QUALITY OF CARE IN OBSTETRIC SERVICES IN RURAL SOUTH INDIA: EVIDENCE FROM TWO STUDIES IN A 10 YR PERIOD

BELAKU TRUSTAsha Kilaru, Baneen Karachiwala,Saraswathy Ganapathy

Objectives•Compare changes in pregnancy and delivery

services over a decade in a taluka of Ramnagaram District (1996-98 and 2007-09)

• Identify gaps in the quality of services currently being delivered to women during pregnancy, delivery and postpartum.

•Make suggestions for how the observed gaps

can be addressed.

MethodsStudy 1 - 1996-98 Study 2 – 2007-2009

Village selection

Study sample

Questionnaires

11 villages randomly selected (population approximately 25,000).

All pregnant women between 1996-98 (520 women), followed 3 months postpartum 

2 antenatal, 1 immediately post-delivery and 1 three months into post-partum

39 villages across 13 PHCs randomly selected, 41 adjacent villages purposively selected (population approximately 150,000.)

All women who planned to deliver in study area and were in 3rd trimester (642) between April 2007 – Jan 2009. 1 antenatal (3rd trimester), 1 within one month postpartum

FindingsAntenatal Study 1

1996-98Study 2

2007 - 09

Contact in 1st trimester

56% 83%

> 4 antenatal visits 6% 64%Quality of care at antenatal visit

BP measured 57% At most recent visit -Abdomen palpated: 88%

BP: 66%IFA: 64%

Blood test: 13%urine test: 8%

advice on signs or problems: 23%

breastfeeding advice: 5% postnatal visit advice: 2%

Planned to deliverat home

87% 10%

Findings (2)

Study 11996-98

Study 22007 - 09

Planning for problems, and response during onset of labour

Not available, but low according to our

observation

Not available, but low according to our

observation

Switching place of del (planned/anticipated to actual)

30% 33%Switched for reasons other than referral by

provider

Findings (3)Study 11996-98

Study 22007 - 09

Institutional deliveries 35% 82% (35% at Taluk hosp)

ANM in attendance at home delivery

34% 17%

Oxytocin administered at home delivery

53% 17%

Oxytocin administered intramuscular at inst delivery

Not available 23%

Birth weight recorded <25% 76%

Findings (4)Study 11996-98

Study 22007 - 09

Length of stay Usually few hours 62% <6hrs(even with LBW infants)

Postpartum/newborn advice given

Rarely given 56-62%(62% of women w/o

LBW infant and 56% of those w/ LBW received

advice)

Perinatal deaths 11 stillbirths 15 nn deaths

(26/355 live births)

13 stillbirths 14 nn deaths

(27/581 live births)

Findings (5)Study 11996-98

Study 22007 - 09

Postpartum visits 58% with some postpartum contact, most with only 1

93%( 565) at least 1 contact with HCP

Of these, 94% said it was only for baby Most of the visits (68%) reported routine visits for immunization

Findings (6)

Cost of care (Study 2 data)• Costs high, much exceeding JSY payments. • Much of it under-the-table • Antenatal - highest expenditure for medicines • Intrapartum - highest expenditure for provider payments• Normal delivery median costs        Rs 1000-1300 in PHCs and Taluk hosp        Rs 4000 in tertiary gov inst and pvt institutions• C-sections median costs      Rs 8000 at tertiary gov inst, Rs 20,000 at pvt inst       

Women’s perceptions cont’d

Aspect of quality

PHC % Taluk hosp % Private % Other Govt %

Little or no help from health staff

26 45 17 23

companion not allowed

51 87 87 96

Provider did not speak with respect

4 13 21 37

Not comfortable to ask ques

36 38 22 44

not clean 41 49 19 53

Socio-culturally linked factors

• Family members key

• Local ideas about interpretation of symptoms, causes of illness were a significant factor in care-seeking▫Especially true in post-partum e.g., PPH, breast abscess▫Little recognition or acknowledgement of this by providers

• Attitudes that affect planning for emergencies or at onset of labour

• Use of political connections for preferential work by providers

Summary• Improved ANC coverage, content inconsistent•Drop in ANMs attending home births•Little change in ‘switching’ – indicates lack of change

in problem planning• Increase in IDs, cost•Persistent oxytocin use in contravention of guidelines•Duration of stay very short•Little change in provider communication and advice

on warning symptoms, special care, risk assessment• Increase in PN contact, but little change in attention

to woman’s health

Conclusions and Recommendations

1. Improve the availability of 24x7 PHCs

2. Checklists for health providers on specific components of recommended care

3. Emphasize communication - informing women and families about what is being done and why, asking about concerns and confusions

4. Create and mainstream specific protocols for women with LBW newborns, use of oxytocin for labour augmentation and AMSTL

5. Increase length of stay after delivery in institutions, esp for women and newborns at risk

Conclusions and Recommendations (2)

6. Allow women to have a companion of choice present during delivery

7. Identify and address inequities in health care services and advice, content, & quality of care provided by health professionals.

8. Improve safe birth attendance at home births

9. Prioritize routine postpartum care for women, not only for vaccination of the newborn

10. Universal perinatal death review

Goal

Institutional deliveries

or

Safe and supported birth?