Persistence of high maternal mortality in Koppal district, Karnataka, India: observed service delivery constraints

Rural women with obstetric complications access many health providers in Koppal, the poorest district in the state of Karnataka, south India. Yet they die. Based on insights derived from case studies of women seeking emergency obstetric care and participant-observation of government health services, this article highlights service delivery constraints that underlie the persistence of high levels of maternal mortality in Koppal. Weak information systems, discontinuity in care, unsupported health workers, haphazard referral systems and distorted accountability mechanisms are identified as critical service delivery problems. For example, maternal deaths are under-reported and not reviewed, antenatal care and institutional delivery are not linked to post-partum or emergency obstetric care, and health workers use inappropriate injections but don't treat anaemia or sepsis. Families waste valuable time and resources accessing many providers but fail to get effective care, and blame is laid on lower-level health workers and women for not accessing institutional delivery. Lastly, the role of administrators and politicians in ensuring functioning health services is obscured. While important supply and demand-side reforms are being implemented, these do not constructively engage with informal providers nor address systemic service delivery constraints. Critical managerial change is required, without which new budgetary allocations will be squandered with little impact on saving women's lives.     

Poor standards of care in small, private hospitals in Maharashtra, India: implications for public-private partnerships for maternity care

The private health sector in India is generally unregulated. Maharashtra is among the few states which require registration of private hospitals. This paper reports on a study of standards of care in small, private hospitals (less than 30 beds) in Maharashtra state, India, with a focus on maternity care, based on interviews with the hospitals' owners or senior staff, and observation. In the absence of reliable information on the number of private hospitals in the state, a physical listing was carried out in 11 districts and an estimate drawn up; 10% of hospitals found in each location were included in the study sample. We found poor standards of care in many cases, and few or no qualified nurses or a duty medical officer in attendance. Of the 261 hospitals visited, 146 provided maternity services yet 137 did not have a qualified midwife, and though most claimed they provided emergency care, including caesarean section, only three had a blood bank and eight had an ambulance. Government plans to promote public–private partnerships with such hospitals, including for maternity services, create concern, given our findings. The need to enforce existing regulations and collect information on health outcomes and quality of care before the state involves these hospitals further in provision of maternity care is called for.     

To study the incidence,etiology and EEG profile of neonatal seizures: a prospective observational study from India

Aim: To study the incidence, etiology and electroencephalography (EEG) profile of neonatal seizures and also to study the correlation between clinical picture and EEG appearance.

Type of study: Prospective observational cohort study.

Study duration: September 2011 to April 2013.

Inclusion and exclusion: Seizures within first 28?d of life and seizures documented by doctors.

Population: Neonates admitted in intensive care unit: intramural (4412) and extramural (1900) admissions (all together 6312).

Materials and methods: One hundred and seventy-two neonates with seizures were enrolled. All the neonates were evaluated with necessary investigation, ultrasound head and CT scan. All the neonates underwent EEG as early as possible with neonatal stabilization. The etiology of neonatal seizures, CT scan and ultrasound head, characteristic of the EEG and neonatal mortality were noted.

Results: The incidence of neonatal seizure was 0.77% in the intramural and 7.3% among the extramural neonates. The incidence of seizures in term newborn was 0.7% and in preterm was 1.1%. The most common cause of neonatal seizure was hypoxic ischemic encephalopathy (HIE) followed by hypocalcemia. The predominant seizure type was multifocal (51%) followed by subtle seizure (43%). There was an EEG abnormality in 72% of the total EEG with varied patterns. The mortality rate in the cohort was 15% with HIE being the most common cause.

Conclusion: Most common cases of neonatal seizure were HIE and with the most common type being multifocal. EEG was abnormal in the majority of the neonates with various pattern of abnormality.     

Where there is no anesthetist - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Objective

The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs’ experience of the program, and identified factors leading to post-training performance.

Methods

The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n = 14). Data on facility preparedness and monthly case load were also collected.

Results

Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.

