USAID’s MaMoni Maternal and Newborn Care 
Strengthening Project (MaMoni MNCSP)
(USAID Cooperative Agreement # 720388-18-CA00002)
________________________________________________________
Findings from the Quality of Care Survey in 
Manikganj District
MaMoni MNCSP Baseline Survey Report
July 2020
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This report summarizes the baseline findings of MaMoni MNCSP project quality of care (QoC) 
survey in Manikganj. As a consortium member of MaMoni MNCSP, International Centre for 
Diarrheal Disease Research, Bangladesh (icddr,b) conducted the baseline survey of MaMoni 
MNCSP facilities. The aim of this survey was to portray the baseline situation of quality of care 
for maternal and newborn health in MaMoni MNCSP facilities included in the QI initiative. 
Project Team
Sk Masum Billah1
Nazia Binte Ali1
SM Rokonuzzaman1
Mahmoodur Rahman1
Sabrina Sharmin1
Zubair Shams2
Bal Ram Bhui2
Samantha Herrera2
Joby George2
Shams El Arifeen1
Published by:
Maternal and Child Health Division (MCHD)
International Centre for Diarrheal Disease Research Bangladesh(icddr,b)
GPO box: 128, Dhaka-1000
Mohakhali, Dhaka-1212, Bangladesh
Telephone: +880-29827001-10
URL: http://www.icddrb.org
*1 International Centre for Diarrheal Disease Research Bangladesh (icddr,b)
*2 Save the Children, Bangladesh 
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TABLE OF CONTENTS
List of Tables........................................................................................................................................................ iv
List of Figures....................................................................................................................................................... vi
Acronyms............................................................................................................................................................. vii
Executive summary........................................................................................................................................... viii
Background..........................................................................................................................................................13
Methodology .......................................................................................................................................................15
Results...................................................................................................................................................................20
Standard 1: Evidence-based care for during labor, childbirth, and post-partum....................20
Standard 2: Health information systems ..................................................................................................32
Standard 3: Functional referral systems...................................................................................................33
Standard 4: Communication...........................................................................................................................34
Standard 5: Respect and dignity...................................................................................................................35
Standard 6: Emotional support.....................................................................................................................35
Standard 7: Competent and motivated human resources .................................................................36
Standard 8: Essential physical resources available..............................................................................37
Conclusions..........................................................................................................................................................48
Recommendations..............................................................................................................................................49
References............................................................................................................................................................51
Annex 1: MaMoni MNCSP PERFORMANCe indicators..........................................................................54
Annex 2: Data collection process and data sources................................................................................57
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LIST OF TABLES
Table 1: List of study facilities............................................................................................................ 15
Table 2: Sample size......................................................................................................................... 19
Table 3: Percentage of facilities with basic equipment and supplies in the delivery room1 ..................... 20
Table 4: Percentage of women delivered in the facilities assessed appropriately at admission by type of 
facility and by components of assessments [prenatal history/risk factors, vital signs, danger signs, physical 
exam], Manikganj 2019*.................................................................................................................. 22
Table 5: Percentage of women delivered in the facilities who received appropriate monitoring during 
postpartum period by facility type Manikganj 2019* ......................................................................... 26
Table 6: Essential logistics and supplies for management of complications during pregnancy, child birth, 
and postpartum, Manikganj 20191 .................................................................................................... 28
Table 7: Number of women with PROM who received ACS and antibiotic, Manikganj 2019 ................ 29
Table 8: Percentage of newborn received routine care immediately after birth, Manikganj 2019*........ 30
Table 9: Among the women delivered in the facilities, the percentage of women and newborns who received 
routine postnatal care (PNC) before discharge from the facilities, Manikganj 2019*............................ 31
Table 10: Percentage of facilities having complete, accurate, standardized medical records and mechanisms 
for data collection, analysis and feedback, Manikganj 2019 ............................................................... 33
Table 11: Percentage of women/newborns with complications referred, Manikganj 2019**................. 34
Table 12: Among the women delivered in the facilities, percentage who reported that they received 
information about care and had effective interactions with staff, Manikganj 2019 ............................... 34
Table 13: Among the women delivered in the facilities, the percentage who reported physical/verbal or 
sexual abuse and the percentage who reported that they received informed choices about services, 
Manikganj 2019* ............................................................................................................................. 35
Table 14: Percentage of facilities had access at all time to skilled birth attendant and leadership in 
continuous quality improvement (QI), Manikganj 20191 ..................................................................... 37
Table 15: Percentage of facilities with WASH functioning, reliable, safe and sufficient; clean physical 
environment and regular source of electricity; essential supplies of laboratory supplies and tests, Manikganj 
20191 ............................................................................................................................................... 38
Table 16: Percentage of women assessed appropriately during ANC consultation (history taking and 
physical examination), Manikganj 2019*........................................................................................... 40
Table 17: Among women in their first ANC, the percent who were asked or referred to undertake the tests 
or the provider performed the test, Manikganj 2019* ........................................................................ 43
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Table 18: Among women in their follow up ANC visit, the percent who were asked or referred to undertake 
the tests or the provider performed the test, Manikganj 2019*........................................................... 43
Table 19: Percent of women who were prescribed, provided, and given an explanation on how to use 
different routine medicines, and given an explanation of the side effects of different routine medicines, 
Manikganj 2019* ............................................................................................................................. 45
Table 20: Percent of women who received counselling on different topics as per Maternal SOP Bangladesh 
during ANC, Manikganj 2019*.......................................................................................................... 45
Table 21: Percent of women satisfied with different components of counselling during ANC, Manikganj, 
2019* .............................................................................................................................................. 47
Table 22: Percent of women who were satisfied with the provision of care during ANC, Manikganj 2019*
........................................................................................................................................................ 47
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LIST OF FIGURES
Figure 1: Percentage of women delivered in the facilities whose partograph was initiated during first stage 
of labor (taken as a proxy of appropriate monitoring during labor), Manikganj 2019.......................... 23
Figure 2: Mode of delivery among women who gave birth in the study hospitals................................. 23
Figure 3: Percentage of women administered immediate postpartum uterotonic (PPH prevention), 
Manikganj 2019 ............................................................................................................................... 25
Figure 4: Percentage of women who suffered from different complications during labor, delivery and 
postpartum; Manikganj 2019............................................................................................................ 27
Figure 5: Percentage of newborns who suffered from different newborn complications, Manikganj, 2019
........................................................................................................................................................ 27
Figure 6: Percentage of women with severe preeclampsia/eclampsia treated with Mag. Sulfate, Manikganj 
2019 ................................................................................................................................................ 29
Figure 7: Family planning services provided to recently delivered women before discharge from the facility 
*....................................................................................................................................................... 32
Figure 8: Among the women delivered in the facilities, the percentage who reported that they were advised 
to have birth companion*, had a birth companion, *and who reported that they wanted and had a birth 
companion of choice** during labor and delivery, Manikganj, 2019 ................................................... 36
Figure 9: Among the women delivered in the facilities; the percent who reported clean physical 
environment*, Manikganj 2019 ......................................................................................................... 39
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ACRONYMS
ACS Antenatal Corticosteroid
ANC Antenatal Care
CEmONC Comprehensive Emergency Obstetric and Newborn Care
DH District Hospital
EDD Expected Date of Delivery
EmONC Emergency Obstetric and Newborn Care
HBsAg Hepatitis B Surface Antigen 
IFA Iron-Folic Acid
IMCI Integrated Management of Childhood Illness
LMP Last Menstrual Period
MCHIP Maternal and Child Health Integrated Program
MCWC Manikganj Mother and Child Welfare
MEL Monitoring, Evaluation and Learning 
MgSO4 Magnesium Sulfate
MMR Maternal Mortality Ratio
MNCSP Maternal and Newborn Care Strengthening Project
MNH Maternal and Newborn Health
MR Menstrual Regulation
PDCA Plan, Do, Check, Act
PNC Postnatal Care
PPFP Post-partum Family Planning
PPH Post-partum Hemorrhage 
PROM Premature Rupture of Membrane
QED Quality, Equity, Dignity
QI Quality Improvement
QoC Quality of Care
SOP Standard Operating Procedure
UHC Upazila Health Complex
USG Ultrasonogram
VDRL Venereal Disease Research Laboratory
WHO World Health Organization
viii | Page
EXECUTIVE SUMMARY
Background
The World Health Organization (WHO) envisions “a world where every pregnant woman and new￾born receives quality care throughout the pregnancy, childbirth and the postnatal period.” It is evident 
that ANC can save lives by averting maternal deaths from pregnancy-related complications and 
reducing the prevalence of stillbirths. The time around childbirth (labor, delivery and post￾partum) is a crucial period for saving a majority of maternal and newborn lives and preventing 
stillbirths. With the increase in the coverage of facility deliveries, it is important to ensure quality 
of care. Poor quality of care not only increases mortality and morbidity, but also reduces 
utilization of effective interventions. The WHO definition of quality of care is “the extent to which 
health care services provided to individuals and patient populations improve desired health outcomes. In 
order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”
The MaMoni MNCSP Quality of Care (QoC) survey aims to assess the provision of care and 
experience of care for labor, delivery and antenatal care services. 
Methods
We used the WHO QoC framework for the QoC assessment of labor and delivery services in 
selected public and private health facilities. Case observations (labor, delivery and post-partum 
period); exit interviews of the women whose deliveries were observed; and hospital record 
reviews were employed as data collection methods. We also observed ANC consultations from 
the same facilities for assessing provision of care during ANC service delivery. Women receiving 
ANC consultation were interviewed to understand their experience of care during ANC. 
Facilities from Manikganj district under MaMoni MNCSP Quality Improvement (QI) initiatives 
that provided delivery services were included in this study. Data collection continued between 
May and August 2019.
Key Findings
Quality of care for labor and delivery services
Standard 1: Evidence-based care for maternal and newborn health
• Input level indicators
 Overall, 97% of facilities had 7.1% chlorhexidine solution in their delivery 
room; newborn bag and mask was available in 90% of facilities.
 Injection oxytocin was available in 35% of facilities on the day of observation. 
Availability varied by level of facility; 100% in the district hospital and
maternal and child welfare center (MCWC), 66% in upazilla health complexes 
(UHCs), 23% in union level facilities, and 100% in the 2 private hospitals. 
 Overall, 10% facilities had magnesium sulfate available on the day of 
observation; however, this included 100% availability in the district and 
private hospitals, and no availability in the other facilities levels (MCWC, 
UHCs, and union level facilities). 
 Antenatal corticosteroid (ACS) was rarely available in the facilities. 
• Process level indicators
o Routine care during labor, delivery and the immediate postpartum period
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 Appropriate prenatal history and risk assessment is crucial for patient 
management. Overall, 43% of women were asked about current pregnancy 
complications, while only 12% women were asked about previous pregnancy 
complications.
 Partograph was initiated among 26% of women in first stage of labor.
 Overall, 66% women were delivered by C-section; the percentage of delivery 
by C-section was higher at private facilities (84%), followed by tertiary care 
public health facilities (District Hospital/Maternal and Child Welfare Centre) 
at 61%.
 Around 83% of women received injectable oxytocin within one minute of 
delivery (MaMoni MNCSP project performance indicator/WHO Core MNC QoC 
Indicator).
 Less than half of the women received monitoring of danger signs within two
hours’ post-partum. Blood pressure was monitored among 42% of
postpartum women. Monitoring of vaginal bleeding took place for 38% of 
women.
 Around 71% of newborns initiated breastfeeding within one hour of birth
(MaMoni MNCSP’s project performance indicator/WHO Core MNC QoC Indicator).
 Overall 9% of newborns received all five essential newborn care practices. 
 Birth weight was documented for around two-thirds of newborns (WHO Core 
MNC QoC Indicator).
o Maternal and newborn complications
 Among 1,923 deliveries reviewed, the prevalence of prolonged labor, 
eclampsia/severe preeclampsia, and PPH were 4%, 2% and 0.4%, respectively.
 We reviewed a total of 38 eclampsia/severe preeclampsia cases. Overall 
around 65% eclampsia/severe preeclampsia cases admitted in the facilities 
were treated with magnesium sulfate; though administration was higher in 
district hospitals (74%) than in private hospitals (40%) (MaMoni MNCSP project 
performance indicator).
 Out of 1,795 live births reviewed, 5% were preterm and 2.2% of newborns 
suffered from birth asphyxia. KMC was initiated for around 5.8% of preterm 
newborns weighing less than 2500g (WHO Core MNC QoC Indicator). Around 
34% of the premature rupture of membrane (PROM) cases received ACS.
o Postnatal care
 Postnatal assessment of mothers for danger signs was low. Around half of the 
mothers were checked for excessive bleeding before discharge, while blood 
pressure was measured for around 38% of mothers.
 For 31.1% of newborns, providers inspected the cord stump. Monitoring 
practices were better in private hospitals compared to public facilities.
 Around one third (34%) of women were counselled on post-partum family 
planning (PPFP), while 9% of recently delivered women received family 
planning methods before discharge.
Standard 2: Health information systems
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• Only 20% facilities had registers for patients referred for emergency obstetric and 
newborn care (EmONC).
• Availability of referral forms was very low (10%). 
• In 13% of facilities, the Quality Improvement (QI) team regularly extracts data and
calculates and visualizes prioritized quality indicators. Data was used for decision making 
in around 10% of facilities.
Standard 3: Functional referral system
• Observations include cases from both public and private facilities, so any referral note 
(govt. slip and others) given was included in the analysis. 6% of cases were referred out,
out of which 66% were given a referral note
• A majority of the referral notes contain only diagnosis. History and management given 
were not mentioned.
Standard 4: Communication
• Almost all the women who delivered in the facilities received counselling before discharge
(94%) (MaMoni MNCSP project performance indicator/WHO Core MNC QoC Indicator).
• Around 84% of women reported that they were given an opportunity to discuss their 
concerns and preferences.
Standard 5: Respect and dignity
• Around 83% of women reported that they were adequately informed by health workers 
about their health and care.
• Few women (1.1%) reported physical or verbal abuse during their stay at the hospital
discharge (MaMoni MNCSP project performance indicator/WHO Core MNC QoC Indicator).
Standard 6: Emotional support
• Around 63% of women who wanted a companion during labor and childbirth, ending up 
having a birth companion (MaMoni MNCSP project performance indicator/WHO Core MNC 
QoC Indicator). 
Standard 7: Competent and motivated human resources
• Delivery roster was displayed in 17% of facilities.
• One in 10 facilities had regular quality assurance activities with observed documentation.
