Em OC Indian context Em OC provision a
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Em. OC –Indian context • Em. OC provision a policy priority • JSY to promote institutional births, thus provide access to Em. OC • Three tiered health system with referral services • Free referral transport in some states-Janani Express in MP
Figure 1. Model of referral chain, adapted from Jahn A and De Brouwer V 2001. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLo. S ONE 9(5): e 96773. doi: 10. 1371/journal. pone. 0096773 http: //www. plosone. org/article/info: doi/10. 1371/journal. pone. 0096773
Objectives To study quality of referral services in JSY by examining 1. association between maternal referral and adverse birth outcomes 2. spatial access to Emergency obstetric care (Em. OC) among mothers referred to and died at referral facility
Objective 1: Methods • Nested matched case control design • Three heterogenous districts of Madhya Pradesh • Cross sectional facility based study at facilities reporting >10 deliveries/month (n=96), 5 days at each facility • Interviews with mothers delivered at the facility (n= 1182)
Table 2. Study facilities by level and distribution of mothers who accessed intra-partum care at these levels. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLo. S ONE 9(5): e 96773. doi: 10. 1371/journal. pone. 0096773 http: //www. plosone. org/article/info: doi/10. 1371/journal. pone. 0096773
Figure 2. Mothers who reached study facilities for intra-partum care by referral status. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLo. S ONE 9(5): e 96773. doi: 10. 1371/journal. pone. 0096773 http: //www. plosone. org/article/info: doi/10. 1371/journal. pone. 0096773
Design Cases: mothers with adverse birth outcome at term delivery (n=34) Controls : mothers with live neonates at 48 hours postpartum (n=68) Controls matched individually to cases for type of complication and place of delivery Adverse birth outcome: Intra partum foetal death /early in facility neonatal death
Sample characteristics Cases (n==34) Controls (n=68) 22 (18 -35) 23 (18 -40) Below poverty line * 65% 41% Illiterate 32% Referred* 50% 25% Primiparous 50% 44% Caesarean section delivery 15% 28% ANC visits < 2 38% 25% Delivery care by doctor 21% 30% Age in years, median (range) * Significant at p<0. 05
Association bet maternal referral & adverse birth outcome Variable Odds ratio (95% CI) P value Maternal referral 2. 61 (1. 08; 6. 6) 0. 04 Age 1. 83 (0. 60, 5. 51) 0. 28 Education 1. 2 (0. 43 - 3. 43) 0. 70 Below poverty line 2. 06 (0. 80 -5. 31) 0. 13 Parity 0. 63 (0. 19 -2. 02) 0. 43 ANC visit 1. 19 (0. 57, 2. 48) 0. 63 Provider 0. 30 (0. 07, 1. 25) 0. 10 Maternal referral associated with significantly higher odds of adverse birth outcomes
Objective 2 -Methods • Application of Geographical Information System (GIS) tools • Two hours travel time to CEm. OC facility- UN standard for geographical access to Em. OC • Used two hours as desired time travel time to determine spatial access to Em. OC services
Objective 2 -Methods 1. Identification of CEm. OC facilities by survey using UN signal functions Digitization of district map with roads and maternity facilities
Shahdol District: Delivery facilities and major roads Delivery facilities- 63 CEm. OC facility-1 (Dist Hospital)
Objective 2 -Methods ctd……. 2. Review of maternal death records at CEm. OC facility (April 2010 -March 2012) : 124 deaths 3. Identification of deaths among mothers referred to CEm. OC facility : 55 referred in mothers 4. Referring facility locations plotted on GIS map
Facilities that referred the 55 mothers who died
Objective 2 -Methods ctd… 5. Buffer analysis of referring facility locations in Arc Info 10 ØAverage speed for a van in the study area is 50 Km/hr ØBuffers with a radius of 50 Km and 100 Km constructed around CEm. OC facility
100 km Buffer from CEm. OC facility Almost all were referred from within 2 hours travel time
50 km Buffer from CEm. OC facility Most were referred from within 1 hour travel time
Objective 2 - Results • Almost all mothers referred from within 2 hours distance • Most (82%) referred from within one hour distance • Median time between arrival and death- 6. 75 hours (IQR- 2. 1 -32 hours)
Summary results • High odds of adverse birth outcome associated with maternal referral • Maternal deaths despite spatial access to Em. OC
Conclusions • Inefficiencies in referral services resulting in loss of life saving opportunities • Failure to provide successful Em. OC • Possible deficiencies at sender, transfer and receiver levels of referral system • Poor quality of referral services in JSY in MP
Acknowledgements • EU FP 7 grant to project MATIND • Government of Madhya Pradesh, India Thank You!
