Increase In Institutional Deliveries Research Articles

Projections of maternal mortality ratios in Bangladesh.

The objective of this study was to predict when Bangladesh would achieve Sustainable Development Goal Target 3.1, which is to reduce the maternal mortality ratio (MMR) to less than 70 per 100 000 live births. We used secondary data from the 1993 to 2017 Bangladesh Demographic and Health Surveys and other sources to project the MMR until 2060 under several scenario assumptions using an autoregressive moving average model with exogenous variables (ARMAX). Explanatory variables were selected based on the three delays model, and a reference forecast and four practical scenarios were simulated: Scenario 1 assumed a 4% annual increase in institutional deliveries, Scenario 2 followed the national goals, the reference forecast and Scenario 3 varied in terms of district-wise increase rates (Scenario 3 had a lower rate of increase), and Scenario 4 assumed minimal changes in institutional deliveries. Scenario 1 was the earliest, with an MMR of <70 per 100 000 live births in 2026. Scenario 2 would meet the target of <70 per 100 000 live births in 2029. The reference forecast had the third lowest MMR, with 69.78 per 100 000 live births (95% prediction intervals (PI) = 32.44 to 107.11) in 2049. Although the MMR for Scenario 3 decreased slowly, it would not reduce below 70 per 100 000 live births by 2060. Scenario 4, which had the highest MMR, also resulted in the MMR not reducing below 70 per 100 000 live births by 2060. To increase the institutional delivery rate and reduce the MMR, as in Scenarios 1 and 2, it is necessary to improve the institutional delivery rate in regions with low institutional delivery rates. Additionally, health facilities need to provide appropriate quality medical care to increase the institutional delivery rate and contribute to a decrease in the MMR, as shown by the results of this study.

Increase in institutional delivery and child immunisation coverage through an appreciative inquiry-based community dialogue intervention in Afghanistan

ObjectiveA community dialogue intervention with an appreciative inquiry approach was undertaken to improve institutional delivery and child immunisation coverage in a hard-to-reach province, namely, Kandahar, in Afghanistan. This study aimed to evaluate the intervention's effectiveness in promoting institutional delivery and child immunisation. Study designA pre-post intervention evaluation study. MethodsAn intervention and a non-intervention district were selected in Kandahar. Children aged under 5 years participated in surveys at baseline (October 2018) and follow-up (Post-intervention: November 2019). We analysed age, sex, place of birth, and confirmed immunisation coverage data concerning 1046 and 927 children pre- and post-interventions, respectively. Changes in institutional delivery and confirmed immunisation status were evaluated using net intervention effect and difference-in-difference (DID) analysis. ResultsInstitutional delivery rates increased from 66.3% to 83.6% (p = 0.016) in the intervention district and decreased from 71.3% to 46.7% (p < 0.001) in the non-intervention district, with a net intervention effect of 41.9%. Full immunisation coverage among children aged 12–23 months and 24–35 months significantly increased from 26.4% to 76.9% (p < 0.001) and from 40.0% to 78.6% (p < 0.001), respectively, in the intervention district, whereas coverage significantly decreased in the non-intervention district. The net intervention effects were 59.1% and 44.8% for children aged 12–23 months and 24–35 months, respectively. The DID analysis also revealed significant differences in outcomes after intervention at follow-up. The results concerning antigen-specific immunisation coverage indicated a significant increase in immunisation coverage in the intervention district. ConclusionsThe appreciative inquiry-based community dialogue intervention considerably increased institutional delivery and child immunisation coverage, even in a hard-to-reach province in Afghanistan.

