Effect of Physical Violence on Sexually Transmitted Infections and Treatment Seeking Behaviour among Female Sex Workers in Thane District, Maharashtra, India.

BACKGROUND: Violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs). Evidence suggests the risk of acquiring STI/HIV infections among female sex workers (FSWs) who have experienced violence to be almost three-times higher than FSWs, who have not experienced violence. Moreover, an experience of physical and sexual violence makes it difficult for them to negotiate safer sex with their partners and often act as a barrier to utilization of prevention services. METHODS: This study utilizes data from 2785 FSWs aged 18 years and above who participated in a cross-sectional behavioural study conducted during 2013-14 in Thane district, Maharashtra. A probability-based two-stage cluster sampling method was used for data collection. This study assesses the effect of physical violence on self-reported STI symptoms (any STI and multiple STIs) and treatment seeking for the last STI symptom using propensity score matching method. RESULTS: About 18% of sampled FSWs reported physical violence at the time of the survey. The likelihood of experiencing such violence was significantly higher among FSWs who solicited clients at public places, engaged in other economic activities apart from sex work, had savings, and reported high client volume per week. FSWs experiencing violence were also inconsistent condom users while engaging in sex with regular partners and clients. The average adjusted effect of violence clearly depicted an increase in the risk of any STI (11%, p<0.05) and multiple STIs (8%, p<0.10) and reduction in treatment seeking (10%, p<0.05). CONCLUSIONS: This study demonstrates a significant effect of physical violence on reporting of any STI symptom and treatment seeking. Findings call for the immediate inclusion of strategies aimed to address violence related challenges in HIV prevention program currently being provided at Thane district. Such strategies would further help in enhancing the access to tailored STI prevention and care services among FSWs in the district.

Emergency referral transport for maternal complication: lessons from the community based maternal death audits in Unnao district, Uttar Pradesh, India.

BACKGROUND: An effective emergency referral transport system is the link between the home of the pregnant woman and a health facility providing basic or comprehensive emergency obstetric care. This study attempts to explore the role of emergency transport associated with maternal deaths in Unnao district, Uttar Pradesh (UP). METHODS: A descriptive study was carried out to assess the causes of and factors leading to maternal deaths in Unnao district, UP, through community based Maternal Death Review (MDR) using verbal autopsy, in a sample of 57 maternal deaths conducted between June 1, 2009, and May 31, 2010. A facility review was also conducted in 15 of the 16 block level and district health facilities to collect information on preparedness of the facilities for treating obstetric complications including referral transportation. A descriptive analysis was carried out using ratios and percentages to analyze the availability of basic facilities which may lead to maternal deaths. RESULTS: It was found that there were only 10 ambulances available at 15 facilities against 19 required as per Indian Public Health Standards (IPHS). About 47% of the deaths took place in a facility, 30% enroute to a health facility and 23% at home. Twenty five percent of women were taken to one facility, 32% were taken to two facilities, and 25% were taken to three facilities while 19% were not taken to any facility before their death. Sixteen percent of the pregnant women could not arrange transportation to reach any facility. The mean time to make arrangements for travel from home to facility-1 and facility-2 to facility-3 was 3.1 hours; whereas from facility-1 to facility-2 was 9.9 hours. The mean travel time from home to facility-1 was 1 hour, from facility-1 to facility-2 was 1.4 hours and facility-2 to facility-3 was 1.6 hours. CONCLUSION: The public health facility review and MDR, clearly indicates that the inter-facility transfers appropriateness and timeliness of referral are major contributing factor for maternal deaths in Unnao district, UP. The UP Government, besides strengthening Emergency Obstetric and Newborn Care (EmONC) and Basic Emergency Obstetric and Newborn Care (BEmONC) services in the district and state as a whole, also needs to focus on developing a functional and effective referral system on a priority basis to reduce the maternal deaths in Unnao district.

Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India.

BACKGROUND: Uttar Pradesh (UP) is the most populous state in India with the second highest reported maternal mortality ratio in the country. In an effort to analyze the reasons for maternal deaths and implement appropriate interventions, the Government of India introduced Maternal Death Review guidelines in 2010. METHODS: We assessed causes of and factors leading to maternal deaths in Unnao District, UP, through 2 methods. First, we conducted a facility gap assessment in 15 of the 16 block-level and district health facilities to collect information on the performance of the facilities in terms of treating obstetric complications. Second, teams of trained physicians conducted community-based maternal death reviews (verbal autopsies) in a sample of maternal deaths occurring between June 1, 2009, and May 31, 2010. RESULTS: Of the 248 maternal deaths that would be expected in this district in a year, we identified 153 (62%) through community workers and conducted verbal autopsies with families of 57 of them. Verbal autopsies indicated that 23% and 30% of these maternal deaths occurred at home and on the way to a health facility, respectively. Most of the women who died had been taken to at least 2 health facilities. The facility assessment revealed that only the district hospital met the recommended criteria for either basic or comprehensive emergency obstetric and neonatal care. CONCLUSIONS: Life-saving treatment of obstetric complications was not offered at the appropriate level of government facilities in a representative district in UP, and an inadequate referral system provided fatal delays. Expensive transportation costs to get pregnant women to a functioning medical facility also contributed to maternal death. The maternal death review, coupled with the facility gap assessment, is a useful tool to address the adequacy of emergency obstetric and neonatal care services to prevent further maternal deaths.