Deliveries In India Research Articles

Socio-demographic Determinants of Caesarean Section Deliveries in India: Descriptive analysis of Cross-sectional data from National Family Health Survey

Background: Increase in global rate of Caesarean deliveries poses significant public health concerns as it is associated with high costs and risks for maternal, new born health. In India understanding determinants of Caesarean deliveries is of paramount importance in order to prevent maternal and child health morbidity and mortality. Aims and Objective: To investigate the socio-demographic determinants of Caesarean deliveries in India using cross-sectional data from National Family Health Survey. Methodology: The present study is a cross-sectional record based study using data from National Family Health Survey conducted in India between 2019 and 2021. The primary outcome variable is Caesarean delivery, while predictors are socio-demographic and obstetric factors. Frequency analysis used for socio-demographic variables and binary logistic regression was used to determine the determinants of Caesarean deliveries among women in the reproductive age group. The analysis was done using IBM SPSS Statistics 26.0 Software. Results: The socio-demographic and obstetric factors like maternal age, residence, education, employment, BMI, Birth order, number of Antenatal visits, place of delivery, wealth index, and media exposure are associated with Caesarean delivery. Conclusions: The study provides insights into the factors influencing Caesarean deliveries rates among women in India.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data.

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India. We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model. We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India. Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

Factors Impacting Quality of Skilled Birth Attendant Services in Rural India

Availability of skilled birth attendant (SBA) is a crucial factor in reducing mortality rates among mothers and children. The lower- and middle-income countries show low use of these service causing increased risk of maternal and child mortality. While there has been a remarkable improvement in the coverage of SBA-monitored deliveries in India, its impact on outcome indicators such as perinatal and neonatal mortality rates have not been significant. Although the country performs better than the world average in the former, its performance is poor in the latter. This raises question on the quality of SBA services in India. The present study examines SBA services in the context of availability of attendants, infrastructural support and level of training of the SBAs in the rural areas of the four large states in India—Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. The findings are that SBA lack sufficient training to provide the services effectively. The effectiveness of their services is also hampered by the absence of the essential infrastructure at public health facilities. Moreover, there is congestion and overcrowding at the higher level of facilities such as PHCs and CHCs as compared to village level sub-centres.

Association between the use of Accredited Social Health Activist (ASHA) services and uptake of institutional deliveries in India.

This study examines the impact of accredited social health activists (ASHAs), on increasing rates of institution-based deliveries among Indian women with a specific focus on the nine low-performing, empowered action group states and Assam (EAGA) in India. Using the latest round of the National Family Health Survey-V (2019-21), we first investigate the association between the use of ASHA services and socio-demographic attributes of women using a multivariate logistic regression. We then use propensity-score matching (PSM) to address observable selection bias in the data and assess the impact of ASHA services on the likelihood of institution-based deliveries using a generalized estimating equations model. Of the 232,920 women in our sample, 55.5% lived in EAGA states. Overall, 63.3% of women (70.6% in EAGA states) reported utilizing ASHA services, and 88.6% had an institution-based delivery (84.0% in EAGA states). Younger women from the poorest wealth index were more likely to use ASHA services and women in rural areas had a two-fold likelihood. Conversely, women with health insurance were less likely to use ASHA services compared to those without. Using PSM, the average treatment effect of using ASHA services on institution-based deliveries was 5.1% for all India (EAGA = 7.4%). The generalized estimating equations model indicated that the use of ASHA services significantly increased the likelihood of institution-based delivery by 1.6 times (95%CI = 1.5-1.7) for all India (EAGA = 1.8; 95%CI = 1.7-1.9). Our study finds that ASHAs are effective in enhancing the uptake of maternal services particularly institution-based deliveries. These findings underscore the necessity for continual, systematic investments to strengthen the ASHA program and to optimize the program's effectiveness in varied settings that rely on the community health worker model, thereby advancing child and maternal health outcomes.

