Kranti Suresh Vora

Achieving Millennium Development Goal 5: is India serious?

India has the largest number of births per year (27 million) in the world.1 With its high maternal mortality of about 300–500 per 100 000 births, about 75 000 to 150 000 maternal deaths occur every year in India.2,3 This is about 20% of the global burden hence India’s progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5 (MDG 5). Why is India’s maternal mortality high in spite of rapid economic growth? We believe the key reasons are political, administrative and managerial rather than a lack of technical knowledge.

The State-Led Large Scale Public Private Partnership ‘Chiranjeevi Program’ to Increase Access to Institutional Delivery among Poor Women in Gujarat, India: How Has It Done? What Can We Learn?

Background Many low-middle income countries have focused on improving access to and quality of obstetric care, as part of promoting a facility based intra-partum care strategy to reduce maternal mortality. The state of Gujarat in India, implements a facility based intra-partum care program through its large for-profit private obstetric sector, under a state-led public-private-partnership, the Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians to perform deliveries for poor/tribal women. We examine CY performance, its contribution to overall trends in institutional deliveries in Gujarat over the last decade and its effect on private and public sector deliveries there. Methods District level institutional delivery data (public, private, CY), national surveys, poverty estimates, census data were used. Institutional delivery trends in Gujarat 2000–2010 are presented; including contributions of different sectors and CY. Piece-wise regression was used to study the influence of the CY program on public and private sector institutional delivery. Results Institutional delivery rose from 40.7% (2001) to 89.3% (2010), driven by sharp increases in private sector deliveries. Public sector and CY contributed 25–29% and 13–16% respectively of all deliveries each year. In 2007, 860 of 2000 private obstetricians participated in CY. Since 2007, >600,000 CY deliveries occurred i.e. one-third of births in the target population. Caesareans under CY were 6%, higher than the 2% reported among poor women by the DLHS survey just before CY. CY did not influence the already rising proportion of private sector deliveries in Gujarat. Conclusion This paper reports a state-led, fully state-funded, large-scale public-private partnership to improve poor women’s access to institutional delivery - there have been >600,000 beneficiaries. While caesarean proportions are higher under CY than before, it is uncertain if all beneficiaries who require sections receive these. Other issues to explore include quality of care, provider attrition and the relatively low coverage.

Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu.

BackgroundIndia leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world’s largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women’s access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women’s use of maternal health services in Gujarat and Tamil Nadu.MethodsUsing the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section.ResultsTamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women’s education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands’ education predicted institutional delivery in Gujarat.ConclusionsOverall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.

Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India?

Background The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CYs effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Methods Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Results Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. Conclusions This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation.

Bypassing health facilities for childbirth: a multilevel study in three districts of Gujarat, India

Background Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. Objectives 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. Design A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Results Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facilitys emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53–0.76). Conclusions This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.Background Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. Objectives 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. Design A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Results Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facilitys emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53-0.76). Conclusions This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.

Hygiene on maternity units: lessons from a needs assessment in Bangladesh and India

Background As the proportion of deliveries in health institutions increases in low- and middle-income countries, so do the challenges of maintaining standards of hygiene and preventing healthcare-associated infections (HCAIs) in mothers and babies. Adequate water, sanitation, and hygiene (WASH) and infection prevention and control (IPC) in these settings should be seen as integral parts of the broader domain of quality care. Assessment approaches are needed which capture standards for both WASH and IPC, and so inform quality improvement processes. Design A needs assessment was conducted in seven maternity units in Gujarat, India, and eight in Dhaka Division, Bangladesh in 2014. The WASH & CLEAN study developed and applied a suite of tools – a ‘walkthrough checklist’ which included the collection of swab samples, a facility needs assessment tool and document review, and qualitative interviews with staff and recently delivered women – to establish the state of hygiene as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual determinants or drivers. Results No clear relationship was found between visually assessed cleanliness and the presence of pathogens; findings from qualitative interviews and the facility questionnaire found inadequacies in IPC training for healthcare providers and no formal training at all for ward cleaners. Lack of written policies and protocols, and poor monitoring and supervision also contributed to suboptimal IPC standards. Conclusions Visual assessment of cleanliness and hygiene is an inadequate marker for ‘safety’ in terms of the presence of potential pathogens and associated risk of infection. Routine environmental screening of high-risk touch sites using simple microbiology could improve detection and control of pathogens. IPC training for both healthcare providers and ward cleaners represents an important opportunity for quality improvement. This should occur in conjunction with broader systems changes, including the establishment of functioning IPC committees, implementing standard policies and protocols, and improving health management information systems to capture information on maternal and newborn HCAIs.