Conclusion

Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.     

Where there is no obstetrician - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Background

Maternal mortality continues to be high in rural India. Chief among the reasons for this is a severe shortage of obstetricians to perform cesarean delivery and other skills required for emergency obstetric care (EmOC). In 2006, the Government of India and the Federation of Obstetric and Gynecological Societies of India (FOGSI) with technical assistance from Jhpiego, instituted a nationwide, 16-week comprehensive EmOC (CEmOC) training program for general medical officers (MOs). This program is based on an earlier pilot project (2004-2006).

Objective

To evaluate the pilot project, and identify lessons learned to inform the nationwide scale-up.

Methods

The lead author (CE) visited trainees and their facilities to evaluate the project. Eight data collection tools were created, which included interviews with informants (program/government staff, regional/international experts, trainees and trainers), facility observation, and facility-based data collection of births and maternal/newborn deaths during the study period.

Results

More trainees performed each of the basic EmOC skills after the training than before. After training, 10 of 15 facilities to which trainees returned could provide all signal functions for basic EmOC whereas only 2 could do so before. For comprehensive EmOC, 2 facilities with obstetricians were providing all functions before and 2 were doing so after, even though the specialists had left those facilities and services were being provided by CEmOC trainees. Barriers to providing, or continuing to provide, EmOC for some trainees included insufficient training for cesarean delivery, lack of anesthetists, equipment and infrastructure (operating theater, blood services, forceps/vacuum, manual vacuum aspiration syringes).

Conclusion

Although MOs can be trained to provide CEmOC (including cesarean delivery), without proper selection of facilities and trainees, adequate training, and support, this strategy will not substantially improve the availability of comprehensive EmOC in India.

Recommendations

To implement a successful nationwide scale-up, several steps should be taken. These include, selecting motivated trainees, implementing the training as it was designed, improving support for trainees, and ensuring appropriate staff and infrastructure for trainees at their facilities before they return from training.     

Level of activity of neonatal intensive care units and mortality among very preterm infants: a nationwide study in Italy

Objectives: To investigate the relationships between mortality of infants <32 weeks gestation and neonatal intensive care units’ (NICUs) volume of activity, daily number of high-dependent infants (HDIs) and geographical area in Italy. Methods: The study involved 105 neonatal units in 2005. Data were collected prospectically and through monthly cross-sectional investigations. Patients receiving respiratory care were defined as HDIs. Univariate and multivariable methods were used for analysis. Results: Babies enrolled were 4014. The overall mortality was 18.8%. An adjusted nearly two-fold increase in mortality was found in Southern compared to Northern regions. Volume of activity was not associated with mortality. When compared to infants admitted to NICUs in the highest tertile of the median number of HDIs/day (>2.5 patients/day), the adjusted odds ratios were 1.52 (95% CI = 1.14–2.02) for those in the 2nd tertile (1.1–2.5 patients/day) and 1.47 (95% CI = 1.02–2.13) for those in the lowest tertile (≤1 patient/day). After stratification by geographical area, this relationship was present in Southern, to a lesser extent in Central, but not in Northern regions. Conclusions: In Italy, striking geographical differences in mortality of very preterm infants are present. NICUs’ average daily number of HDIs is a better predictor of mortality than the volume of activity.     

Impact of Cesarean Section on Intermediate and Late Preterm Births: United States, 2000–2003

ABSTRACT: Background: Cesarean section appears to be associated with increased risk of neonatal mortality among infants of low‐risk term pregnancies, but it may offer some survival advantage among the most extremely preterm infants. The impact on intermediate (32–33 wk) and late preterm (34–36 wk) deliveries remains uncertain. The objective of this analysis was to compare the neonatal mortality rate (death at 0–27 days), the mechanical ventilation usage rate, and the incidence of hyaline membrane disease among intermediate and late preterm infants delivered by primary cesarean section compared with those delivered vaginally. Methods: United States Linked Birth and Infant Death Certificate files from the years 2000 to 2003 were used. Maternal demographic characteristics, medical complications, and labor and delivery complications were abstracted from the files along with infant information. Because of concern for misclassification of gestational age, a procedure was used to trim away births in which the birthweight of an infant for a specific gestational age was inconsistent. Adjusted odds ratios were calculated using logistic regression for the risk of the three outcomes of interest relative to the mode of delivery. Results: A total of 422,001 live births were available with complete data from the trimmed data set (60% of untrimmed data). After adjustment by logistic regression for infant size at birth, birthweight, sex, Apgar score at 5 minutes less than 4, multiple births, breech presentation, presence of an anomaly, the presence of any maternal medical condition or complication of labor and delivery, labor induction, maternal race, age, education, and gravidity, the adjusted odds ratios (95% CI for neonatal mortality at gestational ages of 32, 33, 34, 35, and 36 wk) were, respectively, 1.69 (1.31–2.20), 1.79 (1.40–2.29), 1.08 (0.83–1.40), 2.31 (1.78–3.00), and 1.98 (1.50–2.62). Conclusions: These data suggest that for low‐risk preterm infants at 32 to 36 weeks’ gestation, independent of any reported risk factors, primary cesarean section may pose an increased risk of neonatal mortality and morbidity. (BIRTH 36:1 March 2009)     

Barriers to Men's Participation in Antenatal and Prevention of Mother‐to‐Child HIV Transmission Care in Cameroon,Africa

Introduction : Men's role in HIV prevention is pivotal to changing the course of the epidemic. When men participate in Prevention of Mother‐to‐Child Transmission (PMTCT) programs, their knowledge of HIV increases, their behavior becomes supportive, and their receptiveness to HIV testing increases. In Cameroon, Africa, multiple efforts have been implemented that encourage men to “follow” their wives to obstetric/PMTCT care and to undergo HIV testing. However, only 18% of men have participated in this care. Methods : As a quality improvement initiative, a survey was administered to identify men's knowledge and attitudes regarding antenatal care (ANC), PMTCT, and HIV. The survey consisted of a questionnaire with an emphasis on identifying barriers to men's participation in PMTCT programs and obtaining HIV testing. A convenience sampling method was used, and no participant identifying information was collected. Results : Men's participation in ANC/PMTCT is affected by sociocultural barriers centered in tribal beliefs and traditional gender roles. The barriers identified included the belief that pregnancy is a “woman's affair”; the belief that a man's role is primarily to provide financial support for the woman's care; the man's perception that he will be viewed as jealous by the community if he comes to clinic with his pregnant wife; and cultural gender‐based patterns of communication. Discussion : Most men consider accompanying their wife to ANC/PMTCT a good practice. Yet fewer men actually do this, because they feel that the provision of finance for ANC registration and delivery fees is their most important role in supporting their wife's pregnancy. Health care workers should encourage individuals and community leaders to build upon the traditional value of financial responsibility, expanding a man's involvement to include supportive social roles in obstetric care, PMTCT, and HIV testing. J Midwifery Womens Health 2010;55:363–369     

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is to identify problems associated with the quality of hysterectomy care accessed by members of SEWA (Self-Employed Women’s Association), an Indian CBHI scheme, and discuss mechanisms that would optimize quality of care. Data on hysterectomy care were collected through a review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA’s members varied from potentially dangerous to excellent. Dangerous conditions included operating theatres without separate hand-washing facilities or proper lighting, the absence of qualified nursing staff, performing hysterectomy on demand, removing both ovaries without consulting or notifying the patient, and failing to send the excised organs for histopathology, even when signs were suggestive of disease. Women paid substantial amounts of money, even for poor and potentially dangerous care. In order to improve the quality of care for its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocations; (3) contract with providers giving a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better quality care and contract directly with them.     

Impact of Structured Counseling on the Selection of Hormonal Contraceptive Methods: Results of a Multi-Centric,Observational Study in India

Objective

To determine the influence of “structured contraception counseling” on Indian women’s selection of contraceptive methods.

Methods

Women (≥18 and ≤40 years) requesting contraception were enrolled at 36 sites. “Structured contraception counseling” was provided by a health care professional on the available contraceptive methods. Questionnaires on the women’s pre- and post-counseling contraceptive choice, her perceptions, and the reasons behind her post-counseling decision were filled.

Results

Significant reductions were observed in the proportion of women who were indecisive (n = 260; 31.5 % pre-counseling vs. n = 30; 3.6 %, post-counseling [P < 0.001]) and women opting for non-hormonal method (24.6 % pre-counseling vs. 6.8 % post-counseling, [P < 0.001]). Of all the women counseled (n = 825), 89.6 % (739/825) of women chose a hormonal contraceptive method. There were significant difference (P < 0.001) in the women’s choice of contraceptive in the pre- and post-counseling sessions, respectively (combined oral contraceptive: 30.8 vs. 40.7 %; vaginal ring: 1.8 vs. 14.1 %; progestogen only pills: 1.6 vs. 7.9 %; injectable-depot medroxyprogesterone acetate: 5.9 vs. 13.6 %; levonorgestrel-intrauterine system: 3.8 vs. 13.3 %).

Conclusions

Structured contraception counseling using standardized protocol and aids resulted in a significant increase in the selection of modern contraceptive methods. Post-counseling majority of women opted for hormonal methods with an increase in selection of pills and newer alternatives.     

The Impact of Extreme Heat Exposure on Pregnant People and Neonates: A State of the Science Review

The relationship between heat exposure and perinatal morbidity and mortality is of increasing concern as global temperatures rise and extreme heat events become more frequent and intense. Heat exposure can lead to a multitude of harmful outcomes for pregnant individuals and neonates, including hospitalization and death. This state of the science review explored the evidence on the associations between heat exposure and negative health outcomes during pregnancy and the neonatal period. Findings suggest that improving health care provider and patient awareness of heat-related risks and implementing specific interventions could mitigate adverse outcomes. Furthermore, public health and other policy interventions are needed to increase thermal comfort and reduce societal exposure to extreme heat and related risks. Early warning systems, medical alerts, provider and patient education, and increased access to health care and thermal comfort may improve pregnancy and early life health outcomes.     

Influence of time of delivery on risk of adverse neonatal outcome in different size of delivery units: a retrospective cohort study in Finland

Purpose: To evaluate the impact of time of birth on adverse neonatal outcome in singleton term hospital births.

Materials and methods: Medical Birth Register Data in Finland from 2005 to 2009. Study population was all hospital births (n?=?263,901), excluding multiple pregnancies, preterm births <37 weeks, major congenital anomalies or birth defects, and antepartum stillbirths. Main outcome measures were either 1-minute Apgar score 0–3, 5-minute Apgar score 0–6, or umbilical artery pH <7.00, and intrapartum and early neonatal mortality. We calculated risk ratios (ARRs) adjusted for maternal age and parity, and 95% confidence intervals (CIs) to indicate the probability of adverse neonatal outcome outside of office hours in normal vaginal delivery, in vaginal breech delivery, in instrumental vaginal delivery, and in elective and nonelective cesarean sections. We analyzed different size-categories of maternity hospitals and different on-call arrangements.

Results: Instrumental vaginal delivery had increased risk for mortality (ARR 3.31, 95%CI; 1.01–10.82) outside office hours. Regardless of hospital volume and on-call arrangement, the risk for low Apgar score or low umbilical artery pH was higher outside office hours (ARR 1.23, 95%CI; 1.15–1.30). Intrapartum and early neonatal mortality increased only in large, nonuniversity hospitals outside office hours (ARR 1.51, 95%CI; 1.07–2.14).

Conclusions: Compared to office hours, babies born outside office hours are in higher risk for adverse outcome. Demonstration of more detailed circadian effects on adverse neonatal outcomes in different subgroups requires larger data.