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EmOC –Indian context

EmOC –Indian context. EmOC provision a policy priority JSY to promote institutional births, thus provide access to EmOC Three tiered health system with referral services Free referral transport in some states-Janani Express in MP.

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EmOC –Indian context

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  1. EmOC –Indian context • EmOC provision a policy priority • JSY to promote institutional births, thus provide access to EmOC • Three tiered health system with referral services • Free referral transport in some states-Janani Express in MP

  2. Figure 1. Model of referral chain, adapted from Jahn A and De Brouwer V 2001. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

  3. Objectives To study quality of referral services in JSY by examining 1. association between maternal referral and adverse birth outcomes 2. spatial access to Emergency obstetric care (EmOC) among mothers referred to and died at referral facility

  4. Objective 1: Methods • Nested matched case control design • Three heterogenous districts of Madhya Pradesh • Cross sectional facility based study at facilities reporting >10 deliveries/month (n=96), 5 days at each facility • Interviews with mothers delivered at the facility (n= 1182)

  5. Table 2. Study facilities by level and distribution of mothers who accessed intra-partum care at these levels. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

  6. Figure 2. Mothers who reached study facilities for intra-partum care by referral status. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

  7. Design Cases: mothers with adverse birth outcome at term delivery (n=34) Controls : mothers with live neonates at 48 hours postpartum (n=68) Controls matched individually to cases for type of complication and place of delivery Adverse birth outcome: Intra partum foetal death /early in facility neonatal death

  8. Sample characteristics * Significant at p<0.05

  9. Association bet maternal referral & adverse birth outcome Maternal referral associated with significantly higher odds of adverse birth outcomes

  10. Objective2 -Methods • Application of Geographical Information System (GIS) tools • Two hours travel time to CEmOC facility- UN standard for geographical access to EmOC • Used two hours as desired time travel time to determine spatial access to EmOC services

  11. Objective 2 -Methods • Identification of CEmOC facilities by survey using UN signal functions Digitization of district map with roads and maternity facilities

  12. Shahdol District: Delivery facilities and major roads Delivery facilities- 63 CEmOC facility-1 (Dist Hospital)

  13. Objective 2 -Methodsctd……. 2. Review of maternal death records at CEmOC facility (April2010-March 2012) : 124 deaths 3.Identification of deaths among mothers referred to CEmOC facility : 55 referred in mothers 4.Referring facility locations plotted on GIS map

  14. Facilities that referred the 55 mothers who died

  15. Objective 2 -Methodsctd… 5.Buffer analysis of referring facility locations in Arc Info 10 • Average speed for a van in the study area is 50 Km/hr • Buffers with a radius of 50 Km and 100 Km constructed around CEmOC facility

  16. 100 km Buffer from CEmOC facility Almost all were referred from within 2 hours travel time

  17. 50 km Buffer from CEmOC facility Most were referred from within 1 hour travel time

  18. Objective 2- Results • Almost all mothers referred from within 2 hours distance • Most (82%) referred from within one hour distance • Median time between arrival and death- 6.75 hours (IQR- 2.1-32 hours)

  19. Summary results • High odds of adverse birth outcome associated with maternal referral • Maternal deaths despite spatial access to EmOC

  20. Conclusions • Inefficiencies in referral services resulting in loss of life saving opportunities • Failure to provide successful EmOC • Possible deficiencies at sender, transfer and receiver levels of referral system • Poor quality of referral services in JSY in MP

  21. Acknowledgements • EU FP 7 grant to project MATIND • Government of Madhya Pradesh, India Thank You!

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