• 45% of facilities had a mechanism of receiving client feedback on health care services.
Standard 8: Essential physical resources available
• Around 79% of facilities had basic provision of water supply in the delivery area.
• Almost all facilities had basic sanitation facilities available for women during and after 
labor and childbirth. 
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• Electricity was available in 75% of facilities.
• More than half of the facilities (55.2%) provided for safe disposal of sharp waste.
• Safe disposal of infectious waste was available in 44% of facilities.
Quality of care for antenatal care (ANC) services 
Provision of care
• Findings on provision of care for ANC were reported based on observation of ANC case 
consultations.
• Around 85% of the women were asked about history of previous pregnancy loss 
(menstrual regulation (MR)/abortion).
• Inquiry about current pregnancy complications and previous pregnancy complications 
are critical components of history taking during ANC consultation. During history taking, 
around 87% women were asked about current pregnancy complications. Among the 
women who had history of previous pregnancy, around one-third were asked about 
previous pregnancy complications.
• During physical examination at ANC, around three-fourths of women were assessed for 
uterine height. Fetal presentation and fetal heart sound were assessed among 23% and 
45% of the women. Assessment of edema and urine protein were done only among 41% 
of women.
• Routine laboratory tests during pregnancy are important for identification of 
complications and to prevent adverse pregnancy outcomes. Overall, 79% of women were 
asked or referred to for hemoglobin measurement. Blood grouping or typing was 
recommended to 41% of women. Around half of the women were asked or referred to 
undertake different urine tests and an ultrasonogram scan.
• The WHO 2016 ANC guidelines recommend context-specific routine supplementation of 
iron-folic acid (IFA), calcium, vitamins, and deworming medications for improving 
maternal and perinatal outcomes. Among all women observed during ANC, 84% were 
prescribed IFA, 55% calcium and 39% vitamins. None of the women who were in third 
trimester of pregnancy, were either prescribed or supplied misoprostol and 
chlorhexidine.
• Around 48% of women received counselling on nutritious diet, while 16% received 
counselling on danger signs. Less than one-third of women received counselling on 
different components of birth preparedness.
Experience of care among ANC clients 
• Experience of care information was collected during client exit interviews using a 
structured questionnaire. Women were asked about different components of counselling. 
They were asked whether they were satisfied with the level of information received, not 
satisfied, or not informed at all. Overall, satisfaction with counselling on specific topics 
areas was low: 41% of women were satisfied with the counselling on nutritious food, 25% 
on selection of place of delivery, 17% on birth preparedness, and only 10% on danger 
signs during pregnancy.
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• A majority of the participants were satisfied with the attitude of the provider (87%), 
opportunity to discuss concerns (87%), and cleanliness of the facilities (73%).
• Very few participants at the district hospital were satisfied with the waiting time. Overall, 
satisfaction on different ANC service provisions was less among the mothers at the 
district hospital. 
Conclusion
Findings from the MaMoni MNCSP QoC survey provide a comprehensive picture of the quality 
of care with regard to maternal and newborn health in facilities included in the QI initiative. 
These results depict the baseline situation in the study facilities against which progress of the 
project can be measured. The findings provide critical insights into areas that need careful 
attention by the project for improvement.
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BACKGROUND
According to WHO, globally, 2.6 million children died within the first four weeks after birth (neonatal 
period) in 2016 – approximately 7,000 deaths daily. Half of all neonatal deaths occur within 24 hours 
after birth and 75% of the neonatal deaths occur within seven days (1). Moreover, neonatal mortality 
accounts for 46% of all under five deaths (2). Children are at the highest risk of dying during the neonatal 
period (30 deaths per 1000 live births in Bangladesh) with the risk decreasing over the course of time 
(3). The majority of newborn deaths occur in developing countries due to low access to health care (2).
The greatest proportion of newborn deaths occur in southern Asia (39%), followed by sub-Saharan 
Africa (38%) (3).
In Bangladesh, neonatal deaths constitutes 67% of the overall under-five deaths, although the country 
achieved the MDG target for under-five mortality rate (3). From 1994 to 2014, there has been a sharp 
decline in under-5 mortality rate, from 133 to 46 per 1,000 live births. However, within the same 
timeframe, neonatal mortality only declined from 52 to 28 per 1,000 live births (5). This much slower 
reduction of neonatal mortality has led to a rise in the proportion of neonatal deaths as part of overall 
under-five deaths, from 40% in 1993-1994 to 60% in 2010-2014 (5). There are also vast disparities in 
neonatal mortality within the population related to household wealth, mother’s educational level, and 
geographic location. Newborns from poorer families and those in which the mother is uneducated are 
at higher risk of newborn mortality compared to wealthier families or a families with an educated 
mother (5). Neonates who die suffer from conditions or diseases that are mostly due to a lack of quality 
of care during birth and post-birth management (2). Skilled and quality care is essential to avert this 
scenario. The WHO, in collaboration with other international experts, has identified interventions 
proven to result in improved newborn outcomes. These focus on interventions during pregnancy and 
the immediate neonatal period. To achieve SDG target 3.2 (neonatal mortality of 12 per 1,000 live births 
and under-5 mortality of 25 per 1,000 live births), Bangladesh has to further reduce under-5 mortality 
by 44%, including newborn deaths by 60%.
Everyday around 830 women die globally due to complications of pregnancy and childbirth, and 99% of 
these deaths occur in developing countries (6). Most of these deaths could be averted by skilled care 
before, during, and after childbirth. There was a rapid decline of maternal mortality between 2001 and
2010. Within this timeframe the maternal mortality ratio (MMR) decreased to 194 from 322 per 100,000 
live births (7). According to the Bangladesh Maternal Mortality and Health Care Survey (BMMS) 2016, 
Bangladesh’s MMR is 196 per 100,000 live births, which is similar to the 2010 BMMS (194 per 100,000 
live births). 
On the other hand, utilization of the complete continuum of maternity care (antenatal care, delivery 
care, and postnatal care from medically trained provider) has increased from 19% in 2010 to 43% in 
2016 (8). Antenatal care (ANC) seeking from a medically trained provider has increased to 74%,
compared to 55% in BMMS 2010. However, disparities in utilization persists among wealth quintiles (51% 
vs 93% between the lowest and highest quintiles), and educational status (48% vs 93% in mothers with 
no education and mothers with secondary or higher education) (8). In the 2016 BMMS, 37% of pregnant 
women received four or more ANC (8), which was only 23% in the 2010 survey (7). Deliveries attended 
by a medically trained provider more than doubled in six years (27% in 2010 vs 50% in 2016). Seeking 
facility based care for reported maternal complications increased from 29% in 2010 to 46% in 2016 (7,8).
Despite these improvements in utilization of maternity care, maternal mortality reductions in 
Bangladesh have stalled.
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This paradox of increased health care utilization with minimal or no impact on mortality indicators 
raises the issue of quality of care to the forefront. A multi-country analysis found that improvements in 
quality of care are more important in reducing maternal mortality than high utilization of care (9). Low 
quality of care not only causes low reduction of mortality; it also limits the utilization of the program 
itself (10). In order to increase health care utilization along with positive changes in health outcome, 
maintaining WHO Standards for Improving Quality of Maternal and Newborn Care in Health Facilities1
is essential. 
MaMoni MNCSP
The USAID-funded MaMoni Maternal and Newborn Care Strengthening Project (MaMoni-MNCSP) led 
by Save the Children Bangladesh works with a broad objective of increasing equitable utilization of 
quality maternal and newborn care services. Key outcomes will be achieved through improvements in 
four closely linked intermediate results (IRs) to advance health system responsiveness: MNH service 
quality and governance; access to and demand for services and healthy household practices; and 
national capacity to deliver these services with quality at scale.
The MaMoni-MNCSP strategic objective aligns with Government of Bangladesh (GoB) priorities to 
target the major causes of maternal and newborn deaths. The MaMoni-MNCSP consortium embraces 
the GoB vision of “a Bangladesh where there are no preventable deaths of newborns or stillbirths, where 
every pregnancy is wanted, every birth celebrated, and women, babies and children survive, thrive and 
reach their full potential” and will meaningfully contribute to achieving its goals of reducing the neonatal 
mortality rate to less than 18/1,000 live births and the maternal mortality ratio (MMR) to less than 
121/100,000 live births by 2022. 
As a member of MaMoni MNCSP consortium, International Center for Diarrheal Disease Research,
Bangladesh (icddr,b) planned, organized, implemented, analyzed and developed this report with 
technical assistance from the monitoring, evaluation, research and learning team of MaMoni MNCSP. 
Objectives
The MaMoni MNCSP baseline assessment included a household survey, health facility assessment, and 
quality of care survey in priority MaMoni MNCSP districts. The overall aims of the three surveys are to 
track the coverage of maternal and newborn interventions in MaMoni MNCSP priority districts and to 
evaluate the impact of the program on reductions in neonatal mortality in intervention areas at the end 
of the project. In this quality of care (QoC) survey, we investigated quality of maternal and newborn 
health (MNH) care in selected facilities of Manikganj district, using the WHO QoC framework.
 
1 1) Evidence based management of complications; (2) Actionable information systems; (3) Functional referral systems; (4) Effective 
communication with women and families; (5) Patients/caretakers treated with respect; (6) Emotional support for parents/caretakers of newborn 
(7) Competent, motivated staff; (8) Infrastructure, environment and resources to provide care
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METHODOLOGY
Study design 
We employed a cross sectional study design for the QoC assessment in selected public and private 
health facilities. Data collection methods included case observations, exit interviews, and hospital record 
reviews. Data collection was conducted between May and August 2019.
Study sites
For the QoC assessment, facilities under MaMoni MNCSP quality improvement (QI) initiative in 
Manikganj district that provide delivery services were included. Facilities participating in the MaMoni QI 
initiative were purposively selected for the assessment. The selected intervention health facilities were:
• Manikganj District Hospital (DH) (250 bed capacity)
• Manikganj Mother and Child Welfare Centre (MCWC) 
• 3 Upazila Health Complexes (UHCs)
o Saturia UHC 
o Daulatpur UHC
o Shibalaya UHC
• 24 Union Health and Family Welfare Centers (UHFWCs)
• 2 private hospitals
o Monno Medical College and Hospital, Manikganj
o Islami Bank Community Hospital, Manikganj
Table 1: List of study facilities
Sub-district DH MCWC UHC UHFWC Private 
Facilities
Total
Manikganj 1 1 N/A 8 2 12
Shibalaya N/A N/A 1 4 0 5
Saturia N/A N/A 1 8 0 9
Daulatpur N/A N/A 1 4 0 5
Total 1 1 3 24 2 31
Ethical considerations
IRB approval
The survey protocol was approved by the Institutional Review Board of icddr,b and the Ethical Review 
Committee of Save the Children USA.
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Informed consent process
Participants were informed of the objective of the study along with associated risks or benefits and were 
asked to participate voluntarily. Informed written consent was taken from the participants. Participants
were assured of confidentiality in the handling of the information they provided and that they would 
only be identified with unique IDs in the study. Study data were kept in strict confidence and in safe 
storage, only available to the senior staff on the study. Participants were informed that the study was 
entirely voluntary and they had the right to withdraw from the study at any stage. Written consent, 
which was indicated by a signature or thumbprint, was taken from the participants. Only consenting 
subjects were enrolled in the study. All interviews were conducted in Bangla. 
Safety considerations
This was an observational study in which pregnant women presenting in labor and pregnant women 
attending regular ANC in the selected health facilities were observed and interviewed. There were no 
expected risks to the participants in the study.
Reimbursement or compensation to study participants
No direct monetary compensation was provided to the participants in this study. 
Data collection methods and participants
This baseline QoC assessment included a health facility assessment, case observations, structured 
interviews, case simulation interviews and record reviews. Relevant assessment tools and their potential 
sources are provided in Annex 2. The major data collection methods are described below.
Facility assessment
The health facility assessment was conducted using a structured observation checklist adapted from the 
Bangladesh Health Facility Assessment Survey 2017 (Annex 2). The facility assessment focused on 
overall quality of the facility at a structural level, with special attention to the indicators related to 
maternal and newborn health services. The domains of the facility assessment included general service 
availability, readiness of the facilities for MNH services, provision of sanitation, electrical supply,
availability of medicines in the store or pharmacy, laboratory services, infection control, waste 
management, equipment and sterilization facility, and blood transfusion services.
Case observation
We observed the quality of delivery care, immediate newborn care, and postnatal care services within
the first 24 hour period (before discharge from the facility) at the district hospital, MCWC, UHCs and 
private facilities. Delivery case observations were not done in union level facilities, as delivery service 
utilization was very low during the data collection period. A structured observation checklist adapted 
from USAID’s Maternal and Child Health Integrated Program (MCHIP) was used for the delivery 
observations (Annex 2). Pregnant women coming to the facilities for childbirth were observed 
continuously starting from reception to discharge. Service provision during antenatal check-ups was 
also observed at all facilities, including union level facilities. A structured observation checklist was used 
to assess the quality of history taking, physical examination, laboratory investigations, and counselling 
services. 
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Client exit interview 
Client perceptions regarding the overall services of the health facilities, satisfaction regarding services, 
patient care, behavior of the provider and staff, cleanliness and counselling services were assessed using 
structured interviews. Pregnant women after receiving an antenatal check-up (at all tiers of facilities)
and recently delivered women being observed were interviewed before leaving health facilities.
Case simulation interviews
We were unable to observe deliveries from union level facilities, as delivery service utilization was low 
during our study period. Therefore, we conducted case simulation-based interviews with the health care 
providers to understand their knowledge on recommended practices. A case simulation interview 
questionnaire was developed based on the GoB maternal and newborn standard operating procedure 
(SOP) (Annex 2). We presented to the provider different scenarios regarding delivery, childbirth, 
newborn care, and complications during pregnancy and delivery and asked how they would manage 
the case. The following scenarios were presented to the providers:
• Normal delivery
• Immediate newborn care
• Newborn with birth asphyxia
• Patient in preterm labor with premature rupture of membrane 
• Severe preeclampsia/eclampsia 
• Post-partum hemorrhage 
• Pre-discharge counselling of the patients following facility delivery 
We used findings from simulation interviews as proxy indicators for the provision of care from the union 
level facilities.
Record Review
We reviewed records of 100 delivery cases from each of the facilities to estimate the World Health 
Organization’s Quality, Equity, Dignity Network (QED) outcome level indicators, including maternal 
deaths, facility stillbirth rate, pre-discharge neonatal mortality rate, obstetric case fatality rate, and 
premature newborns initiated on KMC. Data extraction tools were developed based on the government 
registers in the facilities (Annex 2). 