Options for Optimal Coverage of Free C-Section Services for Poor Mothers in Indian State of Gujarat: Location Allocation Analysis Using GIS

Background Gujarat, a western state of India, has seen a steep rise in the proportion of institutional deliveries over the last decade. However, there has been a limited access to cesarean section (C-Section) deliveries for complicated obstetric cases especially for poor rural women. C-section is a lifesaving intervention that can prevent both maternal and perinatal mortality. Poor women bear a disproportionate burden of maternal mortality, and lack of access to C-section, especially for these women, is an important contributor for high maternal and perinatal mortality in resource limited settings. To improve access for this underserved population in the context of inadequate public provision of emergency obstetric services, the state government of Gujarat initiated a public private partnership program called “Chiranjeevi Yojana” (CY) in 2005 to increase the number of facilities providing free C-section services. This study aimed to analyze the current availability of these services in three districts of Gujarat and to identify the best locations for additional service centres to optimize access to free C-section services using Geographic Information System technology. Methodology Supply and demand for obstetric care were calculated using secondary data from sources such as Census and primary data from cross-sectional facility survey. The study is unique in using primary data from facilities, which was collected in 2012–13. Information on obstetric beds and functionality of facilities to calculate supply was collected using pretested questionnaire by trained researchers after obtaining written consent from the participating facilities. Census data of population and birth rates for the study districts was used for demand calculations. Location-allocation model of ArcGIS 10 was used for analyses. Results Currently, about 50 to 84% of populations in all three study districts have access to free C-section facilities within a 20km radius. The model suggests that about 80–96% of the population can be covered for free C-section services with addition of 4–6 centres in critical but underserved regions. It was also suggested that upgrading of public sector facilities with minimal investment can improve the services. Conclusion This study highlights utility of Geographic Information System technology for planning service centres to optimize access to vital lifesaving procedure such as C-section. Although the location allocation methodology has been available for decades, it has been used sparsely by public health professionals. This paper makes an important contribution to the literature for use of the method for planning in resource limited settings.

Is Institutional Delivery Protective Against Neonatal Mortality Among Poor or Tribal Women? A Cohort Study From Gujarat, India

Objectives In low-income settings, neonatal mortality rates (NMR) are higher among socioeconomically disadvantaged groups. Institutional deliveries have been shown to be protective against neonatal mortality. In Gujarat, India, the access of disadvantaged women to institutional deliveries has increased. However, the impact of increased institutional delivery on NMR has not been studied here. This paper examined if institutional childbirth is associated with lower NMR among disadvantaged women in Gujarat, India. Methods A community-based prospective cohort of pregnant women was followed in three districts in Gujarat, India (July 2013–November 2014). Two thousand nine hundred and nineteen live births to disadvantaged women (tribal or below poverty line) were included in the study. Data was analyzed using multivariable logistic regression. Results The overall NMR was 25 deaths per 1000 live births. Multivariable analysis showed that institutional childbirth was protective against neonatal mortality only among disadvantaged women with obstetric complications during delivery. Among mothers with obstetric complications during delivery, those who gave birth in a private or public facility had significantly lower odds of having a neonatal death than women delivering at home (AOR 0.07 95% CI 0.01–0.45 and AOR 0.03, 95% CI 0.00–0.33 respectively). Conclusions for Practice Our findings highlight the crucial role of institutional delivery to prevent neonatal deaths among those born to disadvantaged women with complications during delivery in this setting. Efforts to improve disadvantaged women’s access to good quality obstetric care must continue in order to further reduce the NMR in Gujarat, India.

Knowledge of hepatitis B among healthy population: A community-based survey from two districts of Gujarat, India

Background: Hepatitis B is the worlds most common blood-borne viral infection, accounting for 2 billion infections, 350 million carriers, and 6 lakh deaths annually. Country like India still harbors approximately 30–60 million hepatitis B virus (HBV) carriers. A modest estimate would put the number of deaths occurring due to HBV infection per year in India to around 100,000. To prevent transmission and progression of the disease, proper community awareness including prevention is necessary. Therefore, this study aims to study the knowledge awareness among the healthy population about hepatitis B including knowledge regarding vaccine. Methodology: A community-based cross-sectional study was undertaken in two districts of Gujarat. Cluster sampling (30 clusters) was used, and pretested questionnaire was administered to 600 (with a prevalence rate of 5% in Gujarat having design effect of 2 within 95% confidence interval and 10% nonrespondent) healthy individuals, who heard about hepatitis B. Data handled and analyzed in EpiData Analysis V2.2.2.183. Results: Majority of the participants knew about symptoms whereas only 41% knew about prevention methods and few 34% knew about the mode of transmission. Although 40% sample has knowledge about the availability of vaccination, only 20% were self-vaccinated. The common reason for nonvaccination was lack of awareness. Conclusions: Only one-third of the populations in study districts are aware about hepatitis B and its vaccine. Less than one-fifth of the populations are vaccinated for hepatitis B. Important knowledge deficits about the routes of hepatitis B transmission/prevention were identified. Continued efforts should be made to develop and implement hepatitis B educational campaigns/health promotion for these communities.

Effect of Previous Utilization and Out-Of-Pocket Expenditure on Subsequent Utilization of a State Led Public-Private Partnership Scheme "Chiranjeevi Yojana" to Promote Facility Births in Gujarat, India

BackgroundIn Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat.MethodsThis was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan–Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth.ResultsOf 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2–3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme.ConclusionWomen with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended.