Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province

Abstract

BackgroundIndia launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30%in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter- facility referrals and study quality of referral services in JSY.Methods and ResultsWomen accessing intra natal care (n = 1182) at facilities (reporting >10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR- 2.6, 95% CI: 1.0–6.6 p = 0.04). Maternal death record review (April 10–March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from <2 hours. Median time between arrival and death was 6.75 hours.ConclusionsHigh odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.

Financial incentives in health: New evidence from India's Janani Suraksha Yojana

“…Having a fully functional referral system is thus critical for the success of any A c c e p t e d M a n u s c r i p t intervention which seeks to increase uptake of institutional delivery care (Campbell and Graham, 2006). Existing evidence suggests that the quality of maternity services and the referral system in the public sector remains poor in India (Chaturvedi et al, 2014;Hulton et al, 2007;Nagpal et al, 2015;Stanton et al, 2014).…”

“…One possibility is that the effect on utilisation was not sufficiently large to translate into better health outcomes. A second explanation points to the poor quality of care in the public sector (Chaturvedi et al, 2014;Hulton et al, 2007;Nagpal et al, 2015;Stanton et al, 2014), and the fact that the JSY increased uptake of maternity services at health facilities below the district hospital, which are not equipped to manage emergency complications at childbirth.…”

Postnatal care: increasing coverage, equity, and quality

“…Quality of care encompasses many complex notions that need to be unpacked, including the possibility of iatrogenesis that can occur when the level of quality is poor or unknown. 9 Strengthening health systems is crucial for improving the quality of care for mothers and neonates. To increase the responsiveness of systems and improve quality, it is essential to improve infrastructure and equipment; access to energy, water, and sanitation; and recruitment, training, and retention of health workers.…”

Quality of assessment of women at the time of admission for childbirth in secondary and tertiary public sector referral institutes in southern India

“…[8][9][10][11] Poor quality of intrapartum and immediate post-partum care, compounded by delayed referrals, and third delay at referral centre contribute to most maternal deaths. [12][13][14] In 2012, Health Ministry of India launched 'Dakshata' quality improvement program with an adaptation of WHO SCC supported by extensive mentoring in high delivery load facilities such as District Hospitals (DHs), Community Health Centers (CHCs)/ Block Primary Health Centers (PHCs). 15 A similar coaching based WHO SCC program at CHCs and PHCs, however, reported no improvement in maternal and peri-natal mortality.…”