Increase In Institutional Deliveries Research Articles

WHAT IS THE CAUSE OF THE DECLINE IN MATERNAL MORTALITY IN INDIA? EVIDENCE FROM TIME SERIES AND CROSS-SECTIONAL ANALYSES

Summary Studies on the causes of maternal mortality in India have focused on institutional deliveries, and the association of socioeconomic and demographic factors with the decline in maternal mortality has not been sufficiently investigated. By using both time series and cross-sectional data, this paper examines the factors associated with the decline in maternal mortality in India. Relative effects estimated by OLS regression analysis reveal that per capita state net domestic product (-1.49611, p<0.05), poverty ratio (0.02426, p<0.05), female literacy rate (-0.05905, p<0.10), infant mortality rate and total fertility rate (0.11755, p<0.05) show statistically significant association with the decline in the maternal mortality ratio in India. The Barro-regression estimate reveals that improvements in economic and demographic conditions such as growth in state income (β=0.35020, p<0.05) and reduction in poverty (β=0.01867, p<0.01) and fertility (β=0.02598, p<0.05) have a greater association with the decline in the maternal mortality ratio in India than institutional deliveries (β=0.00305). The negative β-coefficient (β=-0.69578, p<0.05), showing the effect of the initial maternal mortality ratio on change in maternal mortality ratio in the Barro-regression model, indicates a greater decline in maternal mortality ratio in laggard states compared with advanced states. Overall, comparing the estimates of relative effects, the socioeconomic and demographic factors have a stronger statistically significant association with the maternal mortality ratio than institutional deliveries. Interestingly, the weak association between 'increase in institutional deliveries' and 'decline in maternal mortality ratio' suggests that merely increasing deliveries alone will not help in ensuring maternal survival in India. Quality of services provided by the health facility, birth preparedness and avoiding delay in reaching health facility are also important. Deliveries in health facilities will not necessarily translate into increased survival chances of mothers unless women receive full antenatal care services and delays in reaching health facility are avoided.

Trends in institutional deliveries among disadvantaged groups and the impact of intervention in Gujarat: evidence from secondary data analysis

BackgroundAn estimated 1·2 million births per year in Gujarat include a significant number of home deliveries. The District Level Household Survey-3 (DLHS-3; 2007) reported nearly 40% of all deliveries in Gujarat occurred at home. Gujarat's maternal mortality rate was reduced from 202 to 148 per 100 000 deliveries between 2000 and 2010. Despite the overall progress, issues such as access and equity are contributing to wide disparities between different populations in the state. The financial barrier is the limiting factor for access to institutional deliveries among poor women. The Chiranjeevi scheme was introduced to increase access to institutional deliveries, particularly to poor women. The scheme provides free delivery care in private health-care facilities for women from below-poverty-line (BPL) families. MethodsSecondary data analysis was done for the DLHS-3 and the coverage evaluation survey, a UNICEF dataset. The determinants were place of residence, education, caste, and wealth index. The outcome variables included institutional delivery, defined as delivery in a hospital, clinic, or health centre. In the DLHS, wealth index was computed by combining household amenities, assets, and durables, and then divided into quintiles. In this analysis, the poorest and second wealth quintiles were grouped into the poor category while the non-poor included the top three quintiles. Education status was divided into non-literate, fewer than 5 years of education, and 5 or more years of education. The analysis included trends in the institutional deliveries among rural, poor, non-literate, scheduled castes, and scheduled tribe women who delivered during the reference period (Jan 1, 2004, until survey year 2008). Further, we used a before–after intervention approach to evaluate the impact of the Chiranjeevi Yojana on rates of institutional deliveries among the disadvantaged groups. FindingsThe results show an increase in institutional deliveries from 2005 to 2009 among the disadvantaged groups, including the rural population, scheduled caste and tribes, poor, non-literate, and BPL families. Overall, there was a 32% increase in institutional deliveries between 2005 (658 780 of 1 155 148 [57%] deliveries) and 2009 (943 037 of 1 054 852 [89%] deliveries). The increase in institutional deliveries was from 52·2% to 56·5% between DLHS-2 (2002–04) and DLHS-3 (2007–08), respectively. The impact of the intervention is clear when data from 2006, before the Chiranjeevi Yojana programme was implemented, are compared with results since the programme took effect. InterpretationA targeted intervention, the Chiranjeevi scheme in Gujarat, has improved rates of institutional deliveries among disadvantaged groups. Improvement in maternal health outcomes among disadvantaged groups will increase the likelihood of achieving Millennium Development Goal 5 in Gujarat. FundingThis work was part of the Evidence for Policy and Implementation 4 project, a capacity-building project funded by a partner driven cooperation fund provided by the Swedish Government to Karolinska Institutet.