Data collection
Data collection team
A team of 12 research physicians and six field research assistants were involved in data collection. A 
delivery observation team consisted of three physicians and two research assistants whereas one 
physician and one research assistant were in an ANC observation team. Physicians were responsible 
for observation of service provision and research assistants conducted the exit interviews. Two teams 
of physicians (two in each team) conducted case simulation interviews. 
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The research physicians were qualified MBBS doctors. For delivery observation, we recruited female 
physicians and female research assistants since it was culturally and religiously more acceptable for 
them to directly observe deliveries in context of Bangladesh. Field research assistants were first degree 
holders with a science background. They conducted the interviews with the recently delivered mothers 
in the facilities before discharge and the pregnant women who came for ANC consultation. For facility 
assessment, the same trained team collected data from the QoC study facilities involved in the MaMoni 
MNCSP Health Facility Assessment survey.
A central team of researchers coordinated and supervised the study. The team was also responsible for 
local adaptation of the uniform protocols and tools, recruitment of staff, training of staff, planning of 
field implementation, coordination of the supply of logistics for the study, and producing the deliverables 
on time.
Training
After recruitment of the data collectors, we trained the delivery observation team in the last week of 
April 2019. In the first week of May 2019, we trained the data collection teams responsible for ANC 
observations, record reviews, and case simulation interviews. Data collectors were trained on different 
components of data collection, such as basic communication skills, the consent taking process, 
administering tools, and extracting records from different registers. One-day refresher training was 
provided on 13 June 2019 to all team members in their respective field sites. 
Data collection system
A tablet-based data collection system was used for the health facility assessment data collection. For 
the rest of the data collection (e.g., observation of provision of care, exit interviews, record reviews, and 
case simulation interviews), a paper-based system was used. 
Privacy and confidentiality of data
All the client exit interviews took place in a private location chosen by respondents to ensure privacy 
and allow respondents to provide responses freely without fear of retaliation by health care providers. 
Hard copies of the study-related forms were stored in secured cabinets in a storage room, under the 
supervision of the principal investigators. Only approved senior level study personnel had access to the 
data. After completion of the study, identifier information was removed and only study IDs were used 
during analysis. Analyses present in this report are aggregate results without identifier information. 
Sample Size
A total of 90 delivery cases were observed and 90 recently delivered women were interviewed before 
discharge. A total of 249 ANC consultations were observed and all pregnant women whose ANC 
sessions were observed were interviewed before leaving the facility. We have extracted records of 38 
admitted cases of eclampsia/severe preeclampsia. Table 2 summarizes the sample size achieved by 
method and facility type.
19 | Page
Table 2: Sample size
No. of completed questionnaire 
forms
Name of facility
District 
hospital 
MCWC UHC UH&FWC Private 
Facilities
Total 
Facility assessment 1 1 3 24 2 31
ANC observation 31 30 55 102 31 249
Exit interview of pregnant 
women after ANC
31 30 55 102 31 249
Delivery case observation 30 6 23 N/A 31 90
Exit interview of RDW before 
discharge from facilities 
30 6 23 N/A 31 90
Record review (delivery cases ) 100 100 300 1223 200 1923
Eclampsia/Severe Preeclampsia
case review
28 0 0 0 10 38
Case simulation Interview N/A N/A N/A 30 N/A 30
Data analysis
Microsoft SQL was used for data entry. After rigorous data cleaning through range and consistency 
checks, cleaned data were transferred into Stata® version 14.0 (statistical software) for analysis. Basic 
descriptive analysis was done. Percentages were reported for categorical variables. Data was presented 
using appropriate numerical, tabular and graphical methods.
20 | Page
RESULTS 
Standard quality improvement measures during labor, childbirth, and post-partum
The time around childbirth (labor, delivery and postpartum) is a crucial period for saving the majority 
of the maternal and newborn lives and preventing stillbirths. With the increase in the coverage of facility 
deliveries, it is important to ensure quality of care. Poor quality of care not only increases mortality and 
morbidity, it also reduces utilization of effective interventions. WHO’s definition of quality of care is “the 
extent to which health care services provided to individuals and patient populations improve desired health 
outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people￾centered” (10,16). Quality of care includes two interlinked dimensions: provision and experience of care. 
The WHO MNH QoC Framework identifies eight standards based on priority evidence-based 
interventions for measuring progress (9,16). The survey assessed selected quality statements from each 
of the eight standards, for which the indicators are identified at input, process and outcome level. The 
quality statements from the WHO MNH QoC framework are used as is, with their accompanying pre￾fix codes. This section presents findings on the baseline situation of WHO quality standards in MaMoni 
MNCSP facilities included in the QI initiative.
Standard 1: Evidence-based care for during labor, childbirth, and post-partum
The WHO standard 1 quality statement states, “Every woman and newborn receives routine, evidence-based 
care and management of complications during labor, childbirth and the early postnatal period, according to WHO 
guidelines.” The aim of this statement is to ensure the expected evidence-based management of labor, 
childbirth and the immediate postnatal period for mothers and newborns in the first few days of life. It 
includes routine care, early diagnosis of complications, and their appropriate management. Different 
aspects of quality standard one are given below starting from facility readiness to management of 
complications.
Availability of equipment and supplies in delivery room
The GoB Maternal Health Strategy identifies essential lists of equipment and supplies for the delivery 
room (11). The survey data collectors checked availability of supplies in the delivery room using 
structured checklists (HFA tool). Table 3 shows that less than one third of facilities had a baby weighing 
scale and oxygen cylinder. A blank partograph was present in 10% of facilities on the day of observation. 
Among the basic equipment and supplies for routine delivery management, we found that injection 
oxytocin was available in 35% of facilities, while an IV fluid and infusion set was available in 45% of 
facilities. Overall, 97% of facilities had 7.1% chlorhexidine solution in their delivery room, and newborn 
bag and mask were available in 90% of facilities. Availability of logistics and supplies were quite low for 
upazila and union level facilities.
Guidelines or protocols are essential to maintain standards of treatment given to the patients. These 
documents are reference materials for service providers on the provision of clinical care for patients. 
Seven comprehensive emergency obstetric and newborn care (CEmONC) facilities were assessed. Only 
in 14% of the CEmONC facilities were CEmONC guidelines observed. Postnatal Care (PNC) guidelines
were available and observed in 17% of facilities.
Table 3: Percentage of facilities with basic equipment and supplies in the delivery room1
21 | Page
Overall
(N=29)
DH
(n=1)
MCWC
(n=1)
UHC
(n=3)
Union level facilities*
(n=22)
Private 
hospitals
(n=2)
Percentage of facilities with basic essential equipment and supplies available in the delivery 
room
Delivery bed with stirrup 41.4 0.0 0.0 33.3 40.9 100.0
Room thermometer2 0.0 0.0 0.0 0.0 0.0 0.0
Stairs for climbing delivery 
bed
65.5 100.0 100.0 33.3 63.6 100.0
Examination light2 44.8 100.0 100.0 33.3 36.4 100.0
Weight machine for baby2 27.6 0.0 100.0 33.3 18.2 100.0
Stethoscope2 86.2 100.0 100.0 100.0 81.8 100.0
Oxygen cylinder 24.1 100.0 100.0 66.7 4.6 100.0
Kidney Basin or Gallipot 93.1 100.0 100.0 66.7 95.5 100.0
Blank partograph 10.3 0.0 100.0 33.3 0.0 50.0
Equipment needed for mother
Gloves 89.7 100.0 100.0 100.0 86.4 100.0
Drape or blanket to cover 
mother
24.1 100.0 100.0 33.3 13.6 50.0
Inj. Oxytocin3 34.5 100.0 100.0 33.3 22.7 100.0
Syringe 79.3 100.0 100.0 100.0 72.7 100.0
Cord cutting scissors 86.2 100.0 0.0 66.7 90.9 100.0
Needle holder 65.5 100.0 100.0 66.7 59.1 100.0
Clean perineal pad 41.4 0.0 100.0 33.3 40.9 50.0
IV. fluid and saline set3 44.8 100.0 100.0 66.7 36.4 50.0
Equipment needed for newborn 
Clean cloth (1 meter×1 
Meter); 2 pieces
10.3 100.0 0.0 0.0 4.6 50.0
Umbilical cord clamp 
and/or thread
31.0 100.0 0.0 66.7 22.7 50.0
7.1% Chlorhexidine 
solution
96.6 100.0 100.0 100.0 95.5 100.0
Suction bulb or penguin 
sucker2
86.2 100.0 100.0 100.0 81.8 100.0
Newborn bag and mask 
(Ambu bag and mask)2
89.7 100.0 100.0 100.0 86.4 100.0
Percentage of facilities with written, up-to-date clinical protocols4 for newborn care
PNC guideline 17.2 0.0 0.0 33.3 18.2 0.0
Guideline on management 
of preterm baby
0.0 0.0 0.0 0.0 0.0 0.0
IMCI guideline 13.8 100.0 0.0 33.3 4.6 50.0
BEmONC guideline 3.5 0.0 0.0 33.3 0.0 0.0
CEmONC guideline5 14.3 0.0 0.0 33.33 N/A 0.0
Notes: 1Source: Health Facility Assessment. 2Observed and functioning. 3Observed and at least one valid. 4Observed. 5Total 
number of CEmONC facilities 07 (1 DH, 1MCWC, 3 UHCs and 2 private hospitals). *There were 24 union level facilities, 
however this analysis was restricted to 22 union level facilities providing normal delivery services.
Assessments at the time of admission
Proper assessment leads to correct diagnosis and appropriate management of the patients (12,15). 
Clinical assessment of a pregnant woman at the hospital includes proper history taking and physical 
22 | Page
examinations. The survey team observed assessments of the study participants at the time of admission,
using a structured observation checklist. Table 4 presents the percentage of women who were assessed 
appropriately (prenatal history/risk factors, vital signs, danger signs, physical exam) at admission. 
Almost all women were asked about parity and gravida. Health care providers asked 43% of women 
about current pregnancy complications and only 12% about past pregnancy complications. Current 
pregnancy record was checked for routine investigations. The majority of women had their 
ultrasonogram (USG) available and checked by provider (88%), followed by hemoglobin (77%), and 
blood group reports (70%). 
General examinations and assessments of vital signs are important at admission. Around 78% of women 
had their blood measured, while edema was checked for only 39% at admission. Abdominal and vaginal 
examination was performed for 84% and 67% of women, respectively. 
Table 4: Percentage of women delivered in the facilities assessed appropriately at admission by type of facility and by 
components of assessments [prenatal history/risk factors, vital signs, danger signs, physical exam], Manikganj 2019*
Overall**
(N=90)
DH&MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
Union level
facilities***
(n=30)
Percentage of women delivered in the facility whose:
Prenatal history for risk factors were taken on
Age 86.7 72.2 91.3 100.0 70.0
Last menstrual period (LMP) 91.1 77.8 100.0 100.0 96.7
Parity 100.0 100.0 100.0 100.0 86.7
Gravida 100.0 100.0 100.0 100.0 90.0
Time of starting labor pain 71.1 72.2 65.2 74.2 100.0
Frequency and severity of pain 54.4 47.2 60.9 58.1 80.0
Movement of the baby 86.7 83.3 91.3 87.1 80.0
Current pregnancy complications 43.3 27.8 34.8 67.7 56.7
Previous pregnancy complications 11.5 5.0 5.9 26.7 60.0
Current pregnancy record checked for the following:
Urine Routine Microscopic Examination 55.6 33.3 56.5 80.7 50.0
USG 87.8 77.8 91.3 96.8 93.3
Hemoglobin 77.8 69.4 60.9 100.0 96.7
Blood group 70.0 72.2 47.8 83.9 66.7
VDRL 13.3 8.3 17.4 16.1 10.0
HBsAg 41.1 13.9 26.1 83.9 16.7
Blood sugar 48.9 30.6 26.1 87.1 60.0
Tetanus vaccination 3.3 5.6 0.0 3.2 53.3
Physical examination done for:
Vital signs 
Temperature measured 6.7 0.0 0.0 19.4 100.0
Pulse counted 35.6 27.8 26.1 51.6 96.7
Blood pressure measured 77.8 80.6 65.2 83.9 100.0
Others
Anemia checked 44.4 47.2 4.4 71.0 70.0
Jaundice checked 22.2 5.6 0.0 58.1 46.7
Edema checked 38.9 38.9 4.4 64.5 76.7
Dehydration checked 14.4 2.8 0.0 38.7 20.0
Abdominal examination 84.4 94.4 65.2 87.1 86.7
Checked fetal heart rate 80.0 86.1 65.2 83.9 60.0
Performed vaginal examination 66.7 83.3 60.9 51.6 86.7
23 | Page
Notes: *Source: Delivery observation. **Overall estimates are derived from estimates from DH/MCWC, UHC and private 
facilities.***Estimates for union level facilities reported from case simulation interviews (n=30) and are not included in overall 
estimate calculation.
Routine care during labor, delivery and postpartum
Initiation of partograph
Use of a partograph for monitoring of labor is an effective intervention recommended by WHO. 
Evidence suggests that labor monitoring using a partograph helps identify delays in the progress of labor
and reduces stillbirth rates and adverse pregnancy outcomes (13-15). 
Figure 1 depicts that a partograph was initiated for only 1 in 4 women in the first stage of labor. We 
used observation data for reporting this indicator. Use of a partograph was higher in UHCs, whereas a 
partograph was initiated in none of the private facilities. We interviewed providers in union level facilities 
on monitoring of labor using case simulation questionnaire. Of 30 participants, only one-third reported 
that a partograph should be initiated for labor monitoring. 
Figure 1: Percentage of women delivered in the facilities whose partograph was initiated during first stage of labor (taken as 
a proxy of appropriate monitoring during labor), Manikganj 2019
Notes: *Source: Delivery observation. Denominators (n): DH/MCWC= 11; UHC=9; Private=7 and Overall=27. Overall estimates are derived 
from estimates from DH/MCWC, UHC and private facilities. Estimates for union level facilities reported from case simulation interviews (n=30) 
and are not included in overall estimate calculation.
Mode of delivery
WHO set the benchmark for the rate of caesarean deliveries at 15%. Figure 2 shows that 66% of women 
observed were delivered by C-section in the facilities (DH/MCWC, UHC, and private facilities), whereas 
only 34% of the cases observed had normal vaginal delivery. The rate of C-section was higher at private 
facilities (84%) and tertiary care public health facilities (DH/MCWC) (61%).
