Over a decade between two studies in Ramnagaram District, utilization and quality of obstetric care improved in some areas but gaps remain. The percentage of women receiving at least 4 antenatal visits and giving birth in institutions increased from 6% to 64% and 35% to 82%, respectively. However, planning for emergencies remained low and women still lacked companionship during delivery and felt uncomfortable asking questions of providers. The document recommends further steps like improving 24/7 primary health centers, communication between providers and women, and routine postpartum care for mothers.

1. UTILIZATION AND QUALITY OF OBSTETRIC CARE IN RAMNAGARAM DISTRICT: CHANGES OVER A DECADE BELAKU TRUST

2. Objectives Map positive and negative changes in pregnancy and delivery services over a decade in a taluka of Ramnagaram District (1996-98 and 2007-09) Identify gaps in the quality of services currently being delivered to women during pregnancy, delivery and postpartum. Make suggestions for how the observed gaps can be addressed.

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. 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. 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. 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. 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. Findings (6) Cost of care at all stages (Study 2 data) Costs high, much exceeding JSY payments. Much of it under-the-table Antenatal - highest expenditure for medicines Intrapartum - highest expenditure for provider payments Normal delivery median costs Rs 1000-1300 in PHCs and Taluk hosp Rs 4000 in tertiary gov inst C-sections median costs Rs 8000 at tertiary gov inst

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. 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. Findings (9) Perceptions of public-sector care Seem to have improved in the period between the two studies, having been poor during the first one. Satisfaction with interaction Discontent about not having delivery companion present -- 51% (PHC) to 96% (Tertiary govt) Discomfort in asking questions of health care provider during L&D – betw 36 - 44% at govt inst

12. Socio-culturally linked factors Family members key Local ideas about interpretation of symptoms, causes of illness were a significant factor in care-seeking Especially true in post-partum (bananthana) eg PPH, breast abscess Little recognition or acknowledgement of this by providers Attitudes that affect planning for emergencies or at onset of labour Political connections for preferential work by providers

13. Conclusions and Recommendations 1. Improve the availability of 24x7 PHCs, 2. Checklists for health providers on specific components of recommended care 3. Create and mainstream specific protocols for women with LBW newborns, use of oxytocin for labour augmentation and AMSTL 4. Increase length of stay after delivery in institutions

14. Conclusions and Recommendations (2) 5. Allow women to have a companion of choice present during delivery 6. Improve communication in terms of asking women and families about their concerns and confusions 7. Improve safe birth attendance at home births 8. Prioritize routine postpartum care for women, not only for vaccination of the newborn 9. Universal perinatal death review