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  • 1. Chaturvedi, Sarika
    et al.
    Ali, Sayyed
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sabde, Yogesh
    Diwan, Vishal
    De Costa, Ayesha
    Availability and distribution of safe abortion services in rural areas: a facility assessment study in Madhya Pradesh, India2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-7, article id 26346Article in journal (Refereed)
    Abstract [en]

    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.

  • 2. Chaturvedi, Sarika
    et al.
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R D Gardi Medical College, Ujjain, India.
    Diwan, Vishal
    De Costa, Ayesha
    Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province2014In: PLOS ONE, E-ISSN 1932-6203, Vol. 9, no 5, article id e96773Article in journal (Refereed)
    Abstract [en]

    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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  • 3. Chaturvedi, Sarika
    et al.
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India.
    Raven, Joanna
    Diwan, Vishal
    De Costa, Ayesha
    Assessment of the quality of clinical documentation in India's JSY cash transfer program for facility births in Madhya Pradesh2016In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 132, no 2, p. 179-183Article in journal (Refereed)
    Abstract [en]

    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.

  • 4. Kohler, Stefan
    et al.
    Annerstedt, Kristi Sidney
    Diwan, Vishal
    Lindholm, Lars H
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R. D. Gardi Medical College, Ujjain, India..
    Vora, Kranti
    De Costa, Ayesha
    Postpartum quality of life in Indian women after vaginal birth and cesarean section: a pilot study using the EQ-5D-5L descriptive system2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 427Article in journal (Refereed)
    Abstract [en]

    Background: There has been little evaluation of the postpartum quality of life (QOL) of women in India and its association with the mode of birth. This study piloted the use of the generic EQ-5D-5L questionnaire to assess postpartum QOL experienced by rural Indian women.

    Methods: A convenience sample of rural women who gave birth in a health facility in Gujarat or Madhya Pradesh was recruited into this pilot study. QOL was measured during three interviews within 30days of birth using the EQ-5D-5L questionnaire. Patient-level quality-adjusted life days (QALDs) were estimated. Multivariate regression was used to adjust for selected baseline characteristics.

    Results: Forty-six women with cesarean section and 178 with vaginal birth from 17 public and private health facilities were studied. Postpartum QOL in both groups improved between interviews 1 and 3. Comparing between vaginal and cesarean births indicated that the vaginal birth group had a higher QOL (0-3 days postpartum: 0.28 vs. 0.57, 3-7 days postpartum: 0.59 vs. 0.81; P<0.001) and was more likely to report no or slight problems in 4 of 5 health dimensions (mobility, self-care, usual activities, painordiscomfort; P0.04) during interviews 1 and 2. Postpartum QOL converged, but still differed between groups by the time of interview 3 (21-30 days postpartum: 0.85 vs. 0.93; P<0.001). While most women reported no problems by the end of the first postpartum month, the difference in the ability to perform usual activities persisted (P=0.001). In result, fewer QALDs were attained by women in the cesarean section group between day 1 and day 21 postpartum (13.1 vs. 16.6 QALDs; P<0.001). Subgroup analysis showed that having had an episiotomy during vaginal birth was also associated with reduced QOL postpartum, but to a lesser extent than cesarean section. Similar results were obtained when adjusting for socioeconomic, pregnancy and birth characteristics, but postpartum QOL already ceased to be statistically different between groups before interview 3.

    Conclusions: Vaginal births, even with episiotomy, were associated with a higher postpartum QOL than cesarean births among the Indian women in our pilot study. Finding these expected results suggests that the EQ-5D-5L questionnaire is asuitable instrumentto assess postpartum QOL in Indian women.

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  • 5.
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: To accelerate the coverage of skilled birth attendance, in 2005, the Indian government initiated a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY) that provides cash to women upon delivering in health facilities. The attempt to increase the utilization of facilities through the JSY, given the health system’s fragile state, has raised concerns about the programme’s success at achieving its intended goal of reducing maternal mortality ratio (MMR).

    Aim: To understand the implementation of the CCT policy to promote institutional births in India, with a special focus on nine of India’s poorer states.

    Methods: Thesis uses both quantitative and qualitative methods. The changes in coverage and inequalities in institutional births in the nine states following the initiation of JSY were analysed by comparing levels before and during the programme using state and district level data. The association between the coverage of institutional births and MMR was assessed using regression analysis (I). The change in socioeconomic inequalities in institutional births was estimated using the concentration index and concentration curve, and contributions of different factors to inequalities was computed by decomposition analysis (II). The quality of referral services was studied by conducting a survey of health facilities (n=96) and post-partum women (n=1182) in three districts of Madhya Pradesh. Conditional logistic regression was used to study the association between maternal referrals and adverse birth outcomes, while spatial data for referrals were analysed using Geographical Information Systems (III). Semi-structured interviews were conducted with government and non-government stakeholders (n=11) to explore their perceptions of the JSY, and the data were analysed using a thematic framework approach (IV).

    Results: In five years, institutional births increased significantly from a pre-programme average of 20% to 49%. However, no significant association between district-level institutional birth proportions and MMR was found (I). The inequality in access to institutional delivery care, although reduced since the introduction of JSY, still persists. Differences in male literacy, availability of emergency obstetric care (EmOC) in public facilities and poverty explained 69% of the observed inequality. While MMR has decreased in all areas since the introduction of JSY, it has declined four times faster in the richest areas than in the poorest (II). Adjusted odds for adverse birth outcomes among those referred were twice than in those who were not referred (AOR 2.6, 95% CI 1.1-6.6). A spatial analysis of the inter-facility transfer time indicated that maternal deaths occurred despite good geographic access to EmOC facilities (III). While most health officials considered stimulus in the form of JSY money to be essential to promote institutional births, non-government stakeholders criticised JSY as an easy way of addressing basic developmental issues and emphasised the need for improvements to health services, instead. Supply-side constraints and poor care quality were cited as key challenges to programme success, also several implementation challenges were cited (IV).

    Conclusions: Although there was a sharp increase in coverage and a decline in institutional delivery care inequalities following the introduction of JSY, the availability of critical care is still poor. CCT programmes to increase service utilization need to be essentially supported by the provision of quality health care services, in order to achieve their intended impacts on health outcomes.

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  • 6.
    Randive, Bharat B.
    et al.
    RD Gardi Med Coll, Ujjain 456006, Madhya Pradesh, India.
    Chaturvedi, Sarika D.
    Diwan, Vishal
    De Costa, Ayesha
    Effective coverage of institutional deliveries under the Janani Suraksha Yojana programme in high maternal mortality provinces of India: analysis of data from an annual health survey2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, no Supplement: 2, p. 123-123Article in journal (Other academic)
  • 7.
    Randive, Bharat
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    De Costa, A.
    Tolhurst, R.
    India's JSY cash transfer programme to reduce maternal mortality: Stakeholder perceptions of its appropriateness, achievements and challengesManuscript (preprint) (Other academic)
  • 8.
    Randive, Bharat
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, R. D. Gardi Medical College, Ujjain, India.
    Diwan, Vishal
    Department of Public Health, R. D. Gardi Medical College, Ujjain, India.
    De Costa, Ayesha
    Department of Public Health, R. D. Gardi Medical College, Ujjain, India and Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm.
    India's conditional cash transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality?2013In: PLOS ONE, E-ISSN 1932-6203, Vol. 8, no 6, article id e67452Article in journal (Refereed)
    Abstract [en]

    Background: India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR. Method: Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above-mentioned nine states were analysed to assess relationship between MMR and institutional births. Results: Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = 20.11). The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68]. Conclusions: Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

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  • 9.
    Randive, Bharat
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    De Costa, Ayesha
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India2014In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 123, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR). Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities. These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered.

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  • 10. Sabde, Yogesh
    et al.
    Chaturvedi, Sarika
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India.
    Sidney, Kristi
    Salazar, Mariano
    De Costa, Ayesha
    Diwan, Vishal
    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, India2018In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 1, article id e0189364Article in journal (Refereed)
    Abstract [en]

    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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  • 11. Sabde, Yogesh
    et al.
    Diwan, Vishal
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health and Environment, R.D. Gardi Medical College, India.
    Chaturvedi, Sarika
    Sidney, Kristi
    Salazar, Mariano
    De Costa, Ayesha
    The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 116Article in journal (Refereed)
    Abstract [en]

    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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