Abstract
BackgroundIn 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India.MethodsPregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center.ResultsBetween June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0–1.2); moderate or severe anemia (aRR 1.2; 1.2–1.4), gestational age <37 weeks (aRR 1.16; 1.05–1.27), multiple gestation (aRR 1.6; 1.2–2.1), absent fetal heart rate (aRR 1.7; 1.3–2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4–5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred.ConclusionsAlmost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop “at risk” conditions during labor and delivery.Trial registrationClinicalTrials.gov NCT01073475.
Highlights
In 2008, the Indian government introduced financial assistance to encourage health facility deliveries
In 2008, the Indian government introduced a conditional cash transfer (CCT) program, Janani Suraksha Yojana (JSY) that provides financial assistance for women delivering in institutions and to community health workers who bring the expectant mother to institutions for delivery
This is a one time incentive to restrict home deliveries and encourage facility deliveries. It does not cover inter-institutional referrals. This scheme has substantially increased the rates of deliveries in facilities in India, [5] but to date, maternal mortality has not decreased, raising questions about the quality of care provided in facilities and access to a quality referral system when it is needed
Summary
In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Financial incentives are provided to the community health worker (CHW) who accompanies and facilitates the delivery of the pregnant women at the health facility This is a one time incentive to restrict home deliveries and encourage facility deliveries. This scheme has substantially increased the rates of deliveries in facilities in India, [5] but to date, maternal mortality has not decreased, raising questions about the quality of care provided in facilities and access to a quality referral system when it is needed. Hallmarks of a quality referral system include: accurate screening, identification of women at risk, timely referral and transportation to a facility that can provide needed interventions and care, along with experienced and trained medical staff [6]. Such a referral system is so important that it has been called the keystone of safe motherhood [7, 8]
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