Figure 2: Mode of delivery among women who gave birth in the study hospitals
9.1
66.7
0.0
25.9
33.3
0
10
20
30
40
50
60
70
80
90
100
Initiation of partograph
Percentages 
DH/MCWC UHC Private Overall Column1 Union level facilities
24 | Page
Notes: * Source: Delivery observations; Overall (N=90); DH/MCWC (n=36); UHC (n=23); and Private (n=31).
Immediate uterotonic
Post-partum hemorrhage (PPH) contributes to around one-third of maternal deaths in Bangladesh (22). 
Immediate administration of post-partum uterotonics, preferably within one minute of birth, is a proven 
intervention for prevention of PPH (21, 23). Oxytocin (10 IU, IM/IV) is the uterotonic drug recommended 
by WHO (21). Overall, 83% of all women observed received injectable oxytocin within one minute of 
delivery (Figure 3) (MaMoni MNCSP project performance indicator). The percentage of women who 
received injectable oxytocin was higher in private facilities (96%) than in the district hospital (78%) or 
UHCs (74%). Half of the providers from union level facilities reported administration of oxytocin within 
1 minute of delivery during case simulation interviews.
38.9
61.1
52.1 47.8
16.1
83.8
34.4
65.6
0
10
20
30
40
50
60
70
80
90
100
Normal vaginal delivery Caeserean section
Percentages 
DH/MCWC UHC Private Overall
25 | Page
Figure 3: Percentage of women administered immediate postpartum uterotonic (PPH prevention), Manikganj 2019
Notes: Source: Delivery observation. Denominators (n): DH/MCWC= 36; UHC=23; Private=31 and Overall=90.
Overall estimates are derived from estimates from DH/MCWC, UHC and private facilities. Estimates for union level facilities 
reported from case simulation interviews (n=30) and are not included in overall estimate calculation
Postpartum monitoring
Post-partum monitoring of delivered women is crucial for identification and management of 
complications following childbirth. WHO recommends monitoring of vital signs, including bleeding,
within 24 hours of delivery (21). Within a resource-constrained context, the maternal health strategy 
of Bangladesh recommends intensive post-partum monitoring within two hours after birth (2). Vaginal 
bleeding was considered to be monitored if the health care provider estimated the amount bleeding by 
any means and recorded in the patient follow up sheet.
Table 5 presents the percentage of women who received appropriate monitoring within two hours of 
delivery. Blood pressure and vaginal bleeding were monitored in 42% and 38% of postpartum women,
respectively; while less than a third of women had their pulse (29%) and temperature checked (17%). 
Appropriate monitoring in the postpartum period was higher among women who delivered in the private 
facilities. Case simulation interviews, conducted only at union level facilities, depict that the majority of 
the health care providers knew about monitoring of pulse and blood pressure during the post-partum 
period. 
77.8 73.9
96.8
83.3
50
0.0
20.0
40.0
60.0
80.0
100.0
Immediate post partum uterotonic
Percentages 
DH/MCWC UHC Private Overall Union level facilities
26 | Page
Table 5: Percentage of women delivered in the facilities who received appropriate monitoring during postpartum period by 
facility type Manikganj 2019*
Overall**
(N=90)
DH&MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
Union level 
facilities***
(n=30)
Percentage of women delivered in the 
facilities whose:
Pulse monitored within 2 hours of delivery 28.9 11.1 4.4 67.7 93.3
Blood pressure monitored within 2 hours of 
delivery
42.2 25.0 13.0 83.9 96.7
Temperature monitored within 2 hours of 
delivery
16.7 0.0 0.0 48.4 76.7
Vaginal bleeding monitored within 2 hours of 
delivery
37.8 27.8 4.4 74.2 83.3
Notes: *Source of data: observation. **Overall estimates are derived from observation data collected from DH/MCWC, 
UHC and private facilities. ***Estimates reported from case simulation interviews (n=30) and are not included in overall 
estimate calculation.
Maternal and newborn complications
According to the Bangladesh Maternal Mortality Survey (BMMS) 2015 preliminary report, around 55% 
of maternal deaths are from PPH and eclampsia/ severe preeclampsia. We reviewed records of the last 
100 delivery cases in the delivery register from each of the facilities preceding the day of data collection. 
Among 1,923 deliveries reviewed, the prevalence of prolonged labor, eclampsia /severe preeclampsia,
and PPH were 4%, 2% and 0.4% respectively (Figure 4). Among all deliveries reviewed, the distribution 
of PPH case were 0% in DH/MCWC, 2.3% UHC, 0.1% in union level facilities and 0% in private facilities. 
A majority of the complicated cases were reported from tertiary care public facilities and private 
facilities. Figure 5 shows the prevalence of newborn complications from document reviews. Out of 1,795 
live births, 5% were preterm birth, while 2.2% of newborns suffered from birth asphyxia.
27 | Page
Figure 4: Percentage of women who suffered from different complications during labor, delivery and postpartum; Manikganj 
2019
Notes: * Source: Record review; Overall (N=1923); DH/MCWC (n=200); UHC (n=300); UH&FWC (n=1223); Private (n=200);
Figure 5: Percentage of newborns who suffered from different newborn complications, Manikganj, 2019
 Notes: * Source: Record review; Overall (N=1795); DH/MCWC (n=193); UHC (n=254); Private (n=199); UH&FWC (n=1149).
6.5
2.5
0.0 1.7 0.0
2.5 2.3 0.3 0.1
12.0
3.0
0.0
3.7 1.6 0.4
0
5
10
15
20
25
30
35
40
45
50
Prolong labour Eclampsia /pre-eclamsia Post partum
haemorrhage
Percentage 
DH/MCWC UHC UHFWC Private Overall
0.5
4.7
14.6
4.3
0.0
4.5
0.5
6.0
2.2
4.7
0
5
10
15
20
25
30
35
40
45
50
Newborn birth asphyxia Preterm birth
Percentage 
DH/MCWC UHC UHFWC Private Overall
28 | Page
Management of maternal and newborn complications
Availability of essential supplies for complication management
Preeclampsia or eclampsia, post-partum hemorrhage, delayed or obstructed labor, and pre-term labor 
are the major complications that women can face during pregnancy and delivery. Facilities should have 
necessary logistics and supplies to provide quality care in such conditions. 
We found magnesium sulfate (MgSO4) which is essential to treat cases of eclampsia and preeclampsia, 
only available in the district hospital and private facilities (Table 6); overall availability was only 10% 
across the facilities. Injectable oxytocin and availability of blood transfusion services is crucial to manage 
cases of post-partum hemorrhage. Validity of medicines were checked based on date of expiry. Only 
38% of the facilities had at least one valid vial of oxytocin on the day of observation. One UHC and a 
majority of the union level facilities did not have oxytocin available. We also assessed the availability of 
blood transfusion services in the CEmONC facilities. Out of seven CEmONC facilities (district hospital, 
MCWC, three UHCs and two private hospitals), only the district hospital and private facilities had 
functional blood transfusion services available (Table 7). A manual vacuum extractor for vacuum￾assisted delivery was only available in the district hospital. Antenatal corticosteroids to manage preterm 
labor were rarely available in the facilities.
Table 6: Essential logistics and supplies for management of complications during pregnancy, child birth, and postpartum, 
Manikganj 20191
Total 
(29)
DH (1) MCWC
(n=1)
UHC
(n=3
Union 
level 
facilities
(n=22)
Private 
hospitals
(n=2)
1.2.Women with Preeclampsia or Eclampsia
Percentage of facilities with magnesium sulfate 
available2
10.3 100.0 0.0 0.0 0.0 100.0
1.3. Women with post-partum hemorrhage (PPH)
Percentage of facilities with injectable uterotonic 
drug (oxytocin) available2
37.9 100.0 100.0 66.7 22.7 100.0
Percentage of CEmONC facilities with functional 
blood transfusion service3
42.9 100.0 0.0 0.0 N/A 100.0
1.4. Women with delayed or obstructed labor
Percentage of facilities with Manual vacuum 
extractor (for vacuum-assisted delivery)4
3.5 100.0 0.0 0.0 0.0 0.0
1.6.a. Women in pre-term labor
% facilities with antenatal corticosteroids available
Betamethasone injection2 6.9 0.0 0.0 66.7 0.0 0.0
Dexamethasone injection (oradexon)2 13.8 0.0 0.0 66.7 0.0 100.0
Notes: 1Source: Health Facility Assessment. 2Availability of the drugs were checked at drug store and if at least one 
unexpired medication is found then considered as available. 3Total number of CEmONC facilities 07 (1 DH, 1MCWC, 3 
UHCs and 2 private hospitals). 4 Defined as equipment was available and functional.
Management of eclampsia/severe preeclampsia
Treating cases of severe preeclampsia or eclampsia with magnesium sulfate is an effective intervention. 
We reviewed severe preeclampsia/eclampsia cases from the past six months of the survey to assess the
quality of the management provided. A total of 38 cases were identified from the delivery register: 28 
from the district hospital and 10 from private hospitals. Figure 6 shows that 65% of the admitted severe 
preeclampsia/eclampsia cases were treated with magnesium sulfate (findings from case sheet review)
29 | Page
(MaMoni MNCSP project performance indicator). The practice was more prevalent in the district 
hospital than in the private hospitals (74% vs 40%). Findings from case simulation interviews at union 
level facilities suggest that very few providers (6.7%) reported providing magnesium sulfate for treatment 
of eclampsia/severe preeclampsia.
Figure 6: Percentage of women with severe preeclampsia/eclampsia treated with Mag. Sulfate, Manikganj 2019
Notes: Data for this indicator has been derived from record review of severe preeclampsia and eclampsia cases. All severe 
preeclampsia and eclampsia cases from the past 6 months of survey were included. Overall estimates are derived from 
estimates from DH/MCWC, UHC and private facilities. Estimates for union level facilities reported from case simulation 
interviews (n=30) and are not included in overall estimate calculation.
Management of premature rupture of membrane (PROM)
We reviewed 29 cases of premature rupture of membrane: 23 from private facilities, four from UHCs,
and two from the district hospital and MCWC. One in five PROM cases received antenatal 
corticosteroids (ACS) and more than half of PROM cases received antibiotic (Table 7).
Table 7: Number of women with PROM who received ACS and antibiotic, Manikganj 2019
Overall
(N=29)
DH&MCWC
(n=2)
UHC
(n=4)
Private 
facilities
(n=23)
Percentage of women with PROM who 
Received ACS 10 1 3 6
Received antibiotic 28 2 3 23
Immediate newborn care
Table 8 describes the percentage of newborns who received essential care immediately after birth. We 
assessed five essential newborn care components: drying, immediate skin-to-skin, delayed cord clamping, 
chlorhexidine cord care, and early initiation of breastfeeding. The percentage of newborns that received 
the different essential newborn care practices varied by component. Around 71% of newborns were 
74.1
40.0
64.9
6.67
0
10
20
30
40
50
60
70
80
90
100
Mag. Sulfate for severe pre-eclamsia /eclampsia
Percentage 
DH/MCWC Private Overall Union level facilities
30 | Page
initiated breastfeeding within one hour of birth (MaMoni MNCSP project performance indicator). Birth 
weight was documented for around two-thirds of newborns (MaMoni MNCSP project performance 
indicator). More than two-fifths of newborns received delayed cord clamping while only 13% of 
newborns were given immediate skin-to-skin within two hours of birth. Around 87% of newborns 
received chlorhexidine cord care. Overall, only 9% of newborns received all five essential newborn care 
components. 
Information on newborn care practices at union level facilities was drawn from case simulation 
interviews conducted with the providers. The case simulations showed high knowledge of essential 
newborn care practices among providers from union facilities, particularly on delayed cord clamping, 
Chlorhexidine cord care and early initiation of breastfeeding. 
Table 8: Percentage of newborn received routine care immediately after birth, Manikganj 2019*
Overall**
(N=90)
DH&MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
Union level 
facilities***
(n=30)
1.1.b. Newborns receive routine care immediately after birth
Percentage of newborns with documented 
birthweight 
64.4 94.4 95.7 6.5 66.7
Percentage of newborns who received 
essential early newborn care (ENC) (drying, 
skin to skin, delayed cord clamping, 
chlorhexidine cord care, breastfeeding.)
Drying from head to toe 92.2 100.0 82.6 90.3 83.3
Initiated skin to skin 13.3 2.8 30.4 12.9 83.3
Delayed cord clamping 85.6 80.6 91.3 87.1 96.7
Chlorhexidine cord care 86.7 97.2 95.7 67.7 96.7
Early initiation of breast feeding 71.1 83.3 69.6 58.1 96.7
Received all five ENC components 8.9 0.0 26.1 6.5 63.3
Notes: *Source: Observations.** Overall estimates are derived from estimates from DH/MCWC, UHC and private facilities.
*** Estimates reported from case simulation interviews (n=30) and are not included in overall estimate calculation.
Postnatal care (PNC)
WHO recommends the first PNC check-up of the mother and baby before discharge from the facility. 
We observed first PNC for both mother and baby before leaving the hospital. 
Table 9 shows that the postnatal assessment of mothers and newborns for danger signs was very low. 
Around half of the mothers were checked for excessive bleeding before discharge, blood pressure was 
measured for around 38% of mothers, and about a quarter had their pulse checked and abdominal 
examination. For newborns, assessment of temperature, respiratory rate, and heart rate were very low; 
and only about 31% of newborns had their cord stump examined. Generally, monitoring practices were 
better in private hospitals compared to public facilities.
Counselling on post-partum family planning (PPFP) is an essential component of postnatal care. 
Providers need to counsel recently delivered women on PPFP and offer them choices of methods 
available. Preferably, for women who choose to use a PPFP method, the method should be provided 
before discharge. In figure 7 we can see that about one-third (34%) of women were counselled on PPFP–
the highest percentage in public facilities (50% in DH and 52% in MCWC) and the lowest in private 
facilities (3%). Although, 1 in 5 recently delivered women were offered PPFP methods, only 9% received 
family planning methods before discharge.
