UTILIZATION AND QUALITY OF OBSTETRIC CARE IN RAMNAGARAM DISTRICT:  CHANGES OVER A DECADE BELAKU TRUST
Objectives <ul><li>Map positive and negative changes in pregnancy and delivery services over a decade in a taluka of Ramna...
Findings Antenatal Study 1 1996-98 Study 2 2007 - 09 Contact in 1st trimester 56%  83%  > 4 antenatal visits  6% 64% Quali...
Findings (2) Study 1 1996-98 Study 2 2007 - 09 Planning for problems and for response to onset of labour Not available, bu...
Findings (3) Study 1 1996-98 Study 2 2007 - 09 Institutional deliveries 35% 82% ANM in attendance at home delivery 34% 17%...
Findings (4) Study 1 1996-98 Study 2 2007 - 09 Length of stay Usually few hours 62% <6hrs (even with LBW infants) Postpart...
Findings (5) Study 1 1996-98 Study 2 2007 - 09 Postpartum visits 58% with some postpartum contact, most with only 1 93%(56...
Findings (6) <ul><li>Cost of care at all stages  (Study 2 data) </li></ul><ul><li>Costs high, much exceeding JSY payments....
Findings (7) SC % (n)  Others %(n)  Mean ANC visits 5.3 6.1 Timing of 1 st  ANC 1 st  or 2 nd  month 14.3 (21) 27.7 (128) ...
Findings (8) SC % (n) Others % (n)  Provider spoke with respect 63.0 (92) 70.3 (325) I felt comfortable to ask questions 5...
Findings (9) <ul><li>Perceptions of public-sector care </li></ul><ul><li>Seem to have improved in the period between the t...
Socio-culturally linked factors <ul><li>Family members key </li></ul><ul><li>Local ideas   about interpretation of symptom...
Conclusions and Recommendations  <ul><li>1. Improve the availability of 24x7 PHCs,  </li></ul><ul><li>2. Checklists for he...
Conclusions and Recommendations (2)   <ul><li>5.  Allow women to have a companion of choice present during delivery </li><...
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Quality of care in obstetric services in rural South India-evidence from two studies in a ten year period-Asha kilaru

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  • Planned to deliver at home – study 2 - 14% would like home del next time
  • Poor Planning - Feeling that childbirth is “normal”. Little understanding of urgency of intrapartum problems. Fear of planning being prophetic. Switching reasons 2 nd study - include onset of unexpected problem, lack of time to reach planned facility, anticipating or finding that a provider or facility would not be open, transport difficulties
  • Distribution of inst deliveries - QoC: Significant load on taluk hospital; only 20% delivered at peripheral centres Active mgmt of III stage poor: only 78 women of 501 delivering in institution report any sort of injection in III stage. Very low, even if all these were oxytocin
  • Postpartum contact - Counselling low except for contraception An additional 1.3% said PP visit only for mother, and 4.3% said for both
  • Study 2 data All of these results are statistically significant In timing of first visit, it seems important to look at early care, even before month 3. Women often say they wait until month 3 before they feel it is a pregnancy, and then they go see a provider. So a reporting of month 3 for a consultation may actually be later.
  • 1. women usually do not make decisions about the care they receive
  • The recommendations we have put down are specific to our findings. since a significant number of women switched because facilities were closed. during antenatal check-ups, delivery and discharge (e.g., birth planning during antenatal visits, postpartum and neonatal advice before discharge)
  • for women with uncomplicated normal births and neonates ≥ 2500 gms after observation of breastfeeding; longer for women with complications and/or low birth weight infants.
  • Quality of care in obstetric services in rural South India-evidence from two studies in a ten year period-Asha kilaru