Facility assessment of the best functioning facility providing emergency obstetric care in the selected blocks of Varanasi, Uttar Pradesh

ABSTRACT Background: UP has the 2nd highest MMR which is 197 compared with national average of 113 (RGI-SRS-2016-2018).Although institutional deliveries in India has been increased from 78.9% (NFHS-4) to 89% (NFHS-5) [ UP from 67.8% to 83.4%] but still we are far away from SDG -3 target. It reflects that there may be increase in crude coverage but not in effective coverage. Materials and Methods: It is a cross sectional study conducted in May – June 2017. Out of 8 blocks of rural Varanasi, 4 blocks were selected randomly. Best functioning facility for EmOC services in each selected block were assessed using Facility Gap Assessment Schedule of IPHS. Result: None of the facility met the recommended standard for BEmOC .Tracking of drop out of ANC and PNC services, use of Partograph, treatment of abortion-related complications, were not found at all the 4 facility. Blood grouping and RH typing was also not functional at 2 of the 4 centers. Caesarean section and availability of blood bank were also lacking in CHC (FRU). Conclusion: If condition of best functioning facility in a block is not according to the recommendation then how can we expect to provide a good maternal health service to public.

Out of pocket expenditure and distress financing on cesarean delivery in India: evidence from NFHS-5

BackgroundThough over three-fourths of all births receive medical attention in India, the rate of cesarean delivery (22%) is twice higher than the WHO recommended level. Cesarean deliveries entail high costs and may lead to financial catastrophe for households. This paper examines the out-of-pocket expenditure (OOPE) and distress financing of cesarean deliveries in India.MethodsWe used data from the latest round of the National Family Health Survey conducted during 2019–21. The survey covered 636,699 households, and 724,115 women in the age group 15–49 years. We have used 159,643 births those delivered three years preceding the survey for whom the question on cost was canvassed. Descriptive analysis, bivariate analysis, concentration index (CI), and concentration curve (CC) were used in the analysis.ResultCesarean deliveries in India was estimated at 14.08%, in private health centres and 9.96% in public health centres. The prevalence of cesarean delivery increases with age, educational attainment, wealth quintile, BMI and high for those who had pregnancy complications, and previous birth as cesarean. The OOPE on cesarean births was US$133. It was US$498 in private health centres and US$99 in public health centres. The extent of distress financing of any cesarean delivery was 15.37%; 27% for those who delivered in private health centres compared to 16.61% for those who delivered in public health centres. The odds of financial distress arising due to OOPE on cesarean delivery increased with the increase of OOPE [AOR:10.00, 95% CI, 9.35–10.70]. Distress financing increased with birth order and was higher among those with low education and those who belonged to lower socioeconomic strata.ConclusionHigh OOPE on a cesarean delivery leads to distress financing in India. Timely monitoring of pregnancy and providing comprehensive pregnancy care, improving the quality of primary health centres to conduct cesarean deliveries, and regulating private health centres may reduce the high OOPE and financial distress due to cesarean deliveries in India.

Variations in the prevalence of caesarean section deliveries in India between 2016 and 2021 – an analysis of Tamil Nadu and Chhattisgarh

