Abstract
Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37–0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03–0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual’s characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.
Highlights
Bypassing health facilities for care is a phenomenon where individuals choose to obtain care from a facility that is not their nearest [1]
Most women had three or more antenatal care visits (75.7%), and about half were accompanied by accredited social health activist (ASHA) during childbirth (Table 2)
Most (94.8%) women delivered at a public health care facility, with 57% of all birth occurring in secondary health care facilities (Table 3) that had 31% of all available beds
Summary
Bypassing health facilities for care is a phenomenon where individuals choose to obtain care from a facility that is not their nearest [1]. Studies conducted in low- and middle-income countries found that the magnitude of bypassing facilities for any type of care ranged from 36% in Chad to 67% in Tanzania [1,2]. In the USA, analyses of rural populationsbypassing patterns found that between 37% and 44% of patients bypassed their local hospital for care [3,4]. Research from low- and middle-income settings have highlighted that pregnant women and their families often circumvent their nearest obstetric care facility for childbirth. In Tanzania and Nepal, 44% and 70% of the pregnant women respectively bypassed their nearest facility for childbirth [5,6]. In Uganda, Parkhurst and Sengooba found that between 8–80% of the facility births attributable to a parish were attended by the parish local obstetric facility [7]
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