31 | Page
Table 9: Among the women delivered in the facilities, the percentage of women and newborns who received routine 
postnatal care (PNC) before discharge from the facilities, Manikganj 2019*
Overall*
(N=90)
DH 
&MCW
C
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
Union level 
facilities**
(n=30)
1.1.c. Women and newborns receive routine postnatal care
Percentage of postnatal mothers/babies monitored appropriately for danger signs (vital signs/clinical signs)
Monitoring of mother
Checked Pulse 25.6 22.2 8.7 41.9 100.0
Measured Blood pressure 37.8 8.3 13.0 90.3 100.0
Measured Temperature by thermometer 8.9 0.0 0.0 25.8 83.3
Abdominal examination done by palpation 27.8 19.4 17.4 45.2 46.7
Checked pad for excessive bleeding / discharge 53.3 52.8 13.0 83.9 86.7
Checked for anemia 12.2 25.0 8.7 0.0 50.0
Checked perineum / episiotomy for perineal 
trauma 
2.2 2.8 4.4 0.0 36.7
Assessed Urine Output 20.0 2.8 8.7 48.4 10.0
Assessed bowel movement 13.3 2.8 4.4 32.3 13.3
Monitoring of newborn
Took baby’s temperature by thermometer 0.0 0.0 0.0 0.0 86.7
Checked and counted breathing 4.4 0.0 4.4 9.7 76.7
Checked heart rate 7.8 5.6 4.4 12.9 53.3
Inspected the cord stump 31.1 16.7 21.7 54.8 60.0
Notes: *Overall estimates are derived from estimates from DH/MCWC, UHC & private facilities. ** Estimates reported from 
case simulation interviews (n=30) and are not included in overall estimate calculation 
32 | Page
Figure 7: Family planning services provided to recently delivered women before discharge from the facility *
* Source: Exit interview; Denominators (n): DH/MCWC= 36; UHC=23; Private=31 and Overall=90
Standard 2: Health information systems
Standard 2 states: “The health information system enables use of data to ensure early, appropriate action to 
improve the care of every woman and newborn.” The aim of this standard is to assess provision of accurate 
data collection mechanisms in the facilities and improve the quality of care by using data. As part of an 
actionable information system, we assessed availability of standardized registers and mechanisms of 
data collection, analysis, and use of data. All of the facilities had a delivery register (Table 10). Only 
20% of facilities had a register for patients referred for emergency obstetric and newborn care 
(EmONC). Availability of referral forms was very low (10%). In 13% of facilities, the QI team reported 
to regularly extract data, and calculate and visualize prioritized quality indicators. Data was reported 
to be used for decision making in around 10% of facilities. 
50.0
13.9
5.6
52.2 52.2
17.4
3.2 3.2 6.5
34.4
20.0
8.9
0
10
20
30
40
50
60
70
80
90
100
Counselled on post
partum family planning
Offered any family
planning method before
discharge
Received any family
planning method before
discharge
Percentage 
DH/MCWC UHC Private Overall
33 | Page
Table 10: Percentage of facilities having complete, accurate, standardized medical records and mechanisms for data 
collection, analysis and feedback, Manikganj 2019
Overall
(N=29)
DH
(n=1)
MCWC
(n=1)
UHC
(n=3)
Union 
level 
facilities
(n=22)
Private 
hospitals
(n=2)
2.1. Complete, accurate, standardized medical record
Percentage of facilities with standardized 
registers1
Delivery register 100.0 100.0 100.0 100.0 100.0 100.0
IMCI register 37.9 100.0 0.0 66.7 36.4 0.0
Sick newborn care register 34.5 0.0 0.0 33.3 36.4 50.0
Register for patient referred for EmONC 20.7 0.0 100.0 33.3 13.6 50.0
Referral form 10.3 0.0 0.0 33.3 4.6 50.0
2.2. Mechanism for data collection, analysis and feedback
Percentage of facilities in which QI team 
regularly extracts data, calculates and 
visualizes prioritized quality indicators
13.8 100.0 0.0 66.7 4.6 0.0
Percentage of facilities where data 
regularly reviewed and used to make 
decisions on quality improvement
10.3 100.0 0.0 66.7 0.0 0.0
Notes: Source: Health Facility Assessment. 1
Observed
Standard 3: Functional referral systems
Standard 3 states: “Every woman and newborn with condition(s) that cannot be dealt effectively with the 
available resources is appropriately referred.” For ensuring appropriate management of referred patients, 
communication should be made with the referral facility and a complete referral note should be handed 
over to the patient before referral. Table 11 shows that out of 96 cases observed, 6% of patients were 
referred out after admission. Observations included cases from both public and private facilities, so any 
referral note (govt. slip and others) given was included in the analysis. Among the referred patients, 
around two-thirds were given a referral note.
A proper referral note should contain the patient’s history, treatment given, and the patient condition 
at the time of referral for appropriate management at the referral facility. After investigating the 
components of the referral note, we found that patient history (25%), diagnosis (75%), and the name of 
the referred facility (50%) were there. There was no information on examination findings, given 
treatment, or contact number of the referred facility in any of the referral notes.
34 | Page
Table 11: Percentage of women/newborns with complications referred, Manikganj 2019**
Overall
(N=96)
DH&MCWC
(n=36)
UHC
(n=29)
Private
facilities
 (n=31)
3.1. Decision to refer made without delay
Percentage of women/newborns with complications* 
referred 
6.3 5.6 10.3 3.2
Percentage of women/newborns with complications 
transferred with referral note** 
66.7 50.0 100.0 0.0
Referral note given with *
History written 25.0 100.0 0.0 0.0
Examination findings written 0.0 0.0 0.0 0.0
Diagnosis written 75.0 100.0 66.7 0.0
Given treatment written 0.0 0.0 0.0 0.0
Place of referred facility 50.0 0.0 66.7 0.0
Person whom to contact 0.0 0.0 0.0 0.0
Any contact number of referred facility 0.0 0.0 0.0 0.0
* Denominators (n): Total number of cases observed; Overall (N=96), DH/MCWC= 36; UHC=29; Private=31 
**Denominators (n): Number of cases referred DH/MCWC= 2; UHC=3; Private=1 and Overall=6
Standard 4: Communication
Standard 4 states: “Communication with women and their families is effective and responds to their needs and 
preferences.” Effective communication with the patient and her family is crucial for a positive pregnancy 
experience. Patients should be informed adequately about the care given and should be involved during 
decision-making. The patients should also get the opportunity to discuss their queries and preferences 
with the providers.
Almost all women (94%) received counselling before discharge (MaMoni MNCSP project performance 
indicator). Around 84% women reported that they were given an opportunity to discuss their concerns 
and preferences. A higher percentage of mothers reported effective communication during care at the 
private facilities compared to the public facilities 
(Table 12).
Table 12: Among the women delivered in the facilities, percentage who reported that they received information about care 
and had effective interactions with staff, Manikganj 2019
Overall
(N=90)
DH&MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
4.1. Women and families received information about care and had effective interactions with 
staff
Percentage of women receiving postnatal information 
and counseling before discharge
94.4 88.9 95.7 100.0
Percentage of women who reported they were given an 
opportunity to discuss their concerns and preferences
84.4 83.3 78.3 90.3
35 | Page
Standard 5: Respect and dignity
Standard 5 states: “Women and newborns receive care with respect and can maintain their dignity.” The aim 
of this standard is to ensure respect and dignity of the women by ensuring informed choice of care and 
preventing physical, verbal, and sexual abuse during the stay in the facilities. Around 83% of women 
reported that they were adequately informed by health workers about their health and care (Table 13).
Very few women (only 1.1%) reported physical or verbal abuse during their stay at the hospital (MaMoni 
MNCSP project performance indicator).
Table 13: Among the women delivered in the facilities, the percentage who reported physical/verbal or sexual abuse and 
the percentage who reported that they received informed choices about services, Manikganj 2019*
Overall
(N=90)
DH&MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
5.2. Subjected to mistreatment
Percentage of women who gave birth in facility who 
reported physical or verbal abuse to themselves [or their 
newborns]
1.1 2.8 0.0 0.0
5.3. Informed choices about the services
Percentage of women who felt adequately informed by 
health workers about their health and care
83.3 91.7 65.2 87.1
Standard 6: Emotional support
Standard 6 states: “Every woman and her family are provided with emotional support that is sensitive to their 
needs and strengthens the woman’s capability.” Companion of choice means continuous presence of a
support person during labor and childbirth. Evidence suggests that the presence of a birth companion 
improves confidence of the women, reduces the need for analgesics, improves likelihood of vaginal birth,
and improves women’s birth experience (18). Figure 8 shows that only 13.3% of women were advised 
by the providers to have a birth companion during labor. In UHCs, one-fourth of women got advice 
from the provider to have a birth companion, while only 3% of women who delivered in a private hospital 
received the advice. Less than one-third of women had a birth companion of their choice during labor. 
For UHCs, the percentage is higher (52.2%) and, again, this was very low in private hospitals. To look 
at the data differently, we wanted to see the percentage of women who wanted and had birth 
companion, and observed that more than three-fifths of women (62.5%) wanted and had a birth 
companion (MaMoni MNCSP project’s performance indicator on quality of care). This finding indicates
that many women were not aware of their right to have a birth companion and that providers should 
encourage women to have one.
36 | Page
Figure 8: Among the women delivered in the facilities, the percentage who reported that they were advised to have birth 
companion*, had a birth companion, *and who reported that they wanted and had a birth companion of choice** during 
labor and delivery, Manikganj, 2019
* Denominators (n): DH/MCWC= 36; UHC=23; Private=31 and Overall=90
** Denominators (n): DH/MCWC= 9; UHC=2; Private=5 and Overall=16
Standard 7: Competent and motivated human resources
Standard 7 states: “For every woman and newborn, competent, motivated staff are consistently available to 
provide routine care and manage complications.” Trained and motivated staff play a crucial role in providing 
quality care. A facility should have access at all times to a skilled birth attendant. We found that only 
17% of facilities have a duty roster of providers displayed at facilities (Table 14). We did not find any 
duty roster displayed in the district hospital, two of the upazila health complexes, and one private 
hospital. Almost all facilities received external supervision in the past six months.
Strong and effective leadership is needed to support providers to identify essential gaps in maternal and 
newborn care and to plan, implement, and continuously assess and refine interventions to address 
identified gaps. One in 10 facilities had regular quality assurance activities with observed documentation. 
Another way of improving quality is to have client feedback and act according to address issues raised. 
Less than half of facilities (45%) had a mechanism in place to receive client feedback on health care 
services. The most common feedback mechanism used among the surveyed facilities was a 
suggestion/complaint box. Other feedback mechanisms asked about include client surveys or interview 
forms; meetings with community leaders; informal discussions with client or community; email; facility 
website; letters from clients/community, and phone calls. None of the facilities reported to have client 
interviews or client surveys as mechanism to receive feedback. 
13.9
33.3
66.7
26.1
52.2 50.0
3.2
9.7
60.0
13.3
30.0
62.5
0
10
20
30
40
50
60
70
80
90
100
Advised to have birth
companion
Had birth companion Wanted and had
companion of choice
Percentage 
DH/MCWC UHC Private Overall
37 | Page
Table 14: Percentage of facilities had access at all time to skilled birth attendant and leadership in continuous quality 
improvement (QI), Manikganj 20191
Overall
(N=29)
DH
(n=1)
MCWC
(n=1)
UHC
(n=3)
Union 
level 
facilities
(n=22)
Private 
hospitals
(n=2)
7.1. Access at all times to skilled birth attendant
Percentage of facilities displaying roster of 
staff on duty, shift times2 at delivery service 
area
17.2 0.0 100.0 33.3 9.1 50.0
Percentage of facilities that received
external supervision in past six months
93.1 100.0 100.0 100.0 90.9 100.0
7.3. Leadership in continuous quality improvement (QI)
Percentage of facilities with written up to 
date plan for improving QoC and patient 
safety3
10.3 0.0 0.0 33.3 4.6 50.0
Facilities with regular quality assurance 
activities with reported documentation5 
24.1 100.0 0.0 100.0 9.1 50.0
Facilities with regular quality assurance 
activities with observed documentation5
10.3 0.0 0.0 33.3 9.1 0.0
Percentage of facilities with 
systems/mechanism for determining client’s 
opinions about the health facility or it’s 
service4
44.8 100.0 0.0 66.7 36.4 100.0
Notes: 1 Source: Health Facility Assessment. 2 The duty roster was observed. 3 The document was observed 4 The mechanism includes suggestion/complain box, client survey or interview form, meeting with community leaders, informal 
discussion with client or community, email, facility website, letters from client/community, phone calls etc. 5 This could be a 
report or minutes of a quality assurance meeting, a supervisory checklist, a mortality review or an audit of records or registers
Standard 8: Essential physical resources available
Standard 8 states: “The health facility has an appropriate physical environment, with adequate water, sanitation 
and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management 
of complications.” A clean physical environment and provision of water sanitation and hygiene are crucial 
for preventing infection and better pregnancy outcomes. All facilities had a water supply in the delivery 
care area, except union level facilities. More than one-fourth of union level facilities did not have basic 
water supply (Table 15). We considered basic hygiene to be maintained in the delivery room if there 
was running water (piped, bucket with tap or pour pitcher) and soap (liquid soap was also accepted) 
available on the day of observation. The DH, all UHCs, and private hospitals had basic hygiene provision 
available in the delivery room. We also looked for availability of basic sanitation for women during and 
after labor and childbirth. Almost all, except a few union level facilities, had a functioning flush or pour￾flush toilets or a ventilated improved pit latrine or composting toilet for women during and after labor 
and childbirth. We asked for recently delivered women’s opinion regarding cleanliness of the facility. 
Figure 9 shows that three in four women reported a clean physical environment of the facility. From 
UHCs, only 39% of women reported the same.
Appropriate management of health care waste is crucial for infection prevention. More than half of the 
facilities had safe disposal of sharps waste. Safe disposal of infectious waste was available in 44% of 
facilities (Table 15). A continuous electricity supply is mandatory to ensure quality maternal and 
newborn care. Almost all, except for a few union facilities, had a regular source of electricity. We 
considered a facility to have regular electricity if it was connected to a central power grid and there 
was no interruption in power supply lasting for more than two hours at a time during normal working 
38 | Page
hours in the seven days before the survey, if the facility had a functioning generator with fuel available 
on the day of the survey, or if the facility had back-up solar power.
Our data collectors investigated for essential supplies and tests for maternity care. At least one valid 
test kit for urine protein testing was found in half of the facilities. A test kit for measuring urine glucose 
and blood hemoglobin was found in 48% and 69% facilities, respectively. We also looked for blood 
grouping and typing services. This was considered available if all the reagents (Anti-A, Anti-B, Anti-D, 
Coomb’s and Anti-AB) were observed and at least one valid. Only one private facility had availability 
of blood grouping and typing services. Only the district hospital and one private hospital had a 
functioning ultrasound machine.