BackgroundThe prevalence of C-sections in India increased from 17.2% in 2016 to 21.5% in 2021. This study examines the variations in C-section prevalence and the factors correlating to these variations in Tamil Nadu (TN) and Chhattisgarh (CG).MethodsDelivery by C-section as the outcome variable and several demographic, socio-economic, and clinical variables were considered as explanatory variables to draw inferences from unit-level data from the National Family Health Survey (NFHS-4; 2015-16 and NFHS-5; 2019-21). Descriptive statistics, bivariate percentage distribution, Pearson’s Chi-square test, and multivariate binary logistic regression models were employed. The Slope Index of Inequality (SII) and the Concentration Index (CIX) were used to analyse absolute and relative inequality in C-section rates across wealth quintiles in public- and private-sector institutions.ResultsThe prevalence of C-sections increased across India, TN and CG despite a decrease in pregnancy complications among the study participants. The odds of caesarean deliveries among overweight women were twice (OR = 2.11; 95% CI 1.95–2.29; NFHS-5) those for underweight women. Women aged 35–49 were also twice (OR = 2.10; 95% CI 1.92–2.29; NFHS-5) as likely as those aged 15–24 to have C-sections. In India, women delivering in private health facilities had nearly four times higher odds (OR = 3.90; 95% CI 3.74–4.06; NFHS-5) of having a C-section; in CG, the odds were nearly ten-fold (OR = 9.57; 95% CI:7.51,12.20; NFHS-5); and in TN, nearly three-fold (OR = 2.65; 95% CI-2.27-3.10; NFHS-5) compared to those delivering in public facilities. In public facilities, absolute inequality by wealth quintile in C-section prevalence across India and in CG increased in the five years until 2021, indicating that the rich increasingly delivered via C-sections. In private facilities, the gap in C-section prevalence between the poor (the bottom two quintiles) and the non-poor narrowed across India. In TN, the pattern was inverted in 2021, with an alarming 73% of the poor delivering via C-sections compared to 64% of those classified as non-poor.ConclusionThe type of health facility (public or private) had the most impact on whether delivery was by C-section. In India and CG, the rich are more likely to have C-sections, both in the private and in the public sector. In TN, a state with good health indicators overall, the poor are surprisingly more likely to have C-sections in the private sector. While the reasons for this inversion are not immediately evident, the implications are worrisome and pose public health policy challenges.

A RETROSPECTIVE STUDY OF PREVALENCE AND MAJOR INDICATIONS OF CESAREAN SECTION IN A TERTIARY CARE HOSPITAL IN INDIA

According to the World Health Organisation (WHO), a caesarean section is a surgical procedure that can save the life of a woman and her baby when undertaken for medical reasons. Thus, the procedure should only be used in complicated pregnancies. However, C-sections have gradually become common in developing countries, and it is already quite common in the developed countries for a long time. A number of obstetric complications such as dystocia, foetal distress, breech births, post-term pregnancy, multiple pregnancy, and pregnancy-induced hypertension are recognized as reasonable motives behind caesarean section deliveries. Approximately 18.5 million caesarean births have been recorded each year globally, accounting for 19.1% of total births, which is beyond the cut-off recommended by the World Health Organization (WHO). In India, the rate of caesarean section delivery is dramatically increased from 3% in 1992–93 to 17% in 2015–16. In terms of regional variations, south Indian states have recorded substantially higher levels of caesarean deliveries in comparison to north India. Despite several studies that have investigated the factors contributing to caesarean section delivery, systematic evidence is still lacking towards understanding the determining factors and formulating effective policies to address the increasing rate of caesarean section deliveries in India. With this backdrop, this study attempts to observe the major indications and prevalence of caesarean section among pregnant women in a tertiary care hospital in India

Alarming Trends of Cesarean Section—Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India

