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Maternal health and health care in Madhya Pradesh state of India: an exploration using a human rights lens
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Pregnancy and motherhood are natural processes in the lives of women of reproductive age. These processes are generally considered to be positive and fulfilling experiences. However, for various reasons, many women end up dying as a result of these processes. Improving maternal health and reducing maternal mortality are accepted as human rights challenges and prioritized in several international declarations and national policies. However, progress in achieving these objectives still remains poor.

This thesis aims to explore the maternal health and healthcare in the Indian state of Madhya Pradesh through a human rights lens. A human rights lens provides a framework to study various aspects of the problem of maternal health from a human rights perspective. It helps in highlighting the gaps and challenges related to political priority, sociocultural, economic and individual-level factors and the availability, accessibility, acceptability and quality of maternal healthcare services. A combination of quantitative and qualitative research methodologies was applied in four sub-studies conducted in Madhya Pradesh. The specific objectives were: to investigate, by using John W. Kingdon’s multiple-streams model of agenda setting, why and how maternal health became a political priority in the state (Paper I); to estimate the effects of individual-, community- and district-level characteristics on the utilization of maternal health services with special reference to antenatal care, skilled attendance at delivery and post-natal care (Paper II); to analyse sociocultural and service delivery related dimensions of maternal deaths in rural central India through a human rights lens (Paper III); and to evaluate the technical efficiency of the public district hospitals using data envelopment analysis (Paper IV).

The findings of the first qualitative study indicated that various developments at international, national and state level brought the issue of maternal health to the priority political agenda in Madhya Pradesh state. This resulted in the introduction of new policies and programmes and more resources were allocated for improving maternal health. However, several challenges still remain in ensuring proper implementation of these programmes and policies. The quantitative study on factors affecting the use of maternal health services revealed that 61.7% of women used antenatal care at least once, 49.8% of women used skilled attendance at delivery and 37.4% of women used post-natal care during their most recent pregnancy. The household’s socio-economic status and mother’s education emerged as the most important factors associated with the use of antenatal care and skilled attendance at delivery. Delivery by skilled personnel and the use of antenatal care were the most important factors in the use of post-natal care. This study highlighted the need to identify and focus on community- and district-level intervention along with addressing the individual-level factors.

The findings of the third qualitative sub-study revealed that all pregnant women in the study tried to access medical assistance for obstetric complications but various factors delayed appropriate care. The underestimation of complication symptoms by family members, gender inequity and the negative perceptions regarding delivery services deferred decisions to seek care. Transportation problems and care seeking at multiple facilities also constrained timely reaching of appropriate health facilities. Negligence by health staff in providing care, and unavailability of blood and emergency obstetric care services, delayed the receiving of adequate care after reaching a health facility. This study indicates that normative elements of a human rights approach to maternal health, i.e. availability, accessibility, acceptability and quality, were not fully upheld. The deceased women and their relatives were unable to claim their entitlements and the duty bearers could not meet their obligations despite their conscious efforts to improve maternal health. In the last study, the results of data envelopment analysis revealed that half of the district hospitals (20) in the study were operating inefficiently.

This research establishes a need to give special attention to addressing challenges in the maternal health programmes at the implementation level as well as tackling the social determinants of maternal health. In order to increase the utilization of maternal health services in the state, the need to identify and focus on community- and district- as well as individual level interventions is emphasized. In order to prevent maternal deaths, a need for further concentrated efforts is underlined with a view to honouring human rights elements of maternal health by better community education, women’s empowerment and health system strengthening with the provision of appropriate and timely services including emergency obstetric care of good quality. It also highlights a need to identify the causes of the observed inefficiencies and to take appropriate measures to increase the efficiency of district hospitals.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2014. , 97 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1681
Keyword [en]
Maternal health, right to health, reproductive and sexual health, Madhya Pradesh, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-95900ISBN: 978-91-7601-154-6 (print)OAI: oai:DiVA.org:umu-95900DiVA: diva2:761328
Public defence
2014-11-28, Sal B, 9 tr, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2014-11-06 Created: 2014-11-06 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Technical efficiency of public district hospitals in Madhya Pradesh, India: a data envelopment analysis
Open this publication in new window or tab >>Technical efficiency of public district hospitals in Madhya Pradesh, India: a data envelopment analysis
2013 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6Article in journal (Refereed) Published
Abstract [en]

Background: Scarcity of resources for healthcare is a well-acknowledged problem. In this context, efficient utilization of existing financial and human resources becomes crucial for strengthening the healthcare delivery. The assessment of efficiency of health facilities can guide decision makers in ensuring the optimum utilization of available resources.