Intra-natal Care Practices in Rural Areas of Gaya District, Bihar

Context: Antenatal care (ANC) effectively reduces infant and maternal mortality rates mainly by promoting institutional deliveries. In view of this, the Government of India introduced Janani Suraksha Yojna (JSY) in 2005 and Janani Shishu Suraksha Karyakram (JSSK) in 2011. Aims: To estimate the proportion of home and institutional deliveries in the district, assess the impact of JSK and JSSY on institutional deliveries, and identify the different intranatal care providers. Settings and Design: This cross-sectional study was conducted in the Gaya district, Bihar. A total of 657 females of the reproductive age group (15-49 years) were included in the study. Methods and Material: Predesigned, pre-tested &amp; semi-structured questionnaire was used to collect information on place of delivery, type of delivery, knowledge regarding JSY and JSSK schemes and source of information Statistical analysis used: Data was entered into excel sheets and analyzed using SPSS version 23 utilizing appropriate statistical methods. Results: Out of 519 deliveries, 63% were institutional and 37% were home deliveries. About 91 and 11.4% of respondents were aware of JSY and JSSK schemes. There was a significant association between those who opted for institutional delivery and awareness regarding JSY and JSSK services. Conclusion: Despite awareness and running of various government programs, the percentage of institutional deliveries is still less. An increase in institutional deliveries at primary care level through JSY and JSSK will not only decrease the Out of Pocket expenditure of the population but also help build faith in the government health facilities.

Determinants of institutional maternity services utilization in Myanmar.

Maternal mortality is a persistent public health problem worldwide. The maternal mortality ratio of Myanmar was 250 deaths per 100,000 live births in 2017 which was the second-highest among ASEAN member countries in that year. Myanmar's infant mortality rate was twice the average of ASEAN member countries in 2020. This study examined factors influencing institutional maternity service utilization and identified the need for improved maternal health outcomes. A cross-sectional study design was used to examine the experience of 3,642 women from the 2015-16 Myanmar Demographic and Health Survey by adapting Andersen's Behavioral Model. Both descriptive and inferential statistics were applied. Adjusted odds ratios and 95% confidence interval were reported in the logistic regression results. The findings illustrate that the proportion of women who delivered their last child in a health/clinical care facility was 39.7%. Women live in rural areas, states/regions with a high levels of poverty, poor households, experience with financial burden and the husband's occupation in agriculture or unskilled labor were negatively associated with institutional delivery. While a greater number of ANC visits and level of the couple's education had a positive association with institutional delivery. The determinants of institutional delivery utilization in this study related to the institutional facilities environment imply an improvement of the institutional availability and accessibility in rural areas, and different states/regions, particularly Chin, Kayah and Kachin States- the poorest states in Myanmar. The poverty reduction strategies are urgently implemented because problems on health care costs and household economic status played important roles in institutional delivery utilization. The ANC visits indicated a significant increase in institutional delivery. The government needs to motivate vulnerable population groups to seek ANC and institutional delivery. Moreover, education is crucial in increasing health knowledge, skills, and capabilities. Thus, improving access to quality, formal, and informal education is necessary.

Effect of checklist based box system interventions on improving institutional delivery among reproductive age women in Northwest Ethiopia: generalized structural equation modeling

BackgroundPrevious studies have shown that there is low utilization of institutional delivery in Ethiopia, as well as various factors contributing to this low utilization. Notably, there is paucity around interventions to improve institutional delivery. Hence, this study examines the effectiveness of checklist-based box system intervention on improving institutional delivery and to investigate the association through which the intervention is linked to institutional delivery.MethodThe study used data from a larger trial, on the effectiveness of checklist-based box system intervention on improving maternal health service utilization. In the intervention arm, mothers received regular community-level pregnancy screening and referral, service utilization monitoring boxes, drop-out tracing mechanisms, regular communication between health centers and health posts, and person-centered health education for mothers. This study used the existing government-led maternal health program as a control arm. A total of 1062 mothers who gave birth one-year before the survey were included in the final analysis. A difference-in-difference estimator was used to test the effectiveness of the intervention. Generalized structural equation modeling was used to examine the direct and/ indirect associations between the intervention and institutional delivery.ResultAmong participants, 403 (79.5%) mothers from intervention and 323 (58.2%) mothers from control clusters gave birth at health facilities. The result of the study revealed a 19% increase in institutional delivery in the intervention arm (19, 95%CI: 11.4-27.3%). In this study the pathway from checklist-based box system intervention to institutional delivery was mainly direct - (AOR = 3.32, 95%CI: 2.36-4.66), however, 33% of the effect was partially mediated by attendance of antenatal care four visits (AOR = 1.39, 95%CI: 1.02-1.92). The influence of significant others (AOR = 0.25, 95%CI: 0.15-0.43) and age (AOR = 0.03, 95%CI: 0.01- 0.09) had an inverse relation with institutional delivery.ConclusionThe implementation of a checklist-based box system significantly increased institutional delivery utilization, both directly and indirectly by improving antenatal care four attendance. A larger-scale implementation of the intervention was recommended, taking the continuum of care approach into account.Trial registrationClinicalTrials.gov, NCT03891030, Retrospectively registered on 26 March, 2019.