Cesarean section (CS) delivery rate has increased significantly both globally and in India, thereby posing a burden on overstretched health systems. This study plans to understand the factors associated with CS rate with an objective to (1) analyze the trends of CS delivery from 1998-99 to 2019-21 and (2) understand the proximate determinants of CS deliveries in India. Analysis of secondary data (National Family Health Survey) of a nationally representative sample of 230,870 women (year 2019-21) was undertaken to explore the trends, distribution, and determinants of CS deliveries in India and within states. Multivariable analyses were performed to determine the proximate variables associated with CS and elective CS. The relative interaction effect of confounding factors, such as number of antenatal care (ANC) visits, place of residence, and wealth status, on cesarean delivery was assessed. A composite index was generated using trust, support, and intimate partner violence variables (termed the partner human capital index [PHI]) to study its influence on CS deliveries, with a low PHI indicating abusive partner and a high PHI indicating supportive partner. Statewise spatial distribution of the most significantly associated factors, namely, wealth quintile and ANC checkups, were also analyzed. The overall prevalence of CS was 21.50% (49,634/230,870) which had risen from 16.72% (2312/13,829) in 1998-99. The adjusted odds of CS deliveries were significantly higher among women who were highly educated (odds ratio [OR] 7.30, 95% CI 7.02-7.60; P<.001), had 4 or more ANC visits (OR 2.28, 95% CI 2.15-2.42; P<.001), belonging to the high-wealth quintile (OR 7.87, 95% CI 7.57-8.18; P<.001), and from urban regions. Increasing educational level of the head of the household (OR 3.05, 95% CI 2.94-3.16; P<.001) was also found to be a significant determinant of CS deliveries. The odds of selection of elective and emergency CS were also significantly higher among women from richer families (OR 1.66, 95% CI 1.25-2.21; P<.001) and those belonging to Christian religion (OR 1.67, 95% CI 1.14-2.43; P=.008). Adjusting the cesarean delivery by PHI, the odds of outcome were significantly higher among women with moderate and high PHI compared with those with low PHI (OR 1.46, 95% CI 1.36-1.56 and OR 1.61, 95% CI 1.49-1.74, respectively; P<.001 for both). The interaction effect result reiterates that women with more than 4 ANC checkups, high PHI, and belonging to the richer wealth quintile were more likely to undergo cesarean delivery (OR 22.22, 95% CI 14.99-32.93; P<.001) compared with those with no ANC visit, low PHI, and poorest women. The increasing trend of CS deliveries across India is raising concerns. Better education, wealth, and good support from the partner have been incriminated as the contributory factors. There is a need to institute proper monitoring mechanisms to assess the need for CS, especially when performed electively.

Spatial prevalence and its contextual determinants of early initiation of breastfeeding in cases of C-section deliveries in India: a study based on National Family Health Survey-4, 2015-2016

Background: Delayed early initiation of breastfeeding (EIBF) between 2 to 23 hours has increased 1.3 times risk of neonatal and it goes up double when it crosses more than 24 hours. Babies who were born through caesarean section (C-section) were less likely to initiate early breastfeeding as compared to normal vaginal delivery.Methods: The present study has utilized 14774 weighted samples of C-section delivered women from National Family Health Survey-4 (NFHS-4) (2015-2016). Spatial analysis software i.e. ArcGIS 10.8 and STATA 14 including logistics regression has been utilized to show the spatial prevalence and contextual determinants of EIBF on C-section birth babies in India.Results: In India, around 31.8% of C-section mothers breastfeed their children within one hour of delivery. The prevalence of EIBF is highest in Goa and lowest in Rajasthan. The central part of India mostly from the empowered action group (EAG) states practices a very low level of EIBF practices whereas, the north-east region represents the highest prevalence for the same. The odds of logistic regression shows that mother’s higher education (OR: 1.38), everyday mass media exposure (OR: 1.66), and initiation of postnatal care (PNC) within one hour (OR: 1.79) help to increase the practices of EIBF. On the other hand, delivery in the private hospital (OR: 0.61).Conclusions: The study shows remarkable geographical variations in EIBF and its correlates in the country. It recommends that the public health programmes need to target the states with less practice of EIBF (i.e. EAG state or central part of India) F among C-section delivery mothers. By increasing the level of mothers’ education status, mass media exposure and early PNC care can improve the EIBF practices among C-section mothers in India.

Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

BackgroundIn the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.DataData from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.ResultsA strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).ConclusionThe utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India.