Objective: The objective of this study was to evaluate the technical efficiency (TE) of the public district hospitals in Madhya Pradesh, India, with special emphasis on maternal healthcare services, using data envelopment analysis (DEA).

Methods: Data from 40 district hospitals from January to December 2010 were collected from the health management information system and other records of the department of health and family welfare of the state. DEA was performed with input orientation and variable returns to scale assumption.

Results: TE and scale efficiency scores of the district hospitals were 0.90 (SD = 0.14) and 0.88 (SD = 0.15), respectively. Of the total district hospitals in the study, 20 (50%) were technically efficient constituting the 'best practice frontier'. The other half were technically inefficient, with an average TE score of 0.79 (SD = 0.12) meaning that these hospitals could produce the same outputs by using 21% less inputs from current input levels. Twenty-six (65%) district hospitals were found to be scale inefficient, manifesting a mean score of 0.81 (SD = 0.16).

Conclusions: Half of the district hospitals in the study were operating inefficiently. Decision makers and administrators in the state should identify the causes of the observed inefficiencies and take appropriate measures to increase efficiency of these hospitals.

Place, publisher, year, edition, pages
CoAction Publishing, 2013
Keyword
health services, hospital efficiency, data envelopment analysis, Madhya Pradesh, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-82639 (URN)10.3402/gha.v6i0.21742 (DOI)000324869000001 ()
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2006-1512
Available from: 2013-11-06 Created: 2013-11-05 Last updated: 2017-12-06Bibliographically approved
2. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis
Open this publication in new window or tab >>Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis
2011 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 10, no 1, 59- p.Article in journal (Refereed) Published
Abstract [en]

Background Improving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC).

Methods This study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study.

Results The results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mother's education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services.

Conclusions We found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions.

Place, publisher, year, edition, pages
BioMed Central, 2011
Keyword
Maternal health, antenatal care, skilled attendance at delivery, post natal care, multilevel analysis
National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-51862 (URN)10.1186/1475-9276-10-59 (DOI)000300876400001 ()22142036 (PubMedID)
Available from: 2012-02-03 Created: 2012-02-03 Last updated: 2017-12-08Bibliographically approved
3. The emergence of maternal health as a political priority in Madhya Pradesh, India: a qualitative study
Open this publication in new window or tab >>The emergence of maternal health as a political priority in Madhya Pradesh, India: a qualitative study
Show others...
2013 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, 181- p.Article in journal (Refereed) Published
Abstract [en]

Background: Politics plays a critical role in agenda setting in health affairs; therefore, understanding the priorities of the political agenda in health is very important. The political priority for safe motherhood has been investigated at the national level in different countries. The objective of this study was to explore why and how maternal health became a political priority at sub-national level in the state of Madhya Pradesh in India.

Methods: This study followed a qualitative design. Data were collected by carrying out interviews and review of documents. Semi-structured interviews were carried out with twenty respondents from four stakeholder groups: government officials, development partners, civil society and academics. Data analysis was performed using thematic analysis. The analysis was guided by Kingdon's multiple streams model.

Results: The emergence of maternal health as a political priority in Madhya Pradesh was the result of convergence in the developments in different streams: the development of problem definition, policy generation and political change. The factors which influenced this process were: emerging evidence of the high magnitude of maternal mortality, civil society's positioning of maternal mortality as a human rights violation, increasing media coverage, supportive policy environment and launch of the National Rural Health Mission (NRHM), the availability of effective policy solutions, India's aspiration of global leadership, international influence, maternal mortality becoming a hot debate topic and political transition at the national and state levels. Most of these factors first became important at national level which then cascaded to the state level. Currently, there is a supportive policy environment in the state for maternal health backed by greater political will and increased resources. However, malnutrition and population stabilization are the competing priorities which may push maternal health off the agenda.

Conclusions: The influence of the events and factors evolving from international and national levels significantly contributed to the development of maternal health as a priority in Madhya Pradesh. This led to several opportunities in terms of policies, guidelines and programmes for improving maternal health. These efforts were successful to some extent in improving maternal health in the state but several implementation challenges still require special attention.

Place, publisher, year, edition, pages
Springer, 2013
Keyword
Maternal health; Maternal mortality; Political priority; Madhya Pradesh; India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-82621 (URN)10.1186/1471-2393-13-181 (DOI)000325208400001 ()
Available from: 2013-11-08 Created: 2013-11-05 Last updated: 2017-12-06Bibliographically approved

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