For Mothers, By Mothers: Improving quality of maternal care through mother feedback

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By: Anne Reijns, Business Unit Director, Avegen Pte Ltd.; Lily W. Lee, President, ALMATA, Division of Avegen Pte Ltd.; Mark Allen, Director of Strategic Partnerships, Merck for Mothers; Sumiti Saharan, Design and Research Director, Avegen Pte Ltd.

Patient feedback can play a key role in measuring and improving the quality of healthcare. In developing countries like India, there are few, if any avenues to give or access feedback on the quality of maternal healthcare. Women from low and middle-income segments lack the know-how of what constitutes good quality care as well as the agency to demand it from healthcare practitioners.

To address these gaps and to develop a real-time quality of care metric, Together for Her launched a review platform in India, Together For Her, that allows new mothers receiving care in private hospitals to provide objective feedback on their delivery experience. Comprising a set of nine standard quality-of-care (QoC) indicators based on the WHO Maternal Care Guidelines (World Health Organization, 2016), the indicators were adapted based on local inputs from doctors, maternal health specialists and mothers to the local contexts. Each indicator was field tested to ensure that the language and description of the condition is clear to the Mothers; and if the Mothers responded “No” to the indicator, a drop down manual with specific circumstances were provided for the Mothers to provide additional details on why the service/ support was not provided.  The indicators are:

(i) On-time admission

(ii) Cleanliness

(iii) Privacy

(iv) Skin-to-skin contact

(v) Early initiation of breastfeeding

(vi) Respectful Behavior

(vii) Communication during labor

(viii)Counseling on danger signs

(ix) Family planning counseling and guidance

Mothers, who have delivered within the last year, rate their experience at the hospital across these indicators. Pregnant women can access the site to search and compare hospitals in their localities; they have access to an aggregate score and an overall 5-point rating. The rating is also made visible on Google search. Hospitals and doctors are given access to personalized dashboards, where they can compare their QoC score with a local average and also across time. The dashboard also shows them qualitative feedback from mothers. The platform currently has approximately 30,000 reviews for close to 1000 hospitals across nine states in India.

Feedback from mothers has lead to improvement in quality of care

The avenue for feedback provided by Together for Her, has led to significant improvements in quality of care in the registered hospitals. An in-depth statistical analysis has revealed significant improvements over time in six out of nine QoC indicators including skin-to-skin care, early initiation of breastfeeding, family Planning counselling and guidance, and cleanliness and privacy. Furthermore, other indicators show a marked improvement from the time of registering with Together for Her. 

Sl. No. QOC Before Registration After Registration
Mean (%) SD Mean (%) SD


1 Waiting time/admission 99.36 2.17 99.67 1.43
2 Cleanliness 99.06 2.59 98.97 3.68
3 Privacy 99.29 2.21 99.64 1.52
4 Skin-to-skin care/Kangaroo care 25.37 29.48 33.04 3.25
5 Breastfeeding 74.20 29.57 77.30 27.25
6 Respect and courtesy 99.14 2.27 99.04 3.09
7 Timely communication 99.40 2.44 99.52 1.88
8 Danger signs counseling 95.27 8.07 95.49 7.41
9 Family planning guidance 78.41 16.79 79.50 17.98
Graph showing Average % QOC Score by Time Since Registration (Months)
Attitudes of doctors towards feedback

Attitudes held by healthcare providers are a major factor on the speed and success of incorporating feedback in hospitals. To understand doctors’ viewpoints and attitudes to the Quality of Care feedback, we conducted 12 in-depth semi-structured interviews with doctors from hospitals registered in Together for Her.

All doctors interviewed strongly advocated the value of obtaining feedback from others. The authenticity of ratings was perceived as being very important. Respondents found the ratings on Together for her to be “reliable, unambiguous and unbiased” as they come only from mothers who have delivered at their practice and can speak to their experience:

“Here in TFH they have been associated for nine months and know how the things go on. Whereas in Justdial and Google even a visitor can post anything if they are not really happy with it. So, that’s the best part about TFH and that is why the ratings can be improvised.-AK

 Encouragingly, nearly all doctors who tracked Together for Her ratings reported giving feedback to their staff and making changes to their practice in response to their scores on the QoC indicators. This held particularly for indicators they performed poorly on, such as skin-to-skin contact (kangaroo care) and early initiation of breastfeeding. The feedback was either communicated in one-on-one meetings with relevant staff members or during monthly reviews.

“Skin-to-skin contact had a little lower percentage. Family Planning counseling had lower scores. So we have spoken to our sisters. There is one checklist which is a WHO checklist which has all those points counseling about family planning. And so, we have spoken about that checklist again, they are trained initially also, but then since it was not improving so we had to refresh it and then we have specifically instructed them you have to tick once you have done it and we have also started taking verbal feedbacks from the patient on the follow-up, whether she was counseled on this point or not.” – PG

Furthermore, doctors tracked their performance on the indicators and were cognizant of improvement in their QOC scores with time.

“Since I started this online service by you all we definitely got to know our own score to improve. So it definitely gives us a platform to improve. There is no doubt about that.”-AK

 Qualitative interviews revealed that the feedback system aids hospital administration in identifying the loopholes, offer relevant staff training and hence provide better overall quality of services. This in turn has benefited the hospital, leading to an increase in the number of patients, better reputation and financial growth. Some doctors also reported reduced complaints from existing patients.

“New patients approach our hospital through the website…..Patient monitoring has been better. The alertness and response improved. These complaints have come down.” -PG


While all doctors support internal feedback, open feedback from clients meets resistance. There had to be considerable investment spent on relationship and trust building with healthcare providers, to assure them that feedback collected could help them to improve and were not meant simply to criticize their work. Hospitals and doctors alike are worried about negative bias and perceive ‘public’ feedback, particularly when subjective, as unfair and a threat to their reputation.

Some quality-of-care indicators used did not seem to be a priority for the healthcare providers. Indicators such as skin-to-skin contact, emotional support and respectful care are considered as non-issues and lower down the priority list, compared to indicators such as counseling on danger signs.

“They’re not trained or they are not qualified. Our basic struggle is to first enhance their skills to an optimal level and help them pick up those danger signs, that are signs which will affect the patient’s life or prevent death or serious complications. That is why we give top priority to these things. The rest of the things are important, but once we are comfortable with our basic things then probably we could focus more on patient’s experience oriented parameters.” – SJ

Feedback loop helps both supply and demand

Channeling the voice of mothers in the form of collective actionable feedback to providers offers near real-time monitoring on hospital performance and aids improvement in quality of care. The quality metric also supports pregnant women to make informed choices about where to deliver and seek maternal care, while accounting for quality of care. The metric is a strong complement to training interventions and can aid in successfully identifying hospitals for inspection and/or training.

By building a feedback loop that captures mothers’ voices and delivering them as objective, actionable feedback to healthcare providers, we have been able to build a system that is evidence-based, relevant to stakeholders and localized to the context. Our experience has shown that building transparency and authenticity to gain trust and increase credibility is important for both consumers and providers.

This program is supported by funding from MSD, through MSD for Mothers, the company’s 10-year, $500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co., Inc, Kenilworth, N.J., USA.