Institutional deliveries in India: a study of associates and inequality

PurposeIndia has shown good progress in maternal health outcome indicators. However, an area for improvement is to ensure all deliveries take place in institutions under the supervision of skilled birth attendants. This paper attempts to identify the factors that affect institutional deliveries using nationally representative National Family Health Survey (NFHS) data. Further, the authors investigate the factors contributing to the wealth-based inequality in institutional deliveries.Design/methodology/approachTo address the first aspect of identifying the factors associated with undergoing an institutional delivery, the authors have used logistic and multinominal logistic models. The explanatory variables are broadly socio-economic indicators of the mother and a few other household characteristics. Further, the concentration index and regression-based decomposition were used to carry out an inequality analysis in the institutional deliveries across different wealth groups.FindingsThe authors found that women belonging to poor households, backward social groups and rural areas have significantly fewer odds of undergoing an institutional delivery. Age and education level of the mother, number of antenatal visits during pregnancy and place of residence (urban/rural) have contributed to the inequality in institutional deliveries in 2005–2006. However, the inequality due to these factors went down drastically in 2015–2016.Originality/valueTo the best of the authors' knowledge, this study is a distinct attempt to use pooled data of the NFHS-3 [2005–2006] and NFHS-4 [2015–2016] in identifying factors contributing to a woman undergoing an institutional-based delivery. The study also decomposes the wealth-based inequality in the factors contributing to having an institutional delivery and analyses the contributions to inequality across the two time periods.

Spatial inequalities in skilled birth attendance in India: a spatial-regional model approach

BackgroundDespite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions.MethodsThe study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran’s I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA.ResultsMoran’s I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%.ConclusionThe present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women’s education.

Changing scenario of C-section delivery in India: Understanding the maternal health concern and its associated predictors.

Background:Caesarean section (C-section) delivery is a serious maternal health concern in the long run. Notedly, there is a lack of studies dealing with understanding the ways and reasons of C-section deliveries becoming a public health issue in today’s time in India and the measures to reduce the unnecessary caesarean sections. We have conducted this study to study the changes in the state-wise prevalence of C-section deliveries in India and understand C-section delivery’s socioeconomic and biomedical predictors.Materials and Methods:The study uses data from the fourth and fifth rounds of the National Family Health Surveys (NFHS). The per cent differences in the C-section deliveries from NFHS-4 to NFHS-5 across the states were measured through relative changes. The association between the C-section delivery and socioeconomic and biomedical factors were assessed using multiple logistic regression.Results:This study revealed that the C-section deliveries are higher in the southern states than in the other parts of India. Literacy plays a vital role in C-section deliveries. The probabilities of C-section deliveries are more in 30–40 and 40 + years. The women belonging to the median wealth index category were more likely (OR–CI, 1.62 [1.55–1.66]) to undergo the C-section followed by the women from wealthy households (OR–CI, 1.46 [1.41–1.52]).Conclusion:The Government’s health policymakers should take the initiative to reduce the C-section section delivery by means of building maternal health literacy and awareness among women and the community so that its future implications can be minimised. It is crucial to formulate a mandate and implement it in the states where C-sections are too high through community health workers and primary care providers.

“Everything in India Happens by Jugaad”: Dai-mas in Institutions in Rural Rajasthan

ABSTRACT Since the introduction of a scheme promoting institutional deliveries in India, dai-mas (traditional midwives) have not become obsolete, but remain integral to institutional caregiving in rural areas in ways that are not always recognized. Based on ethnographic fieldwork in rural Rajasthan, I discuss two institutional contexts in which dai-mas were encountered – traditional midwife training event and hospital births. By examining how dai-mas’ authoritative knowledge is reconfigured within institutions, I suggest that the polysemic Hindi term jugaad – a phrase describing the kinds of improvisation required in resource-poor settings – captures different aspects of dai-mas’ relationships with and within institutions and the state of maternal caregiving in rural India.