    1. 1. UTILIZATION AND QUALITY OF OBSTETRIC CARE IN RAMNAGARAM DISTRICT: CHANGES OVER A DECADE BELAKU TRUST
    2. 2. Objectives <ul><li>Map positive and negative changes in pregnancy and delivery services over a decade in a taluka of Ramnagaram District (1996-98 and 2007-09) </li></ul><ul><li>Identify gaps in the quality of services currently being delivered to women during pregnancy, delivery and postpartum. </li></ul><ul><li>Make suggestions for how the observed gaps can be addressed. </li></ul>
    3. 3. Findings Antenatal Study 1 1996-98 Study 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% Bf advice: 5% postnatal visit advice: 2% Planned to deliver at home 87% 10%
    4. 4. Findings (2) Study 1 1996-98 Study 2 2007 - 09 Planning for problems and for response to 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
    5. 5. Findings (3) Study 1 1996-98 Study 2 2007 - 09 Institutional deliveries 35% 82% 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%
    6. 6. Findings (4) Study 1 1996-98 Study 2 2007 - 09 Length of stay Usually few hours 62% <6hrs (even with LBW infants) Postpartum/ newborn advice given Rarely given 55-60% (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)
    7. 7. Findings (5) Study 1 1996-98 Study 2 2007 - 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
    8. 8. Findings (6) <ul><li>Cost of care at all stages (Study 2 data) </li></ul><ul><li>Costs high, much exceeding JSY payments. </li></ul><ul><li>Much of it under-the-table </li></ul><ul><li>Antenatal - highest expenditure for medicines </li></ul><ul><li>Intrapartum - highest expenditure for provider payments </li></ul><ul><li>Normal delivery median costs </li></ul><ul><li>         Rs 1000-1300 in PHCs and Taluk hosp </li></ul><ul><li>         Rs 4000 in tertiary gov inst </li></ul><ul><li>C-sections median costs </li></ul><ul><li>      Rs 8000 at tertiary gov inst </li></ul><ul><li>        </li></ul>
    9. 9. Findings (7) SC % (n) Others %(n) Mean ANC visits 5.3 6.1 Timing of 1 st ANC 1 st or 2 nd month 14.3 (21) 27.7 (128) Place of ANC Only government 68.5 (100) 40.7 (188) Only private 9.6 (14) 37.9 (175) Place of birth Home 24.0 (35) 14.7 (68) Sub-centre/PHC 24.7 (36) 18.4 (85) Taluk hospital 34.9 (51) 34.6 (160) Private hospital 5.5 (8) 18.8 (87) **Other govt hospital 9.6 (14) 11.9 (55) En-route 1.4 (2) 1.5 (7) Total sample size 146 462
    10. 10. Findings (8) SC % (n) Others % (n) Provider spoke with respect 63.0 (92) 70.3 (325) I felt comfortable to ask questions 58.2 (85) 66.9 (265) Other staff were helpful 37% (54) 47.6% (220) Told about postpartum signs needing consultation 50.7% (74) 57.1% (264) LBW 25% 15% Total 146 462
    11. 11. Findings (9) <ul><li>Perceptions of public-sector care </li></ul><ul><li>Seem to have improved in the period between the two studies, having been poor during the first one. </li></ul><ul><li>Satisfaction with interaction </li></ul><ul><li>Discontent about not having delivery companion present -- 51% (PHC) to 96% (Tertiary govt) </li></ul><ul><li>Discomfort in asking questions of health care provider during L&D – betw 36 - 44% at govt inst </li></ul>
    12. 12. Socio-culturally linked factors <ul><li>Family members key </li></ul><ul><li>Local ideas   about interpretation of symptoms, causes of illness were a significant factor in care-seeking </li></ul><ul><ul><li>Especially true in post-partum (bananthana) eg PPH, breast abscess </li></ul></ul><ul><ul><li>Little recognition or acknowledgement of this by providers </li></ul></ul><ul><li>Attitudes that affect planning for emergencies or at onset of labour </li></ul><ul><li>Political connections for preferential work by providers </li></ul>
    13. 13. Conclusions and Recommendations <ul><li>1. Improve the availability of 24x7 PHCs, </li></ul><ul><li>2. Checklists for health providers on specific components of recommended care </li></ul><ul><li>3. Create and mainstream specific protocols for women with LBW newborns, use of oxytocin for labour augmentation and AMSTL </li></ul><ul><li>4. Increase length of stay after delivery in institutions </li></ul>
    14. 14. Conclusions and Recommendations (2) <ul><li>5. Allow women to have a companion of choice present during delivery </li></ul><ul><li>6. Improve communication in terms of asking women and families about their concerns and confusions </li></ul><ul><li>7. Improve safe birth attendance at home births </li></ul><ul><li>8. Prioritize routine postpartum care for women, not only for vaccination of the newborn </li></ul><ul><li>9. Universal perinatal death review </li></ul>

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