This study describes the results of a Morbidity and Performance Assessment (MAP) conducted to provide insight into the medical factors contributing to maternal and newborn morbidity and mortality in a rural district of northern India, and to use these insights to develop a locally appropriate, community-based safe motherhood program The MAP study was based on verbal autopsy method. Five hundred ninety-nine women (or in the case of 9 maternal deaths, a family member) participated in the study. This article describes a subsample of women who reported signs or symptoms suggesting excessive bleeding (n = 159). Findings include a poor knowledge of danger signs; poor problem recognition during labor, birth, and the immediate postpartum period; and a low level of health seeking that was consistent with poor recognition. Maternal sociodemographic characteristics, antenatal care use, and knowledge of danger signs were generally not associated with problem recognition and health seeking. The case fatality rate was 4%. These findings suggest an urgent need to understand the phenomenon of problem recognition and to integrate this into the design of interventions to reduce delays in health seeking.

Birthing women require support, particularly emotional support, during the process of labour and delivery. Traditionally, across cultures, this support was made available by the continuous presence of a companion during labour, childbirth and the immediate post-partum period. However, this practice is not universal, especially in health facilities in low- and middle-income countries. This cross-sectional study was conducted in 18 tertiary health care facilities of India using a mixed-method approach. The quantitative data were collected to document the number of birthing women, birth companions and healthcare providers in the labour rooms, and the typology of disrespect and abuse (D&A) faced by women. This was followed by in-depth interviews with 55 providers to understand their perspective on the various dimensions of D&A and the challenges they face to provide respectful care. This article explores the status of birth companionship in India and its plausible associations with D&A faced by birthing women in public facilities. Our study reveals that birth companionship is still not a common practice in Indian public hospitals. Birth companions were present during less than half of the observational period, also less than half of the birthing women were accompanied by a birth companion. Lack of hospital policy, space constraints, overcrowding and privacy concerns for other patients were cited as reasons for not allowing birth companions in the labour rooms, whose supportive roles, both for women and providers, were otherwise widely acknowledged during the qualitative interviews. Also, the presence of birth companions was found to be critically negatively associated with occurrences of D&A of birthing women. We contend that owing to the high pressure on the public hospitals in India, birth companions can be a low-cost intervention model for promoting respectful maternity care. However, adequate infrastructure is a critical aspect to be taken care of.

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The Frontiers in Reproductive Health Program (FRONTIERS) conducted an operations research study, called the Men in Maternity (MiM) study, in collaboration with the Employees" State Insurance Corporation of India (ESIC), the objective of which was to involve men in the antenatal and postpartum care of their partners to raise knowledge and use of postpartum contraception and preventive practices against sexually transmitted infections, as well as improving pregnancy outcomes. The original operations research study is described elsewhere. As soon as it was clear that the intervention was effective, ESIC decided to scale it up within the Delhi Directorate. The scale-up was initiated in January 2003; during the first phase ESIC expanded the intervention from three to 10 dispensaries. Of these ten dispensaries, six participated in the original MiM study and a further four dispensaries were added. Through two more phases ESIC would introduce the MiM model into the remaining 20 dispensaries by adding 10 dispensaries in each phase. The scale-up process began with the training of Master Trainersnine doctors from two ESIC hospitals and the three original MiM intervention dispensaries.All Auxiliary Nurse Midwives (ANMs) and Doctors working at the dispensaries were to receive training. However, there were many delays in training due to the inability to release staff for training, key staff transfers, long gaps in appointing a new person on key managerial positions, other priorities (e.g. RCH and DOTS), and inability to foresee the materials and supply demands and allocate resources to print and provide materials to dispensaries in time. These delays forced a change in the strategy and the MiM services were introduced as soon as the core staff providing antenatal and postnatal services was trained.Training of supervisors and whole site orientation of all clinical and non-clinical staff at each dispensary were conducted as soon as it was estimated that the core staff of program introducing dispensaries had been trained. During the first phase of scale-up it was planned that the Additional Director of Inspections (ADI) from the four zones would take over supervisory responsibilities, under the supervision of Additional Director (PS&CA). This process had to be abandoned due to ESIC restructuring as the whole cadre of ADIs was removed and personnel were transferred to other responsibilities within ESIC. Realizing that supervision of MiM activities needed to be decentralized, ESIC managers organized a one-day orientation workshop on MiM supervision in which all 30 Medical Officers in-charge of ESIC dispensaries in Delhi participated.FRONTIERS provided all additional BCC materialsposters, brochures, maternity cards and penis modelsfor the first year of implementation. ESIC committed to print and provide these materials during the second phase of scale-up. All requests for MiM materials were channeled through the AD (PS&CA) so that future demands from dispensaries were made through their routine indenting system. Although ESIC made s...