Impacts of COVID-19 on essential health services in Tigray, Northern Ethiopia: A pre-post study.

BackgroundCOVID-19 has proved to have an indirect impact on essential health services in several parts of the world which could lead to increased morbidity and mortality and loss of the gains made in the past decades. There were no synthesized scientific evidences which could show the impact of COVID-19 epidemics/pandemic on essential health services in Tigray, Northern Ethiopia. Therefore, this study aimed to assess the impacts of COVID-19 epidemics/pandemic on essential health services provision in Tigray, Northern Ethiopia.MethodsA pre-post study design was used to assess the impacts of COVID-19 on essential health services delivery in Tigray, Northern Ethiopia in the second quarter of 2020 (Post COVID-19) compared to similar quarter in 2019 (Pre COVID-19). The study focuses on five categories; namely; maternal, neonatal and child health care; communicable diseases with a focus on HIV and TB-HIV co-infection; prevention of mother to child transmission of HIV; basic emergency, outpatient, inpatient and blood bank services, non-communicable diseases and road traffic accidents (RTAs). Analysis was done using Stata version 14.0 software package. The effects of COVID-19 epidemics/pandemic were calculated taking the differences between post COVID -19 and pre COVID-19 periods and the levels of service disruptions presented using proportions. Wilcoxon sign rank test was done and a significance level of ≤0.05 was considered as having significant difference among the two quarters.ResultsThere were significant increase in institutional delivery, delivery by Caesarian Section (CS), still birth, postnatal care within 7 days of delivery, the number of children who received all vaccine doses before 1st birthday, the number of under 5 children screened and had moderate acute malnutrition, the number of under 5 children screened and had severe acute malnutrition and children with SAM admitted for management. However, there were significant decrease in HIV testing and detection along with enrolment to antiretroviral therapy (ART) care, number of patients with cardiovascular disease (CVD) risk ≥ 30% received treatment, RTAs, total units of blood received from national blood transfusion service (NBTS) and regional blood banks, total number of units of blood transfused and emergency referral. There were no significant changes in outpatient visits and admissions.ConclusionDespite commendable achievements in maintaining several of the essential health services, COVID-19 has led to an increase in under nutrition in under five children, decline in HIV detection and care, CVD, cervical cancer screening and blood bank services. Therefore, governments, local and international agencies need to introduce innovative ways to rapidly expand and deliver services in the context of COVID-19. Moreover, lower income countries have to customize comprehensive and coordinated community-based health care approaches, including outreach and campaigns. In addition, countries should ensure that NCDs are incorporated in their national COVID-19 response plans to provide essential health care services to people living with NCDs and HIV or HIV-TB co-infection during the COVID-19 pandemic period.

Do male engagement and couples\u2019 communication influence maternal health care-seeking? Findings from a household survey in Mozambique

