Quality of care in obstetric services in rural South India-evidence from two studies in a ten year period-Asha kilaru

UTILIZATION AND QUALITY OF OBSTETRIC CARE IN RAMNAGARAM DISTRICT: CHANGES OVER A DECADE

BELAKU TRUST

Objectives

Map positive and negative changes in pregnancy and delivery services over a decade in a taluka of Ramnagaram District (1996-98 and 2007-09)

Identify gaps in the quality of services currently being delivered to women during pregnancy, delivery and postpartum.

Make suggestions for how the observed gaps can

be addressed.

Findings

Antenatal Study 11996-98

Study 22007 - 09

Contact in 1st trimester 56% 83%

> 4 antenatal visits 6% 64%

Quality of care at antenatal visit

BP measured 57% At most recent visit -Abdomen palpated: 88%

BP: 66%IFA: 64%

Blood test: 13%urine test: 8%

advice on signs or problems: 23% Bf advice: 5%

postnatal visit advice: 2%

Planned to deliverat home

87% 10%

Findings (2)

Study 11996-98

Study 22007 - 09

Planning for problems and for response to onset of labour

Not available, but low according to our

observation

Not available, but low according to our

observation

Switching place of del (planned/anticipated to actual)

30% 33%Switched for reasons other than referral by provider

Findings (3)

Study 11996-98

Study 22007 - 09

Institutional deliveries 35% 82%

ANM in attendance at home delivery

34% 17%

Oxytocin administered at home delivery

53% 17%

Oxytocin administered intramuscular at inst delivery

Not available 23%

Birth weight recorded <25% 76%

Findings (4)

Study 11996-98

Study 22007 - 09

Length of stay Usually few hours 62% <6hrs(even with LBW infants)

Postpartum/newborn advice given

Rarely given 55-60%(62% of women w/o

LBW infant and 56% of those w/ LBW received

advice)

Perinatal deaths 11 stillbirths 15 nn deaths

(26/355 live births)

13 stillbirths 14 nn deaths

(27/581 live births)

Findings (5)

Study 11996-98

Study 22007 - 09

Postpartum visits 58% with some postpartum contact, most with only 1

93%(565) at least 1 contact with HCP

Of these, 94% said it was only for baby Most of the visits (68%) reported routine visits for immunization

Findings (6)

Cost of care at all stages (Study 2 data) Costs high, much exceeding JSY payments. Much of it under-the-table Antenatal - highest expenditure for medicines Intrapartum - highest expenditure for provider payments Normal delivery median costs        Rs 1000-1300 in PHCs and Taluk hosp        Rs 4000 in tertiary gov inst C-sections median costs      Rs 8000 at tertiary gov inst       

Findings (7)

SC % (n) Others %(n)

Mean ANC visits 5.3 6.1

Timing of 1st ANC 1st or 2nd month 14.3 (21) 27.7 (128)

Place of ANC Only government 68.5 (100) 40.7 (188)

Only private 9.6 (14) 37.9 (175)

Place of birth Home 24.0 (35) 14.7 (68)

Sub-centre/PHC 24.7 (36) 18.4 (85)

Taluk hospital 34.9 (51) 34.6 (160)

Private hospital 5.5 (8) 18.8 (87)

**Other govt hospital 9.6 (14) 11.9 (55)

En-route 1.4 (2) 1.5 (7)

Total sample size 146 462

Findings (8)

SC % (n) Others % (n)

Provider spoke with respect

63.0 (92) 70.3 (325)

I felt comfortable to ask questions

58.2 (85) 66.9 (265)

Other staff were helpful 37% (54) 47.6% (220)

Told about postpartum signs needing consultation

50.7% (74) 57.1% (264)

LBW 25% 15%

Total 146 462

Findings (9)

Perceptions of public-sector care Seem to have improved in the period between the

two studies, having been poor during the first one.

Satisfaction with interaction Discontent about not having delivery companion

present -- 51% (PHC) to 96% (Tertiary govt) Discomfort in asking questions of health care

provider during L&D – betw 36 - 44% at govt inst

Socio-culturally linked factors

Family members key

Local ideas about interpretation of symptoms, causes of illness were a significant factor in care-seeking Especially true in post-partum (bananthana) eg PPH,

breast abscess Little recognition or acknowledgement of this by providers

Attitudes that affect planning for emergencies or at onset of labour

Political connections for preferential work by providers

Conclusions and Recommendations

1. Improve the availability of 24x7 PHCs,

2. Checklists for health providers on specific components of recommended care

3. Create and mainstream specific protocols for women with LBW newborns, use of oxytocin for labour augmentation and AMSTL

4. Increase length of stay after delivery in institutions

Conclusions and Recommendations (2)

5. Allow women to have a companion of choice present during delivery

6. Improve communication in terms of asking women and families about their concerns and confusions

7. Improve safe birth attendance at home births

8. Prioritize routine postpartum care for women, not only for vaccination of the newborn

9. Universal perinatal death review