Table 15: Percentage of facilities with WASH functioning, reliable, safe and sufficient; clean physical environment and 
regular source of electricity; essential supplies of laboratory supplies and tests, Manikganj 20191
Overall
(N=29)
DH
(n=1)
MCWC
(n=1)
UHC
(n=3)
Union 
level 
facilities
(n=22)
Private 
hospitals
(n=2)
8.1. WASH functioning, reliable, safe and sufficient
Percentage of facilities with basic water 
supply in delivery care area2
79.3 100.0 100.0 100.0 72.7 100.0
Percentage of facilities with basic healthcare waste management system
Safe final disposal of sharps 
waste3
55.2 100.0 0.0 33.3 54.6 100.0
Safe final disposal of infectious 
waste4
41.4 100.0 0.0 0.0 45.5 50.0
Percentage of facilities with basic 
hygiene provisions in delivery room5
69.0 100.0 0.0 100.0 63.6 100.0
Percentage of facilities with basic 
sanitation available for women during 
and after labor and childbirth (toilet, 
latrine)6
96.5 100.0 100.0 100.0 95.5 100.0
8.3. Adequate stock of medicines, supplies and equipment
Percentage of facilities with regular
source of electricity7
75.9 100.0 100.0 100.0 68.2 100.0
Percentage of facilities with essential laboratory supplies and tests
Urine Protein Test8 51.7 0.0 100.0 33.3 54.6 50.0
Urine Glucose Test8 48.3 100.0 100.0 33.3 45.5 50.0
Any rapid test for Hemoglobin8 69.0 100.0 100.0 33.3 72.7 50.0
Syphilis Rapid Diagnostic Test8 6.9 100.0 0.0 0.0 0.0 50.0
VDRL test for Syphilis8 10.3 0.0 0.0 33.3 4.6 50.0
Urine Pregnancy Test8 72.4 100.0 0.0 66.7 72.7 100.0
Blood grouping and typing9 3.45 0.00 0.00 0.00 0.00 50.0
USG10 10.3 100.0 0.00 0.00 0.00 100.0
Notes: 1 Source: Health Facility Assessment. 2 Observed running water (piped, bucket with tap or pour pitcher). 3The process 
of sharps waste disposal is incineration and the facility has a functioning incinerator with fuel on the day of survey, or else the 
facility disposes of sharps waste by open burning in a protected area, dumping without burning in a protected area, or removing 
offsite with storage in a protected area prior to removal offsite. 4The process of infectious waste disposal is incineration and 
the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes of infectious waste by means 
of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected 
area prior to removal offsite. 5 Observed running water (piped, bucket with tap or pour pitcher) and hand washing soap (liquid 
soap is also accepted). 6 Facility has functioning flush or pour-flash toilet or a ventilated improved pit latrine or composting 
toilet for women during and after labor and childbirth. 7 Facility is connected to a central power grid and there was no 
interruption in power supply lasting for more than two hours at a time during normal working hours in the seven days before 
the survey, or facility has a functioning generator with fuel available on the day of the survey, or else facility has back-up solar 
39 | Page
power. 8 Observed and found at least one valid kit. 9 Blood grouping and typing service was considered available if all the 
reagents (Anti-A, Anti-B, Anti-D, Coomb’s and Anti-AB) were observed at least one valid. 10 Functioning.
Figure 9: Among the women delivered in the facilities; the percent who reported clean physical environment*, Manikganj 
2019
Notes: *Data collected using exit interviews of women who delivered in the facilities. Denominators (n): DH/MCWC= 36; 
UHC=23; Private=31 and Overall=90,
QoC for antenatal care (ANC) services
Provision of care for antenatal care (ANC) services
The World Health Organization (WHO) envisions “a world where every pregnant woman and newborn
receives quality care throughout the pregnancy, childbirth and the postnatal period” (16). ANC can save lives 
by averting maternal deaths from pregnancy-related complications and reduce prevalence of stillbirths. 
Within the continuum of care, ANC provides the opportunity for timely implementation of evidence￾based interventions including health promotion, screening and diagnosis, and disease prevention. The 
recent WHO 2016 ANC model aims to provide positive pregnancy experiences to the pregnant women 
by ensuring the following components (19):
1. Respectful, individualized, person-centered care at every contact
2. Implementation of effective clinical practices (interventions and tests)
3. Provision of relevant and timely information
4. Psychosocial and emotional support
5. ANC by practitioners with good clinical and interpersonal skills within a well-functioning health 
system
Therefore, ANC not only provides the platform for medical care but also the opportunity for counselling 
on important aspects of health, nutrition, and family planning in a respectful way. This respectful care 
and support functions of ANC are important for preventing mortality and morbidities and improving 
health care utilization and quality of care. We observed a total of 249 cases of ANC consultations to 
investigate the quality of ANC provided to pregnant women. Findings from those observations are 
presented below.
91.7
39.1
80.7
74.4
0
10
20
30
40
50
60
70
80
90
100
Reported clean physical environment
Percentage 
DH/MCWC UHC Private Overall
40 | Page
History taking and physical examination
Appropriate history taking and physical examinations are critical steps for early diagnosis of pregnancy 
complication and management. Table 16 presents the percentage of women that were assessed 
appropriately – having their history taken and a physical examination - during their ANC consultation. 
As an integral part of quality history taking during ANC, we observed whether the provider took history 
on age, occupation, last menstrual period date (LMP), parity, gravida, previous abortion/menstrual 
regulation (MR)/deliveries, previous ANC, family history of certain diseases, existing illnesses, current 
medicine intake, TT vaccination, and complications during current and previous pregnancy. Almost all 
women were asked about their age, LMP, parity and gravida. History of previous pregnancy loss 
(MR/abortion) was asked of around 85% of women. Overall, 87% of women were asked about current 
pregnancy complications, while around one-third were asked about previous pregnancy complications. 
We also assessed different components of physical examinations during ANC. Weight was measured 
for around 86% of the women, while height was taken for around 34%. Among the vital signs, blood 
pressure was measured among 93% of the women during their ANC. Assessment of pulse and 
temperature was done among a negligible number of participants. Assessment of uterine height, fetal
presentation, and fetal heart sound is important for identification of intrauterine growth restriction, mal￾presentation and fetal distress, respectively. Around three-fourths of women were assessed for uterine 
height. Fetal presentation and fetal heart sound were assessed among 23% and 45% of the women. 
Assessment of edema and urine protein was done only among 41% of women. 
Table 16: Percentage of women assessed appropriately during ANC consultation (history taking and physical examination), 
Manikganj 2019*
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union level 
facilities
(n=102)
Private 
hospitals
(n=31)
Percentage of women whose 
History was taken for 
Age 99.6 96.8 100.0 100.0 100.0 100.0
Occupation 0.4 0.0 0.0 0.0 1.0 0.0
LMP 99.6 100.0 96.7 100.0 100.0 100.0
Expected date of delivery 98.4 100.0 96.7 98.2 99.0 96.8
Gravida 99.6 100.0 96.7 100.0 100.0 100.0
Para 99.6 100.0 96.7 100.0 100.0 100.0
Number of 
abortion/MR/deliveries
84.7 100.0 66.7 92.7 78.4 93.6
Any prior ANC 
visit/check-ups during 
current pregnancy
58.2 19.4 46.7 40.0 70.6 100.0
Family history
(DM/HTN/TB)
27.3 0.0 0.0 7.3 34.3 93.6
Existing illness (allergy, 
TB, hypertension, 
diabetes, asthma, heart 
disease, goiter, hepatitis)
37.8 35.5 3.3 32.7 34.3 93.6
Current medicine use 
(iron, folic acid, vitamin, 
calcium, anti￾hypertensive)
6.8 0.0 6.7 16.4 2.0 12.9
TT vaccination 69.9 12.9 93.3 65.5 74.5 96.8
41 | Page
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union level 
facilities
(n=102)
Private 
hospitals
(n=31)
Current pregnancy complications 
Any complications in 
current pregnancy
87.2 100.0 90.0 87.3 78.4 100.0
Vaginal bleeding 2.8 0.0 0.0 7.3 2.0 3.2
Severe anemia 0.0 0.0 0.0 0.0 0.0 0.0
Convulsion 4.0 0.0 0.0 16.4 1.0 0.0
Excessive fever 13.3 0.0 46.7 25.5 3.9 3.2
Severe headache 13.7 3.2 50.0 32.7 0.0 0.0
Blurring of vision 5.2 0.0 6.7 18.2 1.0 0.0
Swelling of hand or feet 
or face
3.2 0.0 10.0 7.3 1.0 0.0
Foul smelling vaginal 
discharge
2.0 0.0 3.3 7.3 0.0 0.0
Less fetal movement 0.4 0.0 0.0 1.8 0.0 0.0
High blood pressure 2.0 0.0 0.0 5.5 1.0 3.2
Premature rupture of 
membrane
0.0 0.0 0.0 0.0 0.0 0.0
Diabetics in pregnancy 4.0 0.0 0.0 10.9 0.0 12.9
Injury 0.0 0.0 0.0 0.0 0.0 0.0
Complications in previous pregnancy 
H/O Previous Pregnancy 31.3 0.0 63.3 49.1 28.4 9.7
Any complications in 
previous pregnancy 
30.8 26.3 37.0 24.1 66.7 26.3
High fever or infection 0.0 0.0 0.0 0.0 0.0 0.0
Pregnancy induced 
hypertension
0.0 0.0 0.0 0.0 0.0 0.0
Convulsion 0.0 0.0 0.0 0.0 0.0 0.0
Multiple pregnancy 0.0 0.0 0.0 0.0 0.0 0.0
Prolonged labor 1.3 0.0 0.0 3.7 0.0 0.0
UTI 0.0 0.0 0.0 0.0 0.0 0.0
Assisted delivery 5.1 0.0 5.3 3.7 6.9 0.0
Bleeding during 
pregnancy
1.3 0.0 0.0 3.7 0.0 0.0
Heavy bleeding during or 
after delivery
1.3 0.0 0.0 3.7 0.0 0.0
Preterm labor 0.0 0.0 0.0 0.0 0.0 0.0
Still birth 6.4 0.0 0.0 11.1 6.9 0.0
Abortion 5.1 0.0 5.3 7.4 3.5 0.0
Infant’s death 7.7 0.0 0.0 7.4 6.9 66.7
Gestational diabetes 1.3 0.0 0.0 3.7 0.0 0.0
Physical examination
Weight 86.8 74.2 93.3 96.4 81.4 93.6
Height 34.1 6.5 90.0 32.7 7.8 96.8
Vital signs
Pulse 1.6 3.2 0.0 0.0 0.0 9.7
Blood pressure 92.8 83.9 100.0 96.4 91.2 93.6
Temperature with 
thermometer
1.6 0.0 13.3 0.0 0.0 0.0
Abdominal examination
42 | Page
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union level 
facilities
(n=102)
Private 
hospitals
(n=31)
Uterine height 75.5 67.7 93.3 56.4 82.4 77.4
Uterine girth/ liquor
volume
0.0 0.0 0.0 0.0 0.0 0.0
Fetal presentation 22.5 6.4 30.0 23.6 28.4 9.7
Fetal heart rate 45.0 64.5 16.7 43.6 48.0 45.2
Others
Eye (conjunctiva) or palm
for anemia
28.1 77.4 20.0 41.8 15.7 3.2
Eye (sclera) or tongue for 
jaundice
12.9 9.7 0.0 38.2 5.9 6.5
Hand or feet or leg for 
edema
41.8 58.1 50.0 43.6 36.3 32.3
Urine protein 41.4 3.2 50.0 1.8 83.3 3.2
Note: *Data collected through observations of ANC consultations. 
Routine diagnostic tests
Routine laboratory tests during pregnancy are important for identification of complications and to 
prevent adverse pregnancy outcomes. Routine tests vary during first ANC and follow up ANC (11). In
the first ANC, it is recommended to confirm the pregnancy and conduct the following tests:
1. Blood tests for hemoglobin, blood grouping and typing, blood sugar, venereal disease research 
laboratory (VDRL), and Hepatitis B surface antigen (HBsAg)
2. Urine tests for albumin, glucose, RME 
3. Ultrasonogram
Anemia, eclampsia or preeclampsia, asymptomatic urine infection, and gestational diabetes are some 
of the common complications during pregnancy, which can be identified by routine urine and blood tests. 
It is important to know the blood group of the women for immediate blood transfusion in case of life -
threatening bleeding during labor or post-partum. An ultrasound scan during the first trimester is 
important for estimating the expected date of delivery (EDD), while USG in the second trimester helps 
to identify anomalies of the baby within the mother’s womb. 
Table 17 presents the percentage of women during ANC who were asked or referred to undertake the 
recommended tests or the provider himself performed the tests during ANC. Overall 79% of women 
were asked or referred to undertake hemoglobin measurement. Blood grouping or typing exercise was 
advised to 41% women. Around half of the women were asked or referred to undertake different urine 
tests and an ultrasonogram scan. 
The percent of women who were asked or referred to undertake the recommended tests or the provider 
himself performed the routine investigations during follow up ANC are shown in Table 18. A hemoglobin
test was advised for 70% of women, while an ultrasonogram anomaly scan was advised for 33% of 
women. 
43 | Page
Table 17: Among women in their first ANC, the percent who were asked or referred to undertake the tests or the provider 
performed the test, Manikganj 2019*
Overall
(N=116)
DH
(n=17)
MCWC
(n=21)
UHC
(n=28)
Union 
level 
facilities
(n=40)
Private 
hospitals
(n=10)
Percentage of women who were asked/ referred to undertake the tests or the provider himself 
performed the tests 
Pregnancy test 17.2 0.0 14.3 53.6 0.0 20.0
Blood test for hemoglobin 78.5 100.0 76.2 78.6 70.0 80.0
Blood grouping and typing 41.4 88.2 38.1 71.4 0.0 50.0
Blood sugar (2hABF) 37.9 100.0 28.6 50.0 0.0 70.0
Blood test for VDRL 28.5 82.4 14.3 53.6 0.0 10.0
Blood test for HBsAg 40.5 94.1 28.6 60.7 0.0 80.0
Urine test for albumin 55.2 0.0 85.7 60.7 72.5 0.0
Urine test for glucose 56.0 0.0 85.7 64.3 72.5 0.0
Urine test for RME 50.9 94.1 57.1 82.1 0.0 80.0
Ultrasonogram 50.9 94.1 47.6 85.7 0.0 90.0
Note: *Data collected through observations of ANC consultations. 