BackgroundThis study explored effects of couples’ communication and male participation in birth preparedness and complication readiness (BPCR) on delivery in a health facility (“institutional delivery”). A cross-sectional, baseline household survey was conducted in November 2016 prior to an integrated maternal and child health project in Nampula and Sofala Provinces in Mozambique.MethodsThe study used the Knowledge, Practices and Coverage survey tool, a condensed version of the Demographic and Health Survey and other tools. The sample included 1422 women. Multivariable logit regression models tested the association of institutional delivery with couples’ communication and four elements of BPCR both with and without male partners: 1) saving money, 2) arranging transport, 3) choosing a birth companion, and 4) choosing a delivery site; controlling for partners’ attendance in antenatal care and social and demographic determinants (education, wealth, urban/rural location, and province).ResultsThe odds that women would deliver in a health facility were 46% greater (adjusted odds ratio (aOR) = 1.46, 95% confidence interval (CI) = 1.02–2.10, p = 0.04) amongst women who discussed family planning with their partners than those who did not. Approximately half of this effect was mediated through BPCR. When a woman arranged transport on her own, there was no significant increase in institutional delivery, but with partner involvement, there was a larger, significant association (aOR = 4.31, 2.64–7.02). Similarly, when a woman chose a delivery site on her own, there was no significant association with institutional delivery (aOR 1.52,0.81–2.83), but with her partner, there was a larger and significant association (aOR 1.98, 1.16–3.36). Neither saving money nor choosing a birth companion showed a significant association with institutional delivery—with or without partner involvement. The odds of delivering in a facility were 28% less amongst poor women whose partners did not participate in BPCR than wealthy women, but when partners helped choose a place of delivery and arrange transport, this gap was nearly eliminated.ConclusionsOur findings add to growing global evidence that men play an important role in improving maternal and newborn health, particularly through BPCR, and that couples’ communication is a key approach for promoting high-impact health behaviors.

Maternal and Perinatal Complications from a Hospital-based Intra-partum Complications Registry Established in Remote Referral Hospitals of a Desert District of India

Background: Despite increase in institutional deliveries, maternal and neonatal mortality has reduced slower than expected. It is important to know the reasons of maternal and perinatal deaths for doing focused efforts for reducing them. Objective: The objective of this study was to establish a system to improve estimation of maternal and perinatal complications among deliveries. Methods: The study was designed as a descriptive study. An Intrapartum Complications Registry was set up in eleven government hospitals of Bikaner. In each facility, a “champion” nurse ensured the complete documentation in case sheets and delivery register, and entered all maternal and perinatal complications into an Intrapartum Complications Register which was digitized into a registry database. The data for a six-month period in 2014 was analysed. Results: Out of 3675 women admitted to the labour rooms of the study facilities, 295 women were referred out with complications before delivery, and 3380 mothers delivered 3386 new-borns (including 6 twins). The registry documented 828 cases (22.5%) (512 mothers and 363 new-borns, 47 cases having both mother and new-born complications) with 1014 complications (535 maternal and 479 perinatal complications). The commonest maternal complications were haemorrhage (47.1%), prolonged or obstructed labour (28.4%) and hypertensive disorders (15.3%). The commonest perinatal complications were low birth weight (33.6%), birth asphyxia (18.6%) and neonatal sepsis (16.2%). No maternal or neonatal deaths occurred up to the first 48 hours. Conclusion: Intrapartum Complications Registry improved the documentation of and revealed the profile of maternal and perinatal complications in the study area.

NEONATAL HYPOGLYCEMIA REVISITED: INCIDENCE AND CLINICAL PROFILE IN A TERTIARY CENTER HOSPITAL OF TRIPURA

Introduction: Hypoglycemia is a common but preventable metabolic abnormality in neonates associated with long-term sequelae. Controversies still exist about its definition, screening methodology, management, and outcome making it a subject for further exploration. Objectives: The study was taken up to find out the proportion of neonate developing hypoglycemia in the neonatal intensive care unit (NICU) and to study the clinical profile of hypoglycemia in neonates. Materials and Methods: All intramural and extramural neonates admitted in the NICU within 2 h of delivery were included in this study. They were screened for hypoglycemia using Accutrend-alpha glucometer. Results along with all neonatal and maternal variables were recorded and analyzed using the SPSS version 15.0. Results: The current study shows the prevalence of hypoglycemia as 32.2%. Proportion of hypoglycemia was more in small for gestational age, large for gestational age neonates, and neonates with prematurity, birth asphyxia, and maternal diabetes mellitus. Besides, hypoglycemia occurred more commonly within 24 h of life. Lethargy, convulsion, apnea, and jitteriness were common presenting symptom. Conclusion: The present study shows despite advances in obstetrical practices and increase in institutional deliveries over years, neonatal hypoglycemia continues to occur with almost same frequency along with the same maternal and neonatal variables.

