Quality of Free Delivery Care among Poor Mothers in Gujarat, India: A Community-Based Study.

BACKGROUND: Government of Gujarat introduced a public-private partnership scheme called the Chiranjeevi Yojana (CY) in 2005, to improve access to delivery care for poor women. Till date, more than 1 million deliveries have been conducted under CY. Although CY has been evaluated, this is the only study using primary data to evaluate the quality of care. OBJECTIVE: The objective of this study was to (i) determine the quality of free delivery care and (ii) examine the differences in the quality of care between public sector facilities and accredited private sector facilities. METHODOLOGY: The community-based survey was conducted in three districts of Indian state of Gujarat. Trained data collectors used pretested questionnaire in vernacular language between 7th and 10th days of delivery. Overall surveyed mothers were 3858 in the prospective study; analytic sample was 1616 mothers. Statistical analysis includes Chi-square test using IBM SPSS version 20. RESULTS: Quality of care was perceived to be good in both public sector and accredited private sector. When free delivery care was compared between two sectors, private sector was perceived to have better quality of care. This difference was statistically significant for indicators, such as infrastructure, allowed to eat/change positions, application of pressure on abdomen, and weighing of baby. CONCLUSION: The study highlights the need for engaging private sector to improve access to delivery care for poor women. Quality assurance programs in Gujarat need to address respectful care issues in the public sector. Future research should include qualitative study to understand the drivers of quality delivery care.

Journey to Death: Are Health Systems Failing Mothers?

BACKGROUND: Annually, about 44,000 maternal deaths occur in India, which is 20% of the global burden. Despite persistent efforts, India failed to meet the fifth millennium development goal by 2015. Lack of reliable data on maternal mortality demands utilization of tools for counting maternal deaths which is vital to implement preventative actions. OBJECTIVES: Our study aims to determine health system-related issues of maternal mortality using the WHO validated tool - Maternal Death Review and demonstrates usefulness of maternal death surveillance and review as a monitoring tool. METHODS: Fourteen maternal deaths were evaluated through community based and facility-based audits from July 2013 to June 2014 in three districts of Gujarat. Pathways to death were traced through Global Positioning System (GPS). Factors contributing to the three delays were analyzed. RESULTS: Type III delay, that is, delay in receiving adequate care was frequently observed in our review including weak referral linkages, lack of blood banking services, inadequate surgical facilities. and staff shortages. Mothers succumbed, not because they did not seek treatment or reach facilities in time but because facilities were incapable of providing appropriate medical care. CONCLUSION: Scaling up of maternal death audits and subsequent use of these findings will help to reduce maternal mortality in India. As we continue to push for institutional deliveries, we need to reevaluate if our health system is prepared to manage an increasing number of facility births and obstetric complications.