3. Should understand important once of reproductive health
4. training to the expectant mothers in mother craft and prenatal exercise
5. family planning advice
6. advice to infertile couples
7. Counseling with regard to pregnancy and genetic problems and excluding congenital malformation or genetic problem through antenatal screening.

Function of maternity services

1. Antenatal check up to ascertain the maternity and fetal well –being and to find out any hazards/complication likely to affect the mother or the child.
2. Administration of necessary medication and /or immunization to improve maternity health and prevent complications.
3. Investigation to ascertain the Rh incompatibility and also to role out any concomitant disease such as STD/HIV.
4. Medical termination of pregnancy (MTP) services.
5. Advice and investigation of infertile couples.
6. Safe conduct if delivery by natural/surgical approach where indicated.
7. Post natal follow-up and care of the mother and child.
8. Counseling regarding family planning and positive reproductive health.
9.  Health education and training of mothers in mother craft and antenatal exercise.

There are three component of quality of service – outcome, structure and process.

Quality of outcome

1. Safe, full term delivery of a healthy baby through natural process (as far as possible) or surgical intervention where indicated.
2. No adverse effect of the health of mother.
3.  full protection of the mother and the child against all the attendant hazard/dangers/complications
4. Improved reproductive health of the mother.
5. Services rendered at a reasonable/affordable cost .in fact this is one service which must available for all regardless of the paying capacity.

Quality of outcome, however depend on the other two factors.

Quality of structure

Similarly the inpatient maternity services (antenatal /pos-natal ward and delivery suit, intensive care) may be clubbed with the adjoining NICU/PICU close to labour room area.
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Space allocation and lay out should be as per norms and should have the usual labour room complements plus an eclampsia bed adjoining the labour room (first stage). It have a floor space of at least 18 sq M because often these rooms have to serve as emergency delivery rooms also .the delivery suit should be about 30sq M. Both thedelivery suit eclampsia room and observation beds in labour room should have controlled temperature and humidity and each bed should nave oxygen (also far the baby) and suction outlets and arrangement for resuscitation. Since about 20% of the deliveries require surgical intervention, a Operation Theater will be located in the labour room complex nearby for operative deliveries.

One LDR the (labour delivery room) may be provided close to labour room as structured changes are not possible at this stage with in the labour room complex.

2.  Quality of Equipment and Materials Available
High safe child birth does not generally depend upon costly gadgets, facility of certain essential equipments (such as examination tables adequate lights, foetal Doppler, infusion pumps, bed side CTG machine, forceps, vacuum extraction, motorized delivery tables, overhead lights, birthing beds, open care system, equipment for the operative deliveries, pan washers, bio-medical management equipment and on line computer terminal can enhance the quality of services and improve the chance if safe child birth even in complicated cases.

3.  Staffing
The department should have consistent (experienced obstetrician) along with and senior consultant along with treating doctor will be conducting and slowly-slowly it will be left to emergency consultant after one year  residents for cover round the clock. It has been agreed that emergency deliveries. Nurses and staff trained and experienced in labour room work should be posted round the clock, adequate enough to provide effective cover to antenatal/ all beds and delivery suite.

4.  Quality of Engineering Support Services

• Stable and uninterrupted power supply with hot and cold water.      
• Piped gas and vacuum supply.
• Adequate lighting and efficient air conditioning system.
• Efficient communication system.

QUALITY OF PROCESS

Quality of process should be such as would ensure the following:

1. Quality manual for assurance of quality of services.
2. SOPs for antenatal check up, schedule of consultations and parameters to be checked, the investigations to be carried out, screening for various diseases, the immunization protocol, precautions to be taken, the advice regarding diet, exercises, effects of smoking/drinking/drugs, etc. on the pregnancy.
3. Protocols for assessing the risks and managing the risks during the pregnancy, delivery and after delivery, through a proactive approach to managing the risks.
4. A protocol for special care for women with poor obstetrical medical history (such as diabetes) for care and advice before conception and during pregnancy.
5. Protocols for full briefing and education of the couples about maternal/fetal health, the precautions to be taken, the delivery complications expected if any and the estimated expenditure so they can take informed decisions.
6. Procedure for obtaining informed consent on standardized form.
7. Detailed SOP on safe conduct of delivery, including the protocol for assisted/caesarian delivery.
8. Protocols for efficient management of complications such as delayed labour, fetal distress, major post-partum haemorrhage.
9. A protocol for pain management and administration of epidural analgesia.
10. A protocol for resuscitation of babies requiring resuscitation.
11. A protocol for ensuring availability of a pediatrician at the time of deliveries for immediate resuscitation.
12. Policy and procedure for decision on admission of the babies requiring readmission.
13. A documented procedure for Infection Control.
14. A procedure for briefing the couple at the time of discharge and the care of mother and child, the follow ups, the dietary advice, immunization and, family planning.
15. A procedure for identification (standardized identity tags) safety/security of new born babies against theft or mix up.
16. Protocol for reporting the adverse/near miss events.
17. A policy for restriction on unnecessary/hazardous investigation as X-rays.
18. A protocol for conduct of abortions as per the rules and regulations.
19. A procedure for safe disposal of bio-medical waste as per the rules.
20. A procedure for maintenance of records and reporting of birth should ensure showing to the parents immediately after birth correctly recording the sex of the child so as to avoid any confusion.
21. A documented SOP on the outreach services giving details policies, procedures, scope and the system of delivery of service

Disputes about the sex of the baby of the  sex baby due to alleged cases baby swapping are not very uncommon in the hospitals. There should be a foolproof system of showing in the baby at the earliest after the birth, authentication by the mother/father in the records, and a system of double check to ensure that correct sex is motional in the records sent.

• Caesarian section rate.
• Maternity death rate.
• Prenatal mortality.
• Instance of maternity /fetal deaths due to mismanagement of labour at any stage.
• Incidence of unexpected complication such as burst uterus, fetal distress,    post –partum hemorrhage hyperbilirunemia, cerebral hemorrhage.
• Instance of avoidable complication/permanent damage to the baby such as birth trauma cerebral anoxia, retrolental fibroplasias, infections, hypoglycemia or hypothermia.
•  Incidence of theft swapping of babies

Maternal and neonatal death rates are, perhaps, the most important indices of quality of health services in a nation. Quality of maternity services is not much depended upon sophisticated equipment. All that is required is arrangement for periodic antenatal problem and safe delivery by trained staff, under aseptic condition and using standard protocols. if this much can be assured, the quality of services will improve and the maternal and infant death rate will come down.

However, to ensure that hospital has to provide adequate facilities and trained staff as per the lay down standards. More then the process of delivery of care has to be standardization by developing and implementation the policies and working protocols as per the national /international norms.
It is also important that the hospital has a system of continuous monitoring to ensure that the services are of desired quality standards.