Women suffer more from disrespectful and abusive care than from the labour pain itself: a qualitative study from Women\u2019s perspective

BackgroundUtilization of institutional delivery services could be hampered by women’s experience of disrespectful and abusive care during childbirth. However, such experiences are not well documented and taken into consideration id planning maternal health services in many developing countries. The aim of this study was to describe women’s experience of disrespect and abuse during giving birth at health facilities in northern Ethiopia.MethodsA qualitative phenomenological study was conducted in Tigray, Ethiopia. Focus group discussions (FGDs) with primipara and multipara women were conducted to collect the necessary information. All study participants had their last delivery at a health facility in the year preceding the study. A semi-structured discussion guide was used to elicit discussion. Discussions were audio recorded and transcribed verbatim in the local language and then translated to English. Data were analyzed using thematic analysis approach assisted by the Open Code qualitative data management software.ResultsThe study participants described disrespect and abuse as serious obstacles to utilization of maternal health services. Women reported experiencing feelings of being infantilized, losing self-control, being overlooked, being informed bad news without proper preparation, repeated examination without being properly communicated/informed, disallow companions, and left unattended during labor. Facility related issues include women’s perception of incompetence of professionals attending delivery, unhygienic facilities, and unavailability of basic supplies.ConclusionWomen consider health facilities not fully prepared to provide respectful maternal care. Sustainable increase in institutional delivery requires ensuring quality, compassionate and caring services in all health facilities.

Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique

BackgroundSkilled birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized improved service delivery and demand for these practices, alongside “humanization of the birth process.” An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries.MethodsA descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert panels—each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels—were convened to formulate the “story” of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding.ResultsThe two sites’ skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. Eight contextual and human factors were found as dominant themes. Though both sites achieved increases, implementation context differed significantly with compelling examples of both respectful and disrespectful care. In one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts.ConclusionFindings support global health recommendations for combined health system and community interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.

High prevalence of cesarean section births in private sector health facilities- analysis of district level household survey-4 (DLHS-4) of India

BackgroundWorldwide rising cesarean section (CS) births is an issue of concern. In India, with increase in institutional deliveries there has also been an increase in cesarean section births. Aim of the study is to quantify the prevalence of cesarean section births in public and private health facility, and also to determine the factors associated with cesarean section births.MethodsWe analyzed data from district level household survey data 4 (DLHS-4) combined individual level dataset for 19 states/UTs of India comprising 24,398 deliveries resulting in 22,111 live births for year 2011. The percentages and Chi-square has been computed for the select variables viz. Socio demographic, maternal, antenatal care and delivery related based on type of births (CS Vs normal births). The multiple logistic regression model has been used to identify the potential risk factors associated with CS births.ResultsOf 22,111 live birth analyzed 49.2% were delivered at public sector, 31.9% at private sector and 18.9% were home deliveries. Prevalence of CS births were 13.7% (95% CI; 13.0- 14.3%) and 37.9% (95% CI; 36.7- 39.0%) in the public and private sectors, respectively. Higher odds of CS births were observed with- delivery at private health facility (OR 3.79; 95% C.I 3.06-4.72), urban residence (OR 1.15; 95% C.I 1.00- 1.35), first delivery after 35 years of maternal age (OR 5.5; 95% C.I 1.85- 16.4), hypertension in pregnancy (OR 1.32; 95% C.I 1.06- 1.65) and breach presentation (OR 2.37; 95% C.I. 1.63- 3.43).ConclusionsOur findings shows that CS births are nearly three times more in private as compared to public sector health facilities.The higher rates of CS births, especially in private sector, not only increase the cost of care but may pose unnecessary risks to women (when there is no indications for CS). The government of India need to take measures to strengthen existing public health facilities as well as ensure that cesarean sections are performed based upon medical indications in both public and private sector health facilities.