Regional Disparities and Determinants of Caesarean Deliveries in India

Background: The caesarean rate in India has been increased from 8.5% (NFHS-III) during 2005-06 to 17.2% (NFHS-IV) during 2015-16. Objective: The main objective of the study is to assess the regional disparities and determinants of caesarean deliveries in India. Material and Method: It is a descriptive study. The fourth round of National Family Health Survey, India (NFHS-4), conducted in 2015-16 has been analysed for the purpose of this study. Result: The study found that the C-section deliveries are significantly higher in southern region followed by western region in India. Social factors such as higher education of mother, residing in urban area, belong to richest wealth group, mothers belong to non-SC/ST category are more likely to opt for C-section delivery. Evidence also indicates that risk factors like high age of mother, high birth order, complicated pregnancy, multiple births, size of child at birth, weight of child at birth significantly influences the decision of C-section deliveries. Institutional and Individual Behavioural Factors such as number of ANC visit, place of delivery, access to mass media are also significant determinants of opting C-section delivery. Delivering high quality timely care and counselling measures throughout the gestation period as a measure to minimise C-section deliveries is the responsibility of every midwife healthcare provider, is an effective way. There is an urgent need to monitor the deliveries in clinics and hospitals to find out the right balance between demand and provisioning of high quality health care services.

The unending burden of high out-of-pocket expenditure on institutional deliveries in India

ObjectiveThis study aims to address the question that whether out-of-pocket expenditure (OOPE) on institutional deliveries remained high or reduced over time in India, in particular after the introduction of conditional cash transfer (CCT) incentive programmes such as Janani Suraksha Yojana (JSY) in 2005. Study designThe study presents the trends in average OOPE on institutional deliveries in India, in an effort to evaluate the impact of the JSY programme on it. MethodsFor the purpose, the study used recently released 75th round of National Sample Survey data, 2017/18 about household social consumption (Health) and two of its previous rounds in 2004 and 2014. ResultsThe results suggest that, except at rural public facilities, the average OOPE for institutional delivery has increased significantly in both rural and urban areas from 2004 to 2017/18, even after adjusting to inflation in the prices. In addition, the results have shown that overall 14 of 33 states for rural public facilities, 20 of 25 states in rural private facilities, 21 of 32 states in urban public facilities and 29 of 32 states in urban private facilities have experienced more than 50% raise in OOPE on institutional delivery during 2004–2017/18, despite JSY incentives. ConclusionThe findings suggest that the current level of JSY incentives will not be sufficient to avoid catastrophic spending on institutional deliveries for the households as the incentives in several states are much less than the state average OOPE per delivery. Thus, there is a need to consider a raise in the state or central contribution for CCT under the JSY programme to reduce the burden of OOPE on institutional deliveries through recently launched Pradhan Mantri Matru Vandana Yojana.

Is newborn survival influenced by place of delivery? A comparison of home, public sector and private sector deliveries in India.

In 2005 and again in 2011, the Government of India launched schemes to encourage institutional delivery among poor women, with the aim of improving maternal and newborn health outcomes. Partly as a result of these initiatives, the proportion of children born in a health facility rose steeply from 42% in 2000-2005 to 81% a decade later. In this context, the objective of this paper was to determine the association between place of delivery (public sector, private sector, home) and early neonatal mortality, defined as death in the first 7 days after birth. The focus was on early neonatal mortality because over half of all under-five deaths occur in his period and because the protective effect of an institutional place of birth should be strongest in those few early days. Both bivariate methods and multivariate logistic regression analysis were applied to data from the fourth round of the National Family Health Survey conducted in 2015-16. For the country as a whole, it was found that the adjusted odds of death in the early neonatal period were lower for deliveries in public health facilities than for home deliveries (OR 0.833 p<0.01), but no significant difference was found between deliveries in private health facilities and at home. Adjusted odds of death were higher for deliveries in private than public sector facilities (OR 1.41 p<0.01). On further investigation, for the poor in Bihar and Uttar Pradesh, it was found that the risks of dying in the early neonatal period were even higher for babies delivered in private health facilities than for home deliveries with adjusted odds of over 2.0. These results raise serious questions about quality of care in the private sector in India. In the context of increased emphasis on public-private partnerships in health services provision in the country, it becomes imperative to enforce better inspection, licensing and quality control of private sector facilities, especially in the states of Bihar and Uttar Pradesh.

