1. QUALITY OF CARE IN OBSTETRIC
SERVICES IN RURAL SOUTH INDIA:
EVIDENCE FROM TWO STUDIES IN A
10 YR PERIOD
BELAKU TRUST
Asha Kilaru, BaneenKarachiwala,
SaraswathyGanapathy

2. Objectives
• Compare changes in pregnancy and delivery
services over a decade in a taluka of
Ramnagaram District (1996-98 and 2007-09)
• Identify gaps in the quality of services currently
being delivered to women during pregnancy,
delivery and postpartum.
• Make suggestions for how the observed gaps
can be addressed.

3. Methods
Study 1 - 1996-98 Study 2 – 2007-2009
Village selection 11 villages randomly 39 villages across 13
selected (population PHCs randomly selected,
approximately 25,000). 41 adjacent villages
purposively selected
(population approximately
150,000.)
All pregnant women All women who planned to
Study sample between 1996-98 (520 deliver in study area and
women), followed 3 were in 3rd trimester (642)
months postpartum between April 2007 – Jan
2009.
2 antenatal, 1 immediately 1 antenatal (3rd trimester),
post-delivery and 1 three 1 within one month
Questionnaires
months into post-partum postpartum

4. Findings
Antenatal Study 1 Study 2
1996-98 2007 - 09
Contact in 1st 56% 83%
trimester
> 4 antenatal visits 6% 64%
Quality of care at BP measured 57% At most recent visit -
antenatal visit Abdomen palpated: 88%
BP: 66%
IFA: 64%
Blood test: 13%
urine test: 8%
advice on signs or problems:
23%
breastfeeding advice: 5%
postnatal visit advice: 2%
Planned to deliver 87% 10%

5. Findings (2)
Study 1 Study 2
1996-98 2007 - 09
Planning for problems, Not available, but low Not available, but low
and response during according to our according to our
onset of labour observation observation
Switching place of del 30% 33%
(planned/anticipated to Switched for reasons
actual) other than referral by
provider

6. Findings (3)
Study 1 Study 2
1996-98 2007 - 09
Institutional deliveries 35% 82% (35% at Taluk
hosp)
ANM in attendance at 34% 17%
home delivery
Oxytocin administered 53% 17%
at home delivery
Oxytocin administered Not available 23%
intramuscular at inst
delivery
Birth weight recorded <25% 76%

7. Findings (4)
Study 1 Study 2
1996-98 2007 - 09
Length of stay Usually few hours 62% <6hrs
(even with LBW infants)
Postpartum/ Rarely given 56-62%
newborn advice given (62% of women w/o
LBW infant and 56% of
those w/ LBW received
advice)
Perinatal deaths 11 stillbirths 13 stillbirths
15 nn deaths 14 nn deaths
(26/355 live births) (27/581 live births)

8. Findings (5)
Study 1 Study 2
1996-98 2007 - 09
Postpartum visits 58% with some 93%( 565) at least 1
postpartum contact, contact with HCP
most with only 1
Of these, 94% said it
was only for baby
Most of the visits
(68%) reported
routine visits for
immunization

9. Findings (6)
Cost of care (Study 2 data)
• Costs high, much exceeding JSY payments.
• Much of it under-the-table
• Antenatal - highest expenditure for medicines
• Intrapartum - highest expenditure for provider payments
• Normal delivery median costs
Rs 1000-1300 in PHCs and Taluk hosp
Rs 4000 in tertiary govinst and pvt institutions
• C-sections median costs
Rs 8000 at tertiary govinst, Rs 20,000 at pvt inst

10. Women’s perceptions cont’d
Aspect of PHC % Taluk hosp % Private % Other Govt%
quality
Little or no 26 45 17 23
help from
health staff
companion 51 87 87 96
not allowed
Provider did 4 13 21 37
not speak
with respect
Not 36 38 22 44
comfortable
to ask ques
not clean 41 49 19 53

11. Socio-culturally linked factors
• Family members key
• Local ideas about interpretation of symptoms, causes of
illness were a significant factor in care-seeking
▫ Especially true in post-partum e.g., PPH, breast abscess
▫ Little recognition or acknowledgement of this by providers
• Attitudes that affect planning for emergencies or at onset of
labour
• Use of political connections for preferential work by
providers

12. Summary
• Improved ANC coverage, content inconsistent
• Drop in ANMs attending home births
• Little change in ‘switching’ – indicates lack of
change in problem planning
• Increase in IDs, cost
• Persistent oxytocinuse in contravention of
guidelines
• Duration of stay very short
• Little change in provider communication and advice
on warning symptoms, special care, risk
assessment
• Increase in PN contact, but little change in attention
to woman’s health

13. Conclusions and Recommendations
1. Improve the availability of 24x7 PHCs
2. Checklists for health providers on specific components
of recommended care
3. Emphasize communication - informing women and
families about what is being done and why, asking
about concerns and confusions
4. Create and mainstream specific protocols for women
with LBW newborns, use of oxytocin for labour
augmentation and AMSTL
5. Increase length of stay after delivery in institutions, esp
for women and newborns at risk

14. Conclusions and Recommendations (2)
6. Allow women to have a companion of choice
present during delivery
7. Identify and address inequities in health care
services and advice, content, & quality of care
provided by health professionals.
8. Improve safe birth attendance at home births
9. Prioritize routine postpartum care for women, not
only for vaccination of the newborn
10. Universal perinatal death review

15. Goal
Institutional deliveries
or
Safe and supported birth?