Table 18: Among women in their follow up ANC visit, the percent who were asked or referred to undertake the tests or the 
provider performed the test, Manikganj 2019*
Overall
(N=133)
DH
(n=14)
MCWC
(n=09)
UHC
(n=27)
Union 
level 
facilities
(n=62)
Private 
hospitals
(n=21)
Percentage of women who were asked/ referred to undertake the tests or the provider himself 
performed the tests 
Blood test for hemoglobin 70.7 50.0 88.9 74.1 74.2 61.9
Blood sugar (2hABF) 27.8 50.0 55.6 37.0 3.2 61.9
Urine test for albumin 54.1 7.1 88.9 44.4 79.0 9.5
Urine test for RME 42.1 71.4 88.9 74.1 4.8 71.4
Ultrasonogram for anomaly scan
(18-22 weeks)
33.8 57.1 11.1 51.9 9.7 76.2
Note: *Data collected through observations of ANC consultations. 
Routine medicines
According to the National Micronutrient Survey Bangladesh 2011-12, around 35% women suffer from 
anemia in pregnancy. WHO 2016 ANC guidelines recommend context-specific routine supplementation 
of iron-folic acid (IFA), calcium, vitamins, and deworming medications for improving maternal and 
perinatal outcomes (19). The GoB maternal health strategy recommends provision of two misoprostol 
tablets during ANC in the third trimester for prevention of post-partum hemorrhage after delivery (11). 
Chlorhexidine (7.1%) cord care is an evidence-based, effective intervention for prevention of neonatal 
sepsis. It is not only important to prescribe and provide the routine medicines during ANC, as 
appropriate, but also to explain the dosages and side effects, which is critical to ensure optimal use and 
outcomes.
Table 19 describes the percentage of women who were prescribed, provided, and given an explanation 
on medicine intake and side effects during their ANC. Among all women, 84% were prescribed IFA, 55% 
calcium, and 39% vitamins. Supply of medicines was lower than the prescriptions; only 68% of women 
44 | Page
received an IFA supply, while less than one-fourth of women received calcium and vitamin. None of the 
women were prescribed or supplied misoprostol or chlorhexidine. 
Counselling
Counselling during ANC is crucial for sharing knowledge on important health- and nutrition-related 
interventions, such as diet during pregnancy, danger signs during pregnancy, vaccination, follow up 
ANC, importance of four ANC, birth preparedness, and immediate newborn care. Less than half of the 
women received counselling on nutritious food intake during pregnancy. Around 16% of women received 
counselling on danger signs in pregnancy. Overall, less than one-third of women received counselling on 
different components of birth preparedness. Only 21% of women were counselled on facility delivery, 
followed by blood grouping at 17%, saving emergency money for delivery at 10%, and identification of 
blood donor and vehicle arrangement at 8%. Less than 5% of women received counselling on different 
components of essential newborn care (Table 20).
45 | Page
Table 19: Percent of women who were prescribed, provided, and given an explanation on how to use different routine 
medicines, and given an explanation of the side effects of different routine medicines, Manikganj 2019*
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union 
level 
facilities
(n=102)
Private 
hospitals
(n=31)
IRON-FOLATE TABLET (IFA) 
Prescribed 83.5 93.6 100.0 74.6 82.4 77.4
Provided 67.9 93.6 100.0 56.4 77.5 0.0
Explained how to use 34.9 58.1 0.0 25.5 30.4 77.4
Explained Side effects 1.6 0.0 0.0 5.5 1.0 0.0
CALCIUM tablet 
Prescribed 55.4 77.4 26.7 61.8 52.9 58.1
Provided 22.9 6.5 3.3 7.3 49.0 0.0
Explained how to use 28.1 51.6 0.0 21.8 23.5 58.1
Explained Side effects 0.4 0.0 0.0 0.0 1.0 0.0
VITAMINS
Prescribed 38.6 51.6 36.7 47.3 35.3 22.6
Provided 23.7 48.4 36.7 1.8 31.4 0.0
Explained how to use 18.9 29.0 0.0 20.0 19.6 22.6
Explained Side effects 0.4 0.0 0.0 0.0 1.0 0.0
MISOPROSTOL for use if delivered at home (only in third trimester)**
Prescribed 0.0 0.0 0.0 0.0 0.0 0.0
Provided 0.0 0.0 0.0 0.0 0.0 0.0
Explained how to use 0.0 0.0 0.0 0.0 0.0 0.0
Explained Side effects 0.0 0.0 0.0 0.0 0.0 0.0
7.15 Chlorhexidine for use if delivered at home (only in third trimester)**
Prescribed 0.0 0.0 0.0 0.0 0.0 0.0
Provided 0.0 0.0 0.0 0.0 0.0 0.0
Explained how to use 0.0 0.0 0.0 0.0 0.0 0.0
Explained Side effects 0.0 0.0 0.0 0.0 0.0 0.0
Deworming medication
Prescribed 0.4 0.0 0.0 0.0 1.0 0.0
Provided 0.4 0.0 0.0 0.0 1.0 0.0
Explained how to use 0.0 0.0 0.0 0.0 0.0 0.0
Explained Side effects 0.4 0.0 0.0 0.0 1.0 0.0
Note: *Data collected through observations of ANC consultations. ** Women in third trimester of pregnancy; overall (N= 
96); DH (n=13), MCWC (n=8), UHC (n=21), UH&FWC (n=45) and Private facilities (n=9).
Table 20: Percent of women who received counselling on different topics as per Maternal SOP Bangladesh during ANC, 
Manikganj 2019*
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union 
level 
facilities
(n=102)
Private 
hospitals
(n=31)
Percentage of women who received counselling during ANC on: 
Nutritious food 48.2 19.4 73.3 49.1 52.9 35.5
Intake of fruits 22.9 3.2 50.0 30.9 21.6 6.5
Intake of green/colored vegetables 37.0 12.9 66.7 43.6 41.2 6.5
Iodized salt 0.4 0.0 3.3 0.0 0.0 0.0
Tetanus Toxoid (TT) vaccine 0.8 0.0 0.0 3.6 0.0 0.0
Rest during daytime 18.5 22.6 16.7 27.3 11.8 22.6
46 | Page
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union 
level 
facilities
(n=102)
Private 
hospitals
(n=31)
Follow up visit 73.5 87.1 86.7 72.7 62.8 83.9
Danger signs during pregnancy 16.1 0.0 30.0 30.9 11.8 6.5
The risks of harmful practices (drinking alcohol, 
smoking tobacco)
0.4 0.0 3.3 0.0 0.0 0.0
Family planning options immediately after 
delivery (post-partum)
7.6 0.0 0.0 20.0 7.8 0.0
The importance of completing four ANC visits 11.2 3.2 6.7 9.1 17.7 6.5
Counselling on birth, neonate and emergency preparedness (BNEP)
Place of delivery 27.7 6.5 13.3 45.5 32.4 16.1
Benefits of facility delivery 20.5 0.0 6.7 29.1 27.5 16.1
Identification of SBA for delivery 4.0 0.0 3.3 5.5 5.9 0.0
Delivery by SBA 6.4 0.0 6.7 7.3 9.8 0.0
Arranging vehicle or transport before delivery 8.0 0.0 0.0 21.8 7.8 0.0
Deposit money for emergency 10.4 0.0 10.0 20.0 11.8 0.0
Blood grouping 16.9 9.7 16.7 36.4 12.8 3.2
Identification of blood donor 8.4 6.5 10.0 10.9 7.8 6.5
Use of safe delivery kit in case the women 
decided to deliver at home 
0.0 0.0 0.0 0.0 0.0 0.0
Misoprostol after home delivery 0.4 0.0 0.0 0.0 1.0 0.0
Counselling on immediate newborn care
Thermal care 2.8 0.0 0.0 12.7 0.0 0.0
Delayed bathing 0.0 0.0 0.0 0.0 0.0 0.0
Early initiation of breast feeding 0.4 0.0 0.0 1.8 0.0 0.0
Exclusive breast feeding 4.8 0.0 0.0 20.0 0.0 3.2
Chlorhexidine cord care 2.8 0.0 0.0 12.7 0.0 0.0
Vaccination 2.0 0.0 0.0 1.8 3.9 0.0
Newborn danger sign 3.2 0.0 0.0 14.6 0.0 0.0
Note: *Data collected through observations of ANC consultations.
Experience of care following ANC 
WHO defines a positive pregnancy experience as “maintaining physical and sociocultural normality, 
maintaining a healthy pregnancy for mother and baby (including preventing or treating risks, illness and 
death), having an effective transition to positive labor and birth, and achieving positive motherhood
(including maternal self-esteem, competence and autonomy) (16).” Respectful care is an integral part of 
a positive pregnancy experience. In this section, we explored women’s satisfaction on different 
components of ANC. 
Satisfaction on counselling
Women were asked about different components of counselling. They were asked whether they were
satisfied with the level of information received, not satisfied, or not informed at all. Table 211 shows 
overall low satisfaction on counselling received during ANC; 41% were satisfied with the counselling on 
nutritious food, 25% on selection of place of delivery, 17% on birth preparedness, and only 10% on
danger signs during pregnancy.
47 | Page
Table 21: Percent of women satisfied with different components of counselling during ANC, Manikganj, 2019*
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union level 
facilities
(n=102)
Private 
hospitals
(n=31)
Percentage of women satisfied with the counselling on:
Danger signs during pregnancy 10.4 3.2 6.7 25.5 8.8 0.0
Importance of taking nutritious 
food during pregnancy
41.0 25.8 80.0 36.4 44.1 16.1
Birth preparedness 16.9 9.7 10.0 32.7 16.7 3.2
Selection of place of delivery 24.9 9.7 13.3 38.2 28.4 16.1
Breast feeding 5.6 0.0 0.0 12.7 6.9 0.0
Four ANC 10.0 0.0 6.7 10.9 14.7 6.5
PNC visits 5.6 0.0 6.7 10.9 5.9 0.0
Importance of PNC 3.2 0.0 3.3 1.8 5.9 0.0
Newborn care 2.8 0.0 0.0 12.7 0.0 0.0
Danger sign of newborn 2.0 0.0 0.0 9.1 0.0 0.0
Postpartum family planning 6.8 0.0 0.0 16.4 7.8 0.0
Follow up visits 53.8 64.5 96.7 50.9 42.2 45.2
Note: *Data collected through observations of ANC consultations.
Satisfaction on provision of care
Women’s satisfaction on different components of provision of care were explored. A majority of the 
participants were satisfied with the attitude of the provider (87%), opportunity to discuss concerns (87%),
and cleanliness of the facilities (73%). Very few participants at the district hospital level were satisfied 
with the waiting time. Overall, satisfaction levels on different ANC service provisions were lower among 
the mothers who received ANC at district hospitals (Table 22).
Table 22: Percent of women who were satisfied with the provision of care during ANC, Manikganj 2019*
Overall
(N=249)
DH
(n=31)
MCWC
(n=30)
UHC
(n=55)
Union 
level 
facilities
(n=102)
Private 
hospitals
(n=31)
Percentage of women satisfied with:
Waiting time 54.2 3.2 96.7 52.7 67.7 22.6
Opportunity to discuss 
concerns
87.2 54.8 100.0 98.2 93.1 67.7
Information received on health 
and care
50.6 48.4 73.3 49.1 46.1 48.4
Privacy during consultation 53.0 41.9 50.0 80.0 42.2 54.8
Privacy during physical 
examination
61.0 41.9 93.3 80.0 49.0 54.8
Cleanliness 73.9 74.2 50.0 83.6 67.7 100.0
Attitude of the provider 86.8 54.8 96.7 92.7 91.2 83.9
Note: *Data collected through observations of ANC consultations.
48 | Page
CONCLUSIONS
Findings from the MaMoni MNCSP QoC survey provide a comprehensive picture of the quality of care 
of maternal and newborn health in facilities included in the QI initiative. These results depict the baseline 
situation in the study facilities against which progress of the project can be measured. The findings 
provide critical insights into areas that need careful attention by the project for improvement.
Quality of care for labor and delivery services
The results showed that overall readiness of the facilities for providing quality care around the period 
of childbirth was inadequate. Availability of essentials drugs for ensuring routine care and complication 
management was low. Variation was observed across different standards. Overall risk assessment at 
admission was low. Implementation of evidence-based interventions like use of partograph was only 
25%. Around 66% of women were delivered by caesarian section, which is higher than the national 
average at 31% (2). The WHO benchmark is a C-section rate between 10 to 15% of all births. 
Unnecessary caesarian section not only creates additional burden on the country’s economy, but also 
has long-term adverse health outcomes for both mother and baby. The prevalence of early initiation of 
breastfeeding was 71%. One study conducted in Bangladesh observed early initiation of breastfeeding 
at 67% among the mothers delivered the facilities in 2016(20). Evidence suggests that women who 
delivered by caesarean section are less likely to initiate breastfeeding with one hour of birth (21). 
Postnatal assessment of mothers for danger signs was not satisfactory. Around half of the mothers were 
checked for excessive bleeding before discharge, while blood pressure was measured for around 38% of
mothers. Overall monitoring practices were better in private hospitals compared to public facilities. 
The presence of a birth companion improves confidence of the women, reduces the need for analgesics, 
improves likelihood of vaginal birth, and improves women’s birth experience (24). Only one-third of 
women had a birth companion during labor and delivery. The literature identifies allocation of resources, 
organization of care, facility-related constraints, and cultural inclinations as the implementation barriers 
to having birth companions in different settings (18). Facility managers and health care providers need 
to be sensitized and orientated on the effectiveness of a birth companion in improving quality of care.
The facilities are lagging behind in terms of the health information system and functional referral system. 
Standard registers for MNH care were not available in majority of the facilities. Only 13% of facilities 
had designated QI teams and use of data for decision-making was even lower (10%). The referral system 
was not functioning appropriately. Only two-thirds of patients were referred with a referral note, the 
majority of which lacked essential components. Major inputs are required from the project for quality 
improvement of the health information system and referral system. 
Quality of care for antenatal care (ANC) services 
Women’s positive experiences during ANC and childbirth can create the foundations for healthy 
motherhood. ANC not only provides platform for clinical care, but also provides opportunity for health 
promotion and behavior change. ANC from a medically trained provider, weight monitoring, abdominal 
examination, blood tests, urine tests, ultrasonography, and counselling on danger signs and birth 
preparedness were identified as part of quality ANC (2,23). Weight was measured for 86% of women,
while abdominal examination was done for around 75%. Blood tests for hemoglobin was prescribed for 
around 78% of women while urine tests were prescribed for around half. Among all women during ANC, 
84% were prescribed IFA, 55% calcium, and 39% vitamins. Supply of medicines was lower than the 
prescriptions. It is important to ensure supplies of essential supplements for improving compliance with 
medications prescribed. Around 16% of women received counselling on danger signs in pregnancy, while 
less than one-third of women received counselling on different components of birth preparedness. 