Increasing trend of C-section deliveries in India: A comparative analysis between southern states and rest of India

ObjectiveTo examine the socio-demographic variations in overwhelming existence of C-section deliveries in south India, with a comparison to rest of India. MethodsThis study analyses data collected from 51,136 mothers under National Family Health Survey (NFHS)-3 (2005–06) and 2,52,183 mothers under NFHS-4 (2015–16), those who have given births during last five years preceding the survey.Main outcome measures.Descriptive statistics, bivariate analysis with Chi-squared tests and binary logistic regression models with 95% confidence intervals are used. ResultsIn south India at least one out of four women deliver through C-section and there was a notable rise in caesarean deliveries in public facilities as well as among tribal population. In aggregate, number of states exceeding 15% prevalence rate of C-section deliveries doubled to sixteen, while nineteen states registered more than 100% rise. Rural-urban difference is slim in south India, while likelihood for C-section deliveries for richest women as compared to poorest has gone down from 2.76 to 1.88 in south India and 7.75 to 4.58 in other regions during 2005–06 to 2015–16. The odds ratio for C-section is higher in private hospitals (3.26) of southern states with reference to public institutions, while the odds are 3.90 times higher for private facilities in other states. In south India, percentage of C-section deliveries were actually lower among those who reported about pregnancy complications. ConclusionsDespite, several maternal and child health related programs being launched in India, their impact on improving the C-section scenario has remained microscopic, or they have continued to contribute towards a rising prevalence of C-section, especially in south India.

Are the labour rooms of primary healthcare facilities capable of providing basic delivery and newborn services? A cross-sectional study.

Objectives:The study aimed to assess the functionality of labour rooms by evaluating the labour room infrastructure with reference to the standard guidelines, the status of the availability of human resources, the availability of essential equipment and consumables in the labour room and by documenting the knowledge of the healthcare provider in terms of labour room practices. The study also explored the facility parameters associated with its delivery load taking the facility as a unit of analysis.Design:A cross-sectional analytical study.Setting:India has realised the importance of improving the quality of care in public health facilities, and steps are being taken to make healthcare more responsive to women's needs. With an increase in the proportion of institutional deliveries in India, the outcome of the delivery process can be improved by optimising the health facility components.Participants:The study was conducted in 52 health facilities and healthcare providers involved in the delivery process in the selected facilities.Results:The infrastructure of the facilities was found to be the best for medical college followed by district hospitals, Community Health Centres (CHCs), Primary Health Centres (PHCs) and subcentres. Similar findings were observed in terms of the availability of equipment and consumables. Lack of healthcare providers was observed as only 20% of the posts for health personnel were fulfilled in CHCs followed by PHCs, subcentres and district hospitals where 43, 50 and 79% of the available vacancies were fulfilled. The level of knowledge of healthcare providers in terms of partograph, active management of the third stage of labour and post-partum haemorrhage ranged as per their designation. The specialists were the most knowledgeable while the Auxiliary Nurse Midwife (AMNs) were the least. All the components of structural capacity, i.e. infrastructure (r2 = 0.377, P value < 0.001), equipment and consumable (r2 = 0.606, P value < 0.001) and knowledge of healthcare providers (r2 = 0.456, P value < 0.001) along with the overall facility score were positively correlated with the average delivery load of the health facility. The results from multivariate linear regression depict significant relation between the delivery load and availability of equipment and consumables (t = 4.015, P < 0.01) and with the knowledge of healthcare providers (t = 2.129, P = 0.039).Conclusions:The higher facilities were better equipped to provide delivery and newborn care. A higher delivery load was found at high-level facilities which can be attributed to better infrastructure, adequate supply of equipment and consumables and availability of trained human resources.