Effectiveness of demand and supply side interventions in promoting institutional deliveries - a quasi-experimental trial from rural north India

We assessed the differential and sequential effects of a Government of India conditional cash transfer scheme for the socio-economically disadvantaged (Janani Suraksha Yojana; JSY) and the strengthening of the primary health centre (PHC) network to provide 24/7 obstetric care in promoting institutional deliveries. This study used 7796 births from the Ballabgarh Health and Demographic Surveillance Site between April 2006 and March 2010 when both schemes were implemented in a staggered manner. The multiple baseline design took advantage of interventions separated by time and geographical zone to compute difference in differences in the rate of institutional deliveries. Logistic regression was used to estimate increases in the odds of institutional deliveries after adjustment for caste and maternal education. Compared with villages with poor access, institutional deliveries nearly doubled among villages with access to 24/7 delivery services; odds ratio (OR) 1.9 [95% confidence interval (CI): 1.3, 2.6]. Introduction of JSY in villages with poor access resulted in a 1.4-fold (95% CI: 1.1, 1.8) increase in institutional deliveries and a 1.1-fold (95% CI: 0.9, 1.4) increase in villages served by PHCs 24/7. However, the introduction of PHC 24/7 care to villages served by JSY doubled the rate of institutional deliveries; OR 2.1 (95% CI: 1.5, 2.8). Among the disadvantaged, institutional deliveries increased by 34.4%, compared with 24.8% among the non-disadvantaged. Introduction of PHC 24/7 care in this group increased institutional deliveries 4-fold; OR 4.2 (95% CI: 1.9, 9.0) compared with 3-fold for JSY alone; OR 3.2 (95% CI: 1.8, 5.6). Both demand and supply side strategies are effective and promote equity. Improving service delivery in a population previously primed by demand side intervention appears to be the most useful.

English

OBJECTIVE : to critically analyze the prevention of parent to child transmission (PPTCT) services offered by a teaching institute located in the Darjeeling district of West Bengal, since it started five years ago. METHOD : All the women registered in the antenatal clinic from 1st January 2004 to 31 st December 2008 were tested for HIV after counseling. Spouse counseling and testing of spouse and children was done where possible. Antiretroviral prophylaxis with Nevirapine was given to laboring mothers and their neonates. All data were compiled retrospectively and analyzed. RESULTS : A total 26319 women were offered counseling during the period. The acceptance of testing rose from 66.32% in 2004 to 90.7% in 2008. The highest seroprevalence was observed in 2007(0.84%) which had dropped in 2008(0.44%). The majority of the 112 seropositive women were rural residents, housewives, practicing no contraception, yet with some knowledge about HIV and its mode of transmission. There has been an increase in institutional delivery and cesarean section from 2004 to 2008. ARV prophylaxis with Nevirapine was given to all 35 women identified to be HIV positive before delivery. Out of 48 live born babies 46 received Nevirapine syrup. CONCLUSION : Seroprevalence has dropped with a greater awareness and acceptance of PPTCT program in the