Performance of Janani Suraksha Yojana on Maternal Health of Assam

The JSY is a safe motherhood intervention under the National Rural Health Mission (NRHM) which focuses on reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. With the introduction of the JSY from the year 2005, there has been almost 22 times increase in institutional delivery in the State. However, improving the safe motherhood still remains a major challenge for overall improvement in the maternal and therefore child health in the State. This paper tries to study the maternal health scenario after the implementation of Janani Suraksha Yojana and also its impact on increasing institutional delivery.

Association of maternal and child health related variables with decline in infant mortality rate in Punjab, India

Background: Infant mortality rate (IMR) is a sensitive indicator for monitoring child health and survival. Punjab state in North India is performing better than most of the other states in various health indicators. Punjab’s IMR has shown a rapid decline from 38/1000 live births in 2008 (Sample registration system (SRS) 2008) to 24/1000 live births in 2014 (SRS 2014). This study was planned to assess which of the maternal and child health services is associated with rapid decline in infant mortality rate. Methods: Association between various components of prenatal care, intranatal care and postnatal care, and child healthcare and socio demographic variables (taken from secondary data of District Level Household Surveys) and Infant Mortality Rate (taken from SRS) of Punjab was studied. Spearman correlation coefficient was calculated to measure the association between the variables. Results: Total fertility rate (TFR), women who had institutional deliveries, safe deliveries and mean children ever born are statistically significantly associated with decline in infant mortality rate. Conclusions: In Punjab, maternal and child health indicators are directly or indirectly associated with decline in infant mortality rate. Findings of the study demonstrate that the recent rapid decline in IMR of Punjab is strongly associated with increase in institutional deliveries and decline in TFR and the mean number of children ever born.

Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programs.

BackgroundAccording to the Bangladesh Demographic and Health Survey 2014, only approximately 37 percent of women deliver in a health facility. Among the eight administrative divisions of Bangladesh, the facility delivery rate is lowest in the Sylhet division (22.6 percent) where we assessed the effect of integrated supply- and demand-side interventions on the facility-based delivery rate.MethodsPopulation-based cohort data of pregnant women from an ongoing maternal and newborn health improvement study being conducted in a population of ~120,000 in Sylhet district were used. The study required collection and processing of biological samples immediately after delivery. Therefore, the project assembled various strategies to increase institutional delivery rates. The supply-side intervention included capacity expansion of the health facilities through service provider refresher training, 24/7 service coverage, additions of drugs and supplies, and incentives to the providers. The demand-side component involved financial incentives to cover expenses, a provision of emergency transport, and referral support to a tertiary-level hospital. We conducted a before-and-after observational study to assess the impact of the intervention in a total of 1,861 deliveries between December 2014 and November 2016.ResultsOverall, implementation of the intervention package was associated with 52.6 percentage point increase in the proportions of facility-based deliveries from a baseline rate of 25.0 percent to 77.6 percent in 24 months. We observed lower rates of institutional deliveries when only supply-side interventions were implemented. The proportion rose to 47.1 percent and continued increasing when the project emphasized addressing the financial barriers to accessing obstetric care in a health facility.ConclusionsAn integrated supply- and demand-side intervention was associated with a substantial increase in institutional delivery. The package can be tailored to identify which combination of interventions may produce the optimum result and be scaled. Rigorous implementation research studies are needed to draw confident conclusions and to provide information about the costs, feasibility for scale-up and sustainability.

Do incentivised community workers in informal settlements influence maternal and infant health in urban India?

Setting: The introduction of accredited social health activists (ASHAs, community workers) in the community is encouraged by the Government of India as being of universal benefit for maternal and infant health. Objectives: In two informal settlements in Chandigarh, India, one with ASHAs and the other without, we assessed 1) whether ASHAs influenced certain selected maternal and infant health indicators, and 2) perceptions among women who did not contact the ASHAs. Design: This was a mixed-methods study conducted from April 2013 to March 2016 using quantitative (retrospective programme data) and qualitative (free-listing) components. Results: The increase in institutional deliveries from 2013 to 2015 was marginal, and was similar in both areas (86-99% in the settlement with ASHAs and 88-97% in the settlement without). Bacille Calmette-Guérin and pentavalent vaccination coverage were close to 100% in both areas during the 3 years of the study. Antenatal registration in the first trimester increased from 49% to 52% in the settlement with ASHAs and from 53% to 71% in the settlement without. Between 18% and 35% of women did not complete at least three antenatal visits. 'Not knowing ASHAs' and 'not feeling a need for ASHAs' were the main reasons for not using their services. Conclusion: While success has been achieved for institutional deliveries and immunisation coverage even without the ASHAs, their presence plays an important role in improving antenatal indicators.

Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India

Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR).Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities.These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered.

Critical Analysis of an Intervention to Improve Maternal and Child Health

This paper critically analyzes Janani Shuraksha Yojana (JSY), the intervention to improve maternal and child health. It highlights that there has been a huge difference in the annual percentage growth rate of JSY beneficiaries and Institutional deliveries for each year, which implies that the increasing JSY beneficiaries did not have proportionate increase in institutional delivery. It argues that the achievement of JSY is more on increasing of JSY beneficiaries, rather than the increasing of institutional delivery as a whole. It further argued that the marginal increases of JSY beneficiaries are not from home delivery but from institutional delivery. It proposes a more tangible and sustainable approach to reach the unreached or underserved in the difficult and hard to reach areas, by changing the present strategy of ‘making the unreached or underserved population to reach the health facilities’ to ‘reaching the unreached with health facilities and services at their homestead’, so as to change the home delivery into institutional delivery.

Study on the Janani Suraksha Yojana (JSY) in Tumkur district, Karnataka

Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM) being implemented with the objective of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. The Yojana, launched on 12th April 2005, by the Hon'ble Prime Minister, is being implemented in all states and UTs with special focus on low performing states. JSY is a 100 per cent centrally sponsored scheme and it integrates cash assistance with delivery and post-delivery care. The success of the scheme would be determined by the increase in institutional delivery among the poor families. The Yojana has identified ASHA, the accredited social health activist as an effective link between the Government and the poor pregnant women. The study has clearly shown that Institutional deliveries increasing by JSY by covering majority (91.02 %) of the eligible pregnant women and reducing maternal and neo-natal mortality rate. Majority (> 71 %) of the JSY beneficiaries were happy with the ASHA motivation to JSY and attitude, whereas, 36 per cent JSY beneficiaries were unhappy with Health Staff attitude. Majority (> 62 %) of the Janani Suraksha Yojana (JSY) beneficiaries were not happy with the Hygiene, Cleanness, Health services and after care in Government health centres.

Increasing institutional deliveries among antenatal clients: effect of birth preparedness counselling

The World Health Organization recommends birth and emergency preparedness (BEP) as essential components of the Focused Antenatal Care model. The purpose of providing BEP messages to women during their antenatal visits is to increase the use of skilled attendance at childbirth. However, the effectiveness of this component has not yet been clearly established in routine contexts. This retrospective cohort study examined the association between exposing women to BEP messages during antenatal visits and the use of the skilled attendance at childbirth in two rural districts of Burkina Faso (Koupela and Dori). The study included 456 antenatal care users in 30 rural health centres in these two districts. Data were collected using modified questionnaires from the Johns Hopkins Program for International Education in Gynecology and Obstetrics and from demographic and health surveys. Logistic regression was performed with a model of generalized estimating equation to adjust for clustered effects. In the Koupela district, where the rate of institutional deliveries (80%) was relatively high, the use of BEP messages was not associated with an increase in institutional deliveries. In contrast, in the district of Dori, where the rate of institutional deliveries (47%) was lower, messages regarding danger signs [Adjusted Odds Ratio (AOR) = 1.93; 95% Confidence Interval (CI): 1.07, 3.49] and cost of care (AOR = 2.13; 95% CI: 1.09, 4.22) were associated with an increased probability of institutional births. Based on these results, it appears that birth and emergency preparedness messages provided during antenatal visits may increase the use of skilled attendance (increase the rate of institutional births) in areas where institutional births are low. Therefore, it is important to adapt the content of the messages to meet the particular needs of the users in each locality. Furthermore, BEP counselling should be implemented in health facilities.