Transcript Emergency Obstetric Care In Two Community Health Centres in

EMERGENCY OBSTETRIC CARE IN
TWO COMMUNITY HEALTH CENTRES IN WARDHA
DISTRICT, MAHARASHTRA
A RAPID ASSESSMENT STUDY
Conducted by
Datta Meghe Institute of Medical Sciences
Sawangi (M) Wardha Maharashtra
Investigators -
Dr S Z Quazi
Dr Abhay Gaidhane
Background
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5th MDG - reduction of the MMR by three quarters by 2015
MMR remained relatively unchanged since 1990
One woman dies every 5 min from a pregnancy related cause
India’s MMR 450 / 100000 live birth* (Regional differences)
Maharashtra MMR 145 / 100000 live birth**
The Challenge
 15 % of all pregnancies will result in complications, which are
extremely difficult to predict
 most of these lives could be saved if affordable, good-quality
emergency OB care available 24X7
* The State of World Children 2009, UNICEF
** State PIP & District PIP
Context
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NRHM promises to provide EmOC through CHC conforming to
minimum standard set by IPHS under NRHM
 ensuring accessibility and quality of EmOC services
MMR of Wardha - 400/100000 live birth*
 need for deeper enquiry into the accessibility & quality of
EmOC
Therefore a rapid assessment was conducted to assess the EmOC
services at CHCs in Wardha District
*source – Wardha District PIP 07-08
Specific Objectives
1.
2.
3.
To assess the readiness of CHCs in Wardha (Maharashtra) in
providing EmOC services with reference to the IPHS
developed under the NRHM
To study the current referral and utilization pattern of EmOC
To identify ‘barriers’ and ‘facilitators’ for providing EmOC at
CHCs from both, user as well as provider perspectives
Study Setting
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Located in Central India, Maharashtra
state, Blocks - 8
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Population - 1.2 million
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Rural - 73.6%
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Urban - 22.4
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Sex Ratio - 935 / 1000
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Birth rate – 16.7 / 1000
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IMR - 35.8/1000 live birth
Health Infrastructure
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Medical College Hospitals – 2
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Civil Hospital – 1
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CHCs – 8
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PHCs - 27
Methods
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Study design - A cross-sectional, qualitative study with facility
assessment
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Sampling – 2 (Arvi & Hinganghat) of 8 CHCs randomly chosen
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Ethical Issues – IRB approval obtained
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Tools of data collection –
 in-depth Interviews
 focus group discussions
 observation using a standard checklist
Data Collection & stakeholders
Issues / objectives
Interviews
(Women – 16
CS – 1
MO CHC – 2
Local leader – 2
Private Provider - 2
Total – 23)
EmOC facilities at
CHC as per the
IPHS
Civil Surgeon
CHC MO
Observation
(Both CHCs
Total -2 )
FGDs
Record review
(One at each
CHC Total 2)
(Districts &
2 CHCs)
Review of district
MIS and CHC data
CHC
Civil Surgeon
Facilitators / barriers
CHC MO
for providing EmOC
Private provider
Women (selected
Facilitators & barriers
from CHC record)
for accessing EmOC
Local leader
Women (selected
Pattern of EmOC
utilization
randomly from CHC
record)
Health provider
Women
Review of MIS &
CHC records
Definitions
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Basic EmOC
 Parenteral administration of antibiotics,
 Parenteral administration of anticonvulsants,
 Parenteral administration of oxytocics,
 Assisted Vaginal delivery
 Manual removal of placenta & retained products of
conception
Comprehensive EmOC
 Basic EmOC plus
 Facility for caesarean deliveries and
 Blood transfusion facilities
Scoring for facility assessment
Services
Available
Max
Score
%
Manpower
15
28.85
Infrastructure
10
19.23
Drugs
8
15.38
Equipment
6
11.54
Emergency
services (OB)
5
9.62
Training
4
7.69
Transport /
Ambulance
4
7.69
All services
(total score)
52
100
Ground realities considered
for designing score
Percentage Scores for facility assessment Hinganghat CHC
Poor
Needs
improvement
Satisfactory
Good
100
100
90
100
100
86.7
100
86.5
80
70
62.5
66.7
60
50
40
30
20
10
0
Manpower Infrastructure
Drugs
Equipment
Emergency
services
available
Training
Transport / Total score
Ambulance
Percentage Scores for facility assessment –
Arvi CHC
Needs
improvement
Satisfactory
Good
70
60
Poor
60
60
60
53.8
50
50
50
50
37.5
40
30
20
10
0
Manpower Infrastructure
Drugs
Equipment
Emergency
services
available
Training
Transport / Total score
Ambulance
Findings
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Both CHC
 Functional 24X7
 Adequate physical infrastructure for comprehensive EmOC
Average distance for women to CHC is 20 Km and money spent
for travel – 20 to 200 Rs
Blood bank - functional at one CHC, supplies frequently out of
stock
EmOC Drugs – frequently in short` supply.