Program evaluation of the Janani Suraksha Yojna

Background – India has seen a gradual decline in maternal mortality to 212/100000 live births. Launched in 2005, the Janani Suraksha Yojana was a response to the high maternal mortality and driven by global evidence that conditional cash transfers enable behaviour change, in this case, rise in institutional delivery. Scheme had a differential incentive entitlement based on urban or rural areas and High or Low performing states. The incentives for women in rural areas of Low performing states are: Rs. 1400 for institutional delivery and Rs. 500 for home deliveries. However in case of home deliveries many exclusionary conditionalities denied benefits of the scheme to women below 19 years of age, higher parity and those entitled but without BPL cards Methodology The programme evaluation was undertaken to understand and improve programme mechanisms leading to improved achievement of measurable outputs expected of this programme. Impact evaluation on maternal mortality was not attempted. The objectives of the evaluation were – to assess trends in institutional delivery, the availability and quality of care at delivery and in post natal period; the capability of health institutions, and the role of ASHA. Three districts in each of eight EAG (Empowered Action Group) states were selected as high performing, poor performing and tribal districts, based on -number of institutional deliveries during 2008-09 and proportion of scheduled caste/ tribe population. Quantitative and qualitative methods were used to map the contexts, mechanisms and outcomes as evidenced from primary and secondary data. The quantitative survey conducted in twelve districts included 2759 institutional deliveries (IDs) and 710 home deliveries. In addition to assessing access and quality of services, the evaluation question was to ask what actually happened and why, and moved beyond the postulated behaviour change induced by the Conditional Cash Transfer. Findings Study shows that over 50% of women who had their previous delivery at home had opted for institutional delivery. However despite this increase, there are about 40% home deliveries, with a range from 7.7% to 63%. Reasons reported for home delivery included limited access to transport, poor service quality and high costs in institutions and cultural preferences. Home deliveries were primarily occurring among women who were younger than 19 years, had higher parity, belonged to the socially marginalized women and without the entitlement card that would provide preferential access. The study also demonstrated significant out of pocket expenses amounting to Rs.1400 to Rs.1600 on an average, primarily on account of payment for transport and drugs. The steep increase in institutional delivery, despite the fact that out of pocket expenditure exceeds the cash transfer signifies that women were making rational decisions as regards place of delivery based on health and safety reasons. The increased availability of services was also a major contributor to the change. Private sector accounts for only about 12.5% of all deliveries, but for complications, private sector provided 60% of care. For complications requiring hospitalization the distribution between public and private sector was almost equal. Conclusions and Recommendations The study supports the contention that JSY has resulted in an increase in institutional deliveries, and that it has enabled and empowered poor women to access public health facilities. However issues like the exclusionary criteria for both home deliveries limit access of the most vulnerable category. Persistent high out of pocket payments also need to be addressed urgently. Increases in human resources and infrastructure had not been sufficient to provide quality services. Major recommendations emphasized, removal of all exclusionary criteria in case of home and institutional deliveries, provision of free pregnancy and newborn care and increasing infrastructure and human resource providing EmONC services. The interpretation of findings and recommendations in the emerging context of universal health care, resulted in converting a scheme based on the logic of CCT into an “enabling entitlement” approach. Emphasis shifted to assured free drugs and transport to pregnant, post partum women and newborns and the pressure builds up to remove all conditionalities.

Empowering mothers as household health workers

Description of the problem: Physical inaccessibility along with lack of awareness has been one of the main constraints to health service delivery in Arunachal Pradesh. Lack of adequate trained health manpower aggravates the situation. With the road density in 2001 of only 17.3 km per 100 sq km of area as against the national average of 82 km and 26.5% population living with had no road connectivity at all, [1] health infrastructure development has been slow and service delivery highly constrained. This has been aggravated by only 700 doctors and 900 nurses [2] , who too are unwilling to serve in remote areas. Methods: The Government of Arunachal Pradesh started the Public-Private Partnership (PPP) project as a part of NRHM in 2006 and outsourced the management of one Primary Health Centers in each of the 16 districts to Non-Governmental Organizations. The one at Sille in East Siang district is being managed by Future Generations Arunachal (FGA). With the premise that empowering the mothers to take care of their own health has the potential to dramatically improve the health status of the communities in inaccessible parts of Arunachal Pradesh, a pilot project entitled Mothers’ Training was carried out from May 2009 to April, 2011. The idea was to train one woman from each household in the catchment areas of the PHC. Each month, one woman from each of the six main villages in the catchment area was selected and was trained on basic home-based health care for a month. The training method consisted of one-hour talk on health issue everyday and involving the trainees in the works in the PHC the rest of the day. The outcome was measured with various health indicators in the PHC. Main findings : Dramatic improvements in health care indicators, especially those related to health behavior, were noted. Outpatient attendance dropped from 10543 in 2008 to 6838 in 2011. Similarly, total antenatal registration dropped from 269 in 2008 to 149 in 2011. However, percentage of pregnant women registering themselves in the ante-natal clinics in the first trimester increased from 39.4% in 2008 to 69.1% in 2011. There was also an increase in institutional deliveries from 33.8% in 2008 to 44.9% in 2011. In 2008, 5742 slides were collected for tests for malarial parasite whereas it was only 2122 in 2011. No death due to malaria has been reported whereas the disease was a major cause of mortality in the area earlier. Since posting of qualified personnel in the remote areas has been a major hurdle to health service delivery in Arunachal Pradesh, it is recommended that the existing health facilities like PHCs, CHCs and District Hospitals be used as community training centers on health so that they can participate in the health care delivery works of the government. This will not only improve the health status of the communities but also imbibe a sense of ownership in the health care process. Since the existing infrastructure and manpower will be utilized, this can be accomplished with minimal additional resource inputs. Conflict of Interest Statement : None Funding Source : Public-Private Partnership project funded by NRHM, Government of India and government of Arunachal Pradesh with additional funding by Future Generations, USA for Mothers’ Training program. [1] Arunachal Pradesh Public Works Department, Government of Arunachal Pradesh,1997. [2] There are 64 specialists, 512 allopathic doctors, 124 AYUSH doctors, 386 staff nurses and 548 ANMs as per the records in the Department of Health & Family Welfare, Government of Arunachal Pradesh.

