Factors associated with stillbirths in Haryana, India: a qualitative study.

Background: Each year, 2.6 million babies are stillborn worldwide, almost all in low- and middle-income countries. Several global initiatives, including the Sustainable Development Goals and the Every Newborn Action Plan, have contributed to a renewed focus on prevention of stillbirths. Despite being relatively wealthy, the state of Haryana in India has a significant stillbirth rate. This qualitative study explored the factors that might contribute to these stillbirths. Methods: This was a sub-study of a case-control study of factors associated with stillbirth in 15 of the 21 districts of Haryana in 2014-2015. A total of 43 in-depth interviews were conducted with mothers who had recently experienced a stillbirth, or with a family member. By use of reflexive and inductive qualitative methodology, the data set was coded to allow categories to emerge. Results: Two categories and several subcategories were identified. First, factors occurring before the woman reached a health-care facility were: lack of awareness of the mothers and family members; intake of sex-selection drugs during pregnancy, in order to have a male child; non-adherence to treatment for high blood pressure; lack of prior identification of an appropriate health-care facility for delivery; and transportation to a health-care facility for delivery. Second, factors occurring once the health-care facility was reached were: lack of timely and adequate management; and use of medication during labour. Conclusion: Intrapartum stillbirths are closely linked to the availability and accessibility of appropriate medical care. Timely and appropriate treatment and care, provided by a trained and skilled health worker during pregnancy and labour, as well as soon after delivery, is an absolute requirement for averting these stillbirths. This study underscores the importance of imparting and increasing awareness regarding factors that have a significant bearing on stillbirth and can be mitigated through prompt and adequate obstetric health-care services.

A composite indicator to measure universal health care coverage in India: way forward for post-2015 health system performance monitoring framework.

BACKGROUND: There is limited work done on developing methods for measurement of universal health coverage. We undertook a study to develop a methodology and demonstrate the practical application of empirically measuring the extent of universal health coverage at district level. Additionally, we also develop a composite indicator to measure UHC. METHODS: A cross-sectional survey was undertaken among 51 656 households across 21 districts of Haryana state in India. Using the WHO framework for UHC, we identified indicators of service coverage, financial risk protection, equity and quality based on the Government of India and the Haryana Government's proposed UHC benefit package. Geometric mean approach was used to compute a composite UHC index (CUHCI). Various statistical approaches to aggregate input indicators with or without weighting, along with various incremental combinations of input indicators were tested in a comprehensive sensitivity analysis. FINDINGS: The population coverage for preventive and curative services is presented. Adjusting for inequality, the coverage for all the indicators were less than the unadjusted coverage by 0.1-6.7% in absolute term and 0.1-27% in relative term. There was low unmet need for curative care. However, about 11% outpatient consultations were from unqualified providers. About 30% households incurred catastrophic health expenditures, which rose to 38% among the poorest 20% population. Summary index (CUHCI) for UHC varied from 12% in Mewat district to 71% in Kurukshetra district. The inequality unadjusted coverage for UHC correlates highly with adjusted coverage. CONCLUSION: Our paper is an attempt to develop a methodology to measure UHC. However, careful inclusion of others indicators of service coverage is recommended for a comprehensive measurement which captures the spirit of universality. Further, more work needs to be done to incorporate quality in the measurement framework.

Improving reporting of infant deaths, maternal deaths and stillbirths in Haryana, India.

Underreporting hampers the accurate estimation of the numbers of infant and maternal deaths and stillbirths in India. In Haryana state, a surveillance-based model - the Maternal Infant Death Review System - was launched in 2013 to try to resolve this issue. The system is a mixture of routine passive data collection and active surveillance by specially recruited and trained field volunteers. The volunteers gather the relevant data from child day-care centres, community health centres, cremation grounds, hospitals, the municipal corporation's offices and primary health centres and regularly visit health subcentres. The collected data are triangulated against the standard death registers and discussions with relevant community members. The details of any unregistered death are rapidly uploaded on the system's web-based platform. In April 2014, we made field observations, reviewed records and conducted in-depth interviews with the key stakeholders to see if the system's performance matched the state government's planned objectives. The data collected indicate that implementation of the system has led to quantitative and qualitative improvements in reporting of infant and maternal deaths and stillbirths. Completeness and consistency in the reporting of deaths are essential for focused policy and programmatic interventions and there remains scope for improvement in Haryana via further reform and changes in policy. The model in its current form is potentially sustainable and scalable in similar settings elsewhere.

En Inde, le sous-signalement empêche d'estimer correctement le nombre de décès infantiles et maternels et de mortinaissances. Dans l'État d'Haryana, un modèle basé sur la surveillance ­ le Maternal Infant Death Review System ­ a été lancé en 2013 afin de tenter de résoudre ce problème. Ce système mélange recueil passif de données de routine et surveillance active par des bénévoles de terrain spécialement recrutés et formés à cet effet. Ces derniers recueillent des données auprès de garderies, de centres de santé communautaires, de crématoriums, d'hôpitaux, de centres de soins primaires et des bureaux des municipalités et se rendent régulièrement dans des centres de soins secondaires. Les données ainsi recueillies sont triangulées par rapport aux registres standards des décès et aux discussions avec des membres de la communauté. Les détails de tout décès non enregistré sont rapidement chargés sur la plate-forme Internet du système. En avril 2014, nous avons effectué des observations de terrain, examiné des registres et mené des entretiens approfondis avec les principales parties prenantes afin de voir si les performances du système répondaient aux objectifs du gouvernement de l'État. Les données recueillies indiquent que la mise en œuvre de ce système a entraîné une amélioration quantitative et qualitative du signalement des décès infantiles et maternels ainsi que des mortinaissances. L'exhaustivité et la cohérence du signalement des décès sont essentielles pour avoir des politiques ciblées et des interventions programmatiques, et l'État d'Haryana présente d'autres possibilités d'amélioration, via d'autres réformes et des changements stratégiques. Le modèle, dans sa forme actuelle, est potentiellement utilisable à long terme et transposable dans des lieux similaires.

La escasez de informes obstaculiza una estimación exacta de las cifras de muertes maternas e infantiles y mortinatos en India. En 2013, en el estado de Haryana, se lanzó un modelo basado en el seguimiento (el Sistema de Análisis de la Mortalidad Infantil y Materna) para tratar de resolver este problema. El sistema combina una recopilación de datos rutinarios pasivos y un seguimiento activo realizados por voluntarios contratados capacitados en este campo. Los voluntarios reúnen información relevante de guarderías, centros de salud, terrenos destinados a incineraciones, hospitales, oficinas de la corporación municipal y centros de atención primaria, y visitan con asiduidad subcentros de salud. Los datos recopilados se triangulan según los registros normalizados de fallecimientos y análisis con miembros relevantes de la comunidad. Los detalles sobre todas las muertes no registradas se introducen con rapidez en la plataforma en línea del sistema. En abril de 2014, se realizaron observaciones de campo, se analizaron los registros y se llevaron a cabo entrevistas en profundidad con las partes interesadas fundamentales para comprobar que el rendimiento del sistema se equiparaba con los objetivos planificados por el gobierno estatal. Los datos recopilados indican que la implementación del sistema logró mejoras cuantitativas y cualitativas a la hora de redactar informes sobre la mortalidad infantil y materna y los mortinatos. Es fundamental que los informes sobre los fallecimientos sean minuciosos y coherentes para poder realizar intervenciones políticas y programáticas, y sigue existiendo margen para implementar mejoras en Haryana mediante más reformas y cambios de las políticas. El modelo actual puede mantenerse y ampliarse en otras ubicaciones similares.