Patients have to purchase from nearby 24X7 private pharmacy
usually all drugs are available)
Referral – ambulance in working condition at one CHC.
Findings
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Unavailability of full time specialist at both CHC
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Two contractual specialists at Hinganghat CHC
Obstetrician from Hinganghat town
 Anesthesiologist called from Wardha town (60 km / 2 hrs)
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Other barriers
 unawareness and lack of involvement of private provider
 lack of EmOC training of available staff at one CHC
 poor economic status of people
Referral / utilization pattern
From experiences of 10 women received EmOC in recent 6 months
Referral in
to CHC
Services
received at
CHC
Reasons for
out referral
Hinganghat CHC
Arvi CHC
Self
2
2
PHC
2
1
GP
1
2
Delivered at 1 (next day morning - assisted)
CHC
Immediately referred to
tertiary care hospital (low birth
weight baby)
1 (normal)
Next day referred to
tertiary care hospital for
blood transfusion
LSCS
1 (anesthesiologist called from
Wardha)
0
Immediate
referrals
Obstructed labour (1)
Hemorrhage (2)
Blood transfusion (2)
Hemorrhage (1)
Multiple pregnancy (1)
Referral / utilization pattern
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Users prefer CHC - less time & cost for transportation
“... I went there (CHC) as it was nearest facility from my home” (mother – 8)
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CHCs refer most EmOC cases to tertiary centers –
Specialist unavailable at CHC during emergency
“... we had to refer ...no other option.. as there are no specialist and blood is
also not available most of time” (Medical Officer Arvi)
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Caesarean delivery costs
CHC (elective CS) - Rs 1,500 to 12,000
 Tertiary Centers - Rs 2,000 to 5,000
“.... we have to call the anaesthesiologist from Wardha (60 Km / 2 hrs distance)
and he charged Rs 2500 ” (mother - 3)
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Conclusions
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Readiness for EmOC: Availability of physical infrastructure
however no full time specialists
Hinganghat CHC - Mostly assisted deliveries & elective caesarean
Arvi CHC - only normal deliveries
Services at CHC expensive than at tertiary centers
Women seek EmOC care at CHC, but most referred to tertiary
centers after supportive treatment
EmOC service delivery and utilization pattern highly skewed
towards tertiary centers
Complicated deliveries are not receiving EmOC at CHCs in its
true sense
Limitation of this study
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Direct care seekers at tertiary centers possibly missed
Patients seeking services from the private provider were not
studied, therefore we could not comment the pattern of EmOC
services utilization from private providers
Findings may not be generalizable to other states or regions,
however across Maharashtra State the infrastructure and health
manpower problem is relatively similar.
Recommendations
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Physical Health Infrastructure remains underutilized in absence
of specialists
 Therefore, need to address the health workforce crisis
comprehensively to provide EmOC services at CHC level
Appointment of contractual specialists for EmOC
 Preferably from the same town
Skill building of staff for EmOC
Better involvement of private providers in EmOC services (PPP)
Involvement of Medical College unto the level of CHC
 Round the clock posting of specialist (24 X 7)
Thank you