49 | Page
We explored the experience of care among the women who received ANC from the study facilities. A 
majority of the participants were satisfied with the attitude of the provider (87%), opportunity to discuss 
concerns (87%), and cleanliness of the facilities (73%). Very few participants at district hospital level 
were satisfied with the waiting time. Overall, satisfaction on different ANC service provisions were less 
among the mothers at district hospitals. Lack of readiness of the health facilities could be one reason 
for poor quality of ANC in Bangladesh, similar to other findings (23). A nationally representative survey 
from Bangladesh also highlighted the gaps in readiness of the health facilities for providing ANC services 
following recommended guidelines. It is imperative to improve facility readiness and consider innovative 
approaches for improving quality of ANC.
RECOMMENDATIONS
In this section, we highlight some of the key gaps identified from the QoC baseline assessment by 
thematic area and our recommendations for how to address the gaps.
Antenatal care (ANC) services
1. Gaps were identified in the distribution of Misoprostol and 7.1% Chlorhexidine solution during 
ANC consultations occurring in the third trimester. To address this gap, MaMoni MNCSP 
recommends working with local governments during microplanning meetings to promote the 
combined distribution of Misoprostol and Chlorhexidine during ANC consultations and 
advocate for the distribution of the two medicines earlier on in pregnancy (to ensure women 
who do not return for ANC visits later on in pregnancy are not missed) and through FWAs. 
2. Observations of ANC assessments revealed gaps in the physical assessments conducted by 
providers, particularly for assessment of fetal presentation and fetal heart sound and edema. 
Implementation of QI initiatives/bundles at the health facility level will be important to address 
these identified quality of care gaps. 
3. Provider provision of counselling on key topic areas during ANC was observed to be low; 
especially on danger signs and birth preparedness. Similarly, client satisfaction with counselling 
was relatively poor, particularly with regards to danger signs during pregnancy, delivery, and 
the postpartum period, birth preparedness, selection of place of delivery, and nutrition. Provision 
of mentorship and training to improve provider counselling during ANC is needed. Educational 
materials that cover these important topic areas can be distributed to clients and used by 
providers to guide counselling sessions during ANC consultations. 
4. Privacy during ANC consultations was an identified gap. Providing a screen to improve visual 
and auditory privacy can help improve the experience of care during ANC, and provide a more 
appropriate space for counselling.
Labor and delivery services
1. Strengthen the implementation of evidence-based interventions during labor and delivery, 
particularly the use of the partograph for monitoring progress of labor and promoting the 
presence of a birth companion, to help improve the quality and experience of care. Improvement 
in partograph use can be addressed through a QI initiative at facility level. Further, counselling 
during ANC should be strengthened as noted above to discuss birth preparedness and the 
important role of a birth companion. 
2. KMC uptake was very low for low birth weight newborns in the DH/UHCs. It will be important 
to strengthen the linkages between maternity wards and the pediatric and neonatal wards to 
improve in-facility referrals. Strengthening health care providers counselling on the importance 
of KMC as a therapy for low birth weight newborns, and including the birth companions of 
50 | Page
mothers as part of these sessions, can be another strategy employed to facilitate improved 
uptake. 
3. The practice of skin-to-skin after birth had the lowest coverage of all essential newborn care 
practices, particularly in DHs, MWCWs, and UHC facilities. We recommend addressing this 
gap through strengthening of counseling with mothers during ANC on the importance of skin￾to-skin, as well as targeted mentorship and coaching of healthcare providers and incorporation 
of ENC practices as part of QI initiatives within facilities. Given the high caesarean section rates, 
ensuring the documentation of essential newborn care practices is required, which will also 
facilitate improved uptake of the practices. 
4. The quality of the postnatal assessment of mothers and newborns was generally poor, 
particularly for assessment of danger signs in mothers and newborns as well as in counselling, 
particularly around PPFP. We recommend incorporating the use of checklist for health care 
providers to improve immediate PNC care. 
5. There is an alarmingly higher proportion of caesarean section deliveries in district hospitals as 
well as in private facilities. Routine clinical audits using validated tools (e.g. the Robson 
classifications) need to be incorporated into the monitoring system for identifying unnecessary 
C-sections (26-29). MaMoni can demonstrate use of Robson classification system in a few 
hospitals with high C-section rates to maintain optimal use of C-section procedures. 
6. Overall, there was inadequate readiness of the facilities for ensuring quality of care during labor 
and delivery. Support should be provided to equip facilities with updated protocols for labor and 
delivery management and to ensure that monitoring mechanisms are in place to assess guideline 
adherence. 
51 | Page
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54 | Page
ANNEX 1: MAMONI MNCSP PERFORMANCE INDICATORS 
Indicator 18: Percentage of health facilities that have improved on at least 50% of Core MNC QoC 
Indicators applicable to level of facility***
Domain Indicator (all Facility-based) Overall** DH & 
MCWC
UHC Private 
facilities
UH&FWC
Outcome
1. Number of maternal deaths 1 (*QED impact 
indicator measured annually)
00 00 00 00 00
2. Maternal deaths by cause 1
(Number of maternal deaths classified by cause 
(ICD-MM)
N/A N/A N/A N/A N/A
3. Newborn deaths by cause1
(Number of neonatal deaths classified by cause 
(ICD-PM)
N/A N/A N/A N/A N/A
4. Facility Stillbirth rate 1$
(Number of stillbirths per 1000 births (live and 
stillbirths))
10.9 35.0 14.7 14.9 5.2
5. Pre-discharge Neonatal Mortality Rate 1
(Percentage of babies born live in a facility dying 
prior to discharge from facility)
0.0 0.0 0.0 0.0 0.0
6. Obstetric Case Fatality Rate 1
(Percentage of women who develop complication 
in facility who die due to an obstetric complication 
(disaggregated by direct and indirect causes when 
feasible))
0.0 0.0 0.0 0.0 0.0
Output/ process
7. Pre-discharge counselling for mother and 
baby 3
(Percentage of women who received pre-discharge 
counselling for mother and baby)
94.4 88.9 95.7 100.0
8. Companion of choice 3, *
(The percentage of women who wanted and had a 
companion supporting them during labor and 
childbirth in the health facility)
62.5 66.7 50.0 60.0
9. Verbal or physical abuse 3
(Percentage of women who experienced physical 
or verbal abuse during labor or childbirth in the 
health facility)
1.1 2.8 0.0 0.0
10. Breastfed within one hour of birth 2
(Percentage of babies born live in a facility 
breastfed within one hour of birth)
71.1 83.3 69.6 58.1 96.75
11. Immediate postpartum uterotonic 2
(Percentage of women and girls who gave birth in 
a facility receiving prophylactic uterotonic 
immediately (within 1 min of delivery) after birth 
for prevention of PPH)
83.3 77.8 73.9 96.8 50.05
12. Newborns birth weight documented 2
(Percentage of newborns with documented 
birthweight)
64.4 94.4 95.7 6.5 66.75
13. Premature newborns initiated on KMC4
(Percentage of newborns < 2,500 gms initiated on 
KMC (or admitted to KMC unit if separate unit 
exists))
5.8 16.7 0 N/A N/A
55 | Page
1Source: Record review of 100 cases per facility: Overall (N=1825); DH/MCWC (n=199) ; UHC( n=272); Private (n=199); 
UH&FWC (n=1155) 
$ Source: Record review: Overall (N=1828); DH/MCWC (n=200) ; UHC (n=272); Private (n=202); UH&FWC (n=1155) 
Denominator: per 1000 delivery 2 Source: Delivery observation; Overall (N=90); DH/MCWC (n=36) ; UHC (n=23); Private (n=31);
3 Source: Exit interview of women delivered in the facilities; Overall (N=90); DH/MCWC (n=36) ; UHC (n=23); Private (n=31)
4 Source: Record review; Overall (N=17); DH (n=6); UHC (n=11); KMC facility was not available in MCWC, Private facilities 
and UH&FWC 5 Estimates reported from case simulation interviews (n=30) and are not included in overall estimate calculation
* among all women delivered in the facility who wanted to have birth companion of choice; Overall (N=16); DH/MCWC (n=9) 
; UHC (n=2); Private (n=5);
** overall estimates are derived from estimates from DH/MCWC, UHC and private facilities
*** Data collection continued between 11th May-August 3rd, 2019
Overall
(29)
DH 
(1)
MCWC 
(1)
UHC(3) Private 
Hospital 
(2)
UH&FWC1
(22)
Input
14. Basic Hygiene Provision2
(The percentage of facilities in 
which delivery rooms have at 
least one functional 
handwashing station with 
water and soap available)
69.0 100.0 0.00 100.0 100.0 63.6
15. Basic sanitation available to 
women and families3 (The 
percentage of facilities with basic 
sanitation available for women 
during and after labor and 
childbirth (private toilet/latrine, 
bathing.)
96.5 100.0 100.0 100.0 100.0 95.5
1 22 out of 24 UHFWC had the provision of delivery service
2Basic Hygiene Provision: Hand-washing soap (may be liquid soap) and Running water (piped, bucket with tap or pour 
pitcher)
3Basic Sanitation: Facility has functioning flush or pour-flash toilet or a ventilated improved pit latrine or composting toilet 
for women during and after labor and childbirth
56 | Page
Indicator 19: Percentage of women who delivered in the health facilities reporting positive experience 
of care.
Indicator (all Facility-based) Overall
(N=90)
DH & 
MCWC
(n=36)
UHC
(n=23)
Private 
facilities
(n=31)
Percentage of women received immediate attention upon 
arrival at the labor ward 
50.0 41.7 56.5 54.8
Percentage of women thought that they were adequately 
informed by health workers about the health and care
83.3 91.7 65.2 87.1
Percentage of women got an opportunity to discuss your 
concerns and preferences with concerned
84.4 83.3 78.3 90.3
The percentage of women had a companion supporting 
them during labor and childbirth in the health facility
30.0 33.3 52.2 9.7
Percentage of women who did not report any physical, 
verbal or sexual abuse during the stay in the facilities
98.9 97.2 100.0 100.0
Percentage of women receive pre-discharge counselling 
for mother and baby
94.4 88.9 95.7 100.0
Percentage of women received positive experience of 
care 
At least 2 out of 6 100.0 100.0 100.0 100.0
At least 3 out of 6 95.6 97.2 91.3 96.7
At least 4 out of 6 83.3 86.1 69.6 90.3
At least 5 out of 6 46.7 38.9 52.2 51.6
6 out of 6 15.6 13.9 34.8 3.2
Indicator 21: Percentage of women with Severe preeclampsia/ eclampsia received appropriate 
management in health facilities1
Indicator (all Facility-based) Overall
(N=37)
DH & 
MCWC
(n=27)
UHC
(n=0)
Private 
facilities
(n=10)
UNION 
level 
facilities
(n=0)
Percentage of women with severe preeclampsia/ 
eclampsia received appropriate management in 
health facilities that had participated in QoC 
Learning Network
64.9 74.1 40.0
1 Data for this indicator has been derived from record review of severe preeclampsia and eclampsia cases. All severe 
preeclampsia and eclampsia cases from the past 6 months of survey were included. 
Data collection continued between 11th May-August 3rd, 2019
57 | Page
ANNEX 2: DATA COLLECTION PROCESS AND DATA SOURCES
Objectives Main indicators Data 
collection 
process
Data 
collection 
tools
Data sources / 
Study 
participants
Data 
collection site 
Objective 1:
Structural readiness
o Delivery area having 
Basic Hygiene 
Provision
o Basic sanitation 
available to women 
and families
o Basic equipment and 
supplies in the delivery 
room
o Essential logistics and 
supplies for 
management of 
complications during 
pregnancy, child birth 
and postpartum
o Standardized medical 
record and 
mechanisms for data 
collection, analysis and 
feedback
o Laboratory supplies 
and tests
o Structured 
observation 
o Health 
care 
provider 
interview
Facility 
readiness 
assessment 
tool 
o Observation 
o Statisticians 
and mangers 
of respective 
health 
facilities
o DH, 
MCWC, 
UHC, 
UH&FWC, 
Private 
facilities
Objective 2:
Quality of care
Delivery Observation
o Complicated and 
uncomplicated labor 
and delivery 
management (if any)-
preterm labor, prolong 
labor, obstructed 
labor, PROM, 
preeclampsia/eclampsia 
and PPH
o Immediate newborn 
care – routine care 
and management of 
newborn complications
o Immediate postnatal 
care within 24 hours 
(before discharge from 
the facility)
o Routine care for 
mother and baby who 
remain in hospital as a 
result of caesarean 
delivery
o Structured
observation 
of delivery 
care, 
immediate 
newborn 
care, 
postnatal 
care within 
24 hours 
(before 
discharge) 
o Delivery 
observation 
tool 
o Case 
simulation 
tool
o Women 
delivered in 
the facilities
o Health care 
providers for 
delivery 
services from 
DH/MCWC/ 
UHC/ private 
hospitals 
o Health care 
providers 
from Union 
level facilities
o DH, 
MCWC, 
UHC, 
Private 
facilities
58 | Page
Objectives Main indicators Data 
collection 
process
Data 
collection 
tools
Data sources / 
Study 
participants
Data 
collection site 
Observation of ANC 
consultation
o Women assessed 
appropriately during 
ANC consultation 
(History taking and 
physical examination)
o Clinical and laboratory
examinations
o Women provided with 
IFA supplements, 
calcium and vitamins
o Counselling on 
nutrition, birth , 
neonate and 
emergency 
preparedness(BNEP), 
immediate newborn 
care
Direct 
observation of 
antenatal 
check-up 
session
ANC 
observation 
tool
o Pregnant 
women during 
their ANC in 
the facilities
o ANC service 
providers
o DH, 
MCWC, 
UHC, 
UH&FWC, 
Private 
facilities
Objective 3: 
Experience of care
o Perception about 
service of the facility
o Satisfaction regarding 
service, patient care, 
behavior of the 
provider and staff,
cleanliness and 
counselling services
Structured 
interview
Exit interview 
tools 
o Pregnant 
women during 
their ANC in 
the facilities
o Recently 
delivered 
women before 
discharge from 
the facilities 
o DH, 
MCWC, 
UHC, 
Private 
facilities