Performance-based financing in low- and middle-income countries: still more questions than answers

Nine studies, of which fewer than half had been published in scientific jour-nals, fulfilled our inclusion criteria: one randomized controlled trial (RCT) and two interrupted time series conducted in Asia, and six controlled before–after studies conducted in Africa. Only two outcomes related to health care uti-lization– institutional deliveries and antenatal care– were assessed in more than one trial. Inconsistent results across studies made summarizing and inter-preting the evidence difficult.The most rigorous African study reported a moderate increase in insti-tutional deliveries, from around 35% to 42% (i.e. 7 percentage points; 95% confidence interval, CI: 1–14).

Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan

BackgroundOnly 39% of deliveries in Pakistan are attended by skilled birth attendants, while Pakistan's target for skilled birth attendance by 2015 is > 90%.MethodsA 12-month maternal health voucher intervention was implemented in Dera Ghazi Khan City, located in Southern Punjab, Pakistan in 2009. A pre-test/post-test non-experimental study was conducted to assess the impact of the intervention. Household interviews were conducted with randomly selected women who delivered in 2008 (the year prior to the voucher intervention), and with randomly selected women who delivered in 2009. A strong outreach model was used and voucher booklets valued at $50, containing redeemable coupons for three antenatal care (ANC) visits, a postnatal care (PNC) visit and institutional delivery, were sold for $1.25 to low-income women targeted by project workers. Regression analysis was conducted to determine the impact of the voucher scheme on ANC, PNC, and institutional delivery. Marginal effects estimated from logistic regression analyses were used to assess the magnitude of the impact of the intervention.ResultsThe women targeted by voucher outreach workers were poorer, less educated, and at higher parity. After adjusting for these differences, women who delivered in 2009 and were sold voucher booklets were significantly more likely than women who delivered in 2008 to make at least three ANC visits, deliver in a health facility, and make a postnatal visit. Purchase of a voucher booklet was associated with a 22 percentage point increase in ANC use, a 22 percentage point increase in institutional delivery, and a 35 percentage point increase in PNC use.ConclusionsA voucher intervention implemented for 12 months was associated with a substantial increase in institutional delivery. A substantial scale-up of maternal health vouchers that focus on institutional delivery is likely to bring Pakistan closer to achieving its 2015 target for institutional delivery.

Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention

BackgroundDemand-side financing projects are now being implemented in many developing countries, yet evidence showing that they reach the poor is scanty.MethodsA maternal health voucher scheme provided voucher-paid services in Jhang, a predominantly rural district of Pakistan, during 2010. A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor. Household interviews were conducted with randomly selected women in the intervention and control union councils, before and after the intervention.A strong outreach model was used. Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan, in the types of problems women could face during delivery, and in the promotion of antenatal care (ANC), institutional delivery and postnatal care (PNC). Voucher booklets valued at Rs. 4,000 ($48), including three ANC visits, a PNC visit, an institutional delivery, and a postnatal family planning visit, were sold for Rs. 100 ($1.2) to low-income women targeted by project outreach workers. Women suffering from complications were referred to emergency obstetric care services.Analysis was conducted at the bivariate and the multivariate levels. At the multivariate level, logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women (defined for this study as women in the fourth or fifth quintiles) relative to non-poor women (defined for this study as women in the first quintile) in the intervention union councils compared to the control union councils.ResultsBivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils. Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils.ConclusionsDemand-side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery.