| 1. |
- Chaturvedi, Sarika, et al.
(author)
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Assessment of the quality of clinical documentation in India's JSY cash transfer program for facility births in Madhya Pradesh
- 2016
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In: International Journal of Gynecology & Obstetrics. - : Wiley. - 0020-7292 .- 1879-3479. ; 132:2, s. 179-183
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Journal article (peer-reviewed)abstract
- Objective: To gain insight into the quality of care in facilities implementing the Janani Suraksha Yojana (JSY) cash transfer program in Madhya Pradesh, India, by reviewing the level of documentation in the clinical records of women who delivered.Methods: The present retrospective, descriptive study reviewed case records of women who delivered at 73 primary, secondary, and tertiary level facilities in three districts of Madhya Pradesh between 2012 and 2013. Twenty elements of care were assessed encompassing clinical history and admission details, care during delivery and postnatal period, and discharge details.Results: A total of 1239 records were reviewed. The extent of documentation varied among the elements assessed-e.g. 24 (1.9%) records documented advice at discharge, 171 (13.8%) documented postnatal blood pressure, 437 (353%) documented fetal heart rate, and 1220 (98.5%) documented admission date. The extent of documentation was better at higher level facilities.Conclusion: The quality of clinical documentation in the JSY program was found to be unacceptably poor in Madhya Pradesh. Improving staff skills and practices in clinical documentation and record keeping will be required to enable clinical processes to be assessed and quality of care to be improved. (C) 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
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| 2. |
- Chaturvedi, Sarika, et al.
(author)
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Availability and distribution of safe abortion services in rural areas : a facility assessment study in Madhya Pradesh, India
- 2015
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In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 8, s. 1-7
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Journal article (peer-reviewed)abstract
- Background: Unsafe abortion contributes to a significant portion of maternal mortality in India. Access to safe abortion care is known to reduce maternal mortality. Availability and distribution of abortion care facilities can influence women's access to these services, especially in rural areas. Objectives: To assess the availability and distribution of abortion care at facilities providing childbirth care in three districts of Madhya Pradesh (MP) province of India. Design: Three socio demographically heterogeneous districts of MP were selected for this study. Facilities conducting at least 10 deliveries a month were surveyed to assess availability and provision of abortion services using UN signal functions for emergency obstetric care. Geographical Information System was used for visualisation of the distribution of facilities. Results: The three districts had 99 facilities that conducted > 10 deliveries a month: 74 in public and 25 in private sector. Overall, 48% of facilities reported an ability to provide safe surgical abortion service. Of public centres, 32% reported the ability compared to 100% among private centres while 18% of public centres and 77% of private centres had performed an abortion in the last 3 months. The availability of abortion services was higher at higher facility levels with better equipped and skilled personnel availability, in urban areas and in private sector facilities. Conclusions: Findings showed that availability of safe abortion care is limited especially in rural areas. More emphasis on providing safe abortion services, particularly at primary care level, is important to more significantly dent maternal mortality in India.
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| 3. |
- Chaturvedi, Sarika
(author)
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Quality of obstetric care in India's Janani Suraksha Yojana cash transfer program to promote facility births : studies from Madhya Pradesh province
- 2015
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Doctoral thesis (other academic/artistic)abstract
- Background: Improving maternal health remains a challenge in most of the developing countries. In-facility births is an accepted strategy to reduce maternal mortality. India, which accounts for 17% of global maternal deaths, had a high proportion of home births- 65.5% in 2005.With encouraging evidence in the early 2000, cash transfer programs are increasingly gaining popularity as measures to increase utilization of health services. In 2005, India, under its National Rural Health Mission (NRHM), launched the Janani Suraksha Yojana (JSY) cash transfer program that pays cash to women on delivering in health facilities. The underlying assumption was that birth in a facility would provide women access to skilled birth attendance (SBA) and emergency obstetric care (EmOC), thus reducing maternal mortality. Along with the JSY, the NRHM also undertook initiatives to improve services, including training staff in skilled birth attendance, the provision of emergency transportation services, and facility infrastructure upgrades. The JSY, which has had over 80 million beneficiaries, has been successful in raising the proportion of facility births to 74.4% in 2013. However, the steep rise in facility births has not translated into a commensurate decline in maternal mortality ratio. Quality of care in the JSY program, although crucial to improved outcomes, has remained less researched. Aims and objectives: This thesis studied the quality of obstetric care provided at facilities implementing the JSY cash transfer program in Madhya Pradesh (MP) province, India by way of (i) assessing the competence of nurse midwives at providing first line EmOC (I), (ii) assessing the quality of obstetric referrals (II), (iii) determining the implementation fidelity of partograph use for monitoring labour (III), and (iv) assessing the quality of routine intra-partum care (IV). Methods: The studies employed both quantitative (I, II, III) and qualitative (III, IV) methods. Data collection methods used were written case vignettes administered to nurse-midwives (n=233) (I, III), cross-sectional survey of post-partum women in health facilities (n=1182), maternal death record review (n=124) (II), case record review (n= 1466) (III), interviews with providers (n=11, 10) (III, IV) and observations of vaginal deliveries (n=18). Quantitative data were analysed using descriptive statistics (I, II, III), and conditional logistic regression to study association between maternal referral and adverse birth outcomes at term delivery in the matched case control design (II), while spatial data for referrals was analysed using buffer analysis in Geographical Information System (II). Thematic framework approach was used for analysis of qualitative data (III, IV). Results: The competence of nurse-midwives at providing first line EmOC was low- 75% of participants scored below 35% of the full score. Overall 14% of participants in the vignette survey were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care. Referral patterns in paper II showed secondary level facilities received few referrals, while referrals were made directly to district hospitals. Prolonged labour was the commonest reason for referral (39%). Adjusted odds for adverse birth outcomes were twice among those referred than those not referred (AOR 2.6, 95% CI 1.1-6.6) (II). Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths showed 98% of the deceased mothers were referred from facilities within the desired 2 hour transfer time, indicating high number of maternal deaths despite good geographic access (II). Of the 1466 records reviewed, only 6 % had a filled partograph. Competence at plotting a partograph was poor - 75% participants scored below 15% of the full score. Analysis of the data from interviews regarding partograph use revealed partographs were used rarely and retrospectively, training does not support correct use of the partographs, and partographs can be useful but are not feasible (III). Observations in paper IV revealed unfavorable delivery environment such as delivery rooms were not conducive to safe, women-friendly care provision, and coordination between providers was poor. Staff do not provide skilled care routinely as known from observations that monitoring was limited to assessment of cervical dilatation, lack of readiness to provide key elements of care, and the execution of harmful/ unnecessary practices coupled with poor techniques. Care provision was characterized by dominant staff and passive recipients - staff sometimes threatened, abused, or ignored women during delivery; women were passive and accepted dominance and disrespect. The interviews revealed providers’ awareness of the compromised quality of care, but they were constrained by structural problems. Positive practices were also observed, including companionship during childbirth and women mobilizing in the early stages of labour. Conclusions: Findings from studies conducted in MP province indicate that the quality of care in the JSY program requires improvement. A key opportunity to translate large gains in coverage of in-facility births achieved through the JSY cash transfer program into reductions in maternal mortality is currently lost owing to deficiencies in the quality of care provided. Quality of care can be improved by addressing problems with training, supervision and ensuring a conducive environment for quality care provision. Cash transfer programs aiming to raise demand for services should ensure the services provided are of good quality in order to achieve intended outcomes.
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| 4. |
- Chaturvedi, Sarika, et al.
(author)
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Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births : A Study from Madhya Pradesh Province
- 2014
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 9:5
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Journal article (peer-reviewed)abstract
- Background:India 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 Results:Women 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.Conclusions:High 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.
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| 5. |
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| 6. |
- Sabde, Yogesh, et al.
(author)
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Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth : A cross-sectional study from Madhya Pradesh, India
- 2018
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In: PLOS ONE. - : PUBLIC LIBRARY SCIENCE. - 1932-6203. ; 13:1
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Journal article (peer-reviewed)abstract
- Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37 +/- 0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03 +/- 0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual's characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.
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| 7. |
- Sabde, Yogesh, et al.
(author)
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The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India
- 2016
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In: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 16
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Journal article (peer-reviewed)abstract
- Background: Since 2005, India has implemented a national cash transfer programme, the Janani Suraksha Yojana (JSY), which provides women a cash transfer upon giving birth in an existing public facility. This has resulted in a steep rise in facility births across the country. The early years of the programme saw efforts being made to strengthen the ability of facilities to provide obstetric care. Given that the JSY has been able to draw millions of women into facilities to give birth (there have been more than 50 million beneficiaries thus far), it is important to study the ability of these facilities to provide emergency obstetric care (EmOC), as the functionality of these facilities is critical to improved maternal and neonatal outcomes. We studied the availability and level of provision of EmOC signal functions in public facilities implementing the JSY programme in three districts of Madhya Pradesh (MP) state, central India. These are measured against the World Health Report (WHR) 2005benchmarks. As a comparison, we also study the functionality and contribution of private sector facilities to the provision of EmOC in these districts. Methods: A cross-sectional survey of all healthcare facilities offering intrapartum care was conducted between February 2012 and April 2013. The EmOC signal functions performed in each facility were recorded, as were human resource data and birth numbers for each facility. Results: A total of 152 facilities were surveyed of which 118 were JSY programme facilities. Eighty-six percent of childbirths occurred at programme facilities, two thirds of which occurred at facilities that did not meet standards for the provision basic emergency obstetric care. Of the 29 facilities that could perform caesareans, none could perform all the basic EmOC functions. Programme facilities provided few EmOC signal functions apart from parenteral antibiotic or oxytocic administration. Complicated EmOC provision was found predominantly in non-programme (private) facilities; only one of six facilities able to provide such care was in the public sector and therefore in the JSY programme. Only 13 % of all qualified obstetricians practiced at programme facilities. Conclusions: Given the high proportion of births in public facilities in the state, the JSY programme has an opportunity to contribute to the reduction in maternal and perinatal mortality However, for the programme to have a greater impact on outcomes; EmOC provision must be significantly improved.. While private, non-programme facilities have better human resources and perform caesareans, most women in the state give birth under the JSY programme in the public sector. A demand-side programme such as the JSY will only be effective alongside an adequate supply side (i.e., a facility able to provide EmOC).
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| 8. |
- Abbafati, Cristiana, et al.
(author)
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- 2020
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Journal article (peer-reviewed)
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