Conducted by Datta Meghe Institute of Medical Sciences Sawangi (M) Wardha Maharashtra

1. EMERGENCY OBSTETRIC CARE IN TWO COMMUNITY HEALTH CENTRES IN WARDHA DISTRICT, MAHARASHTRA A RAPID ASSESSMENT STUDY Conducted by DattaMeghe Institute of Medical Sciences Sawangi (M) Wardha Maharashtra Investigators - Dr S Z Quazi Dr Abhay Gaidhane

2. Background • 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

3. Context • 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

4. Specific Objectives • 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

5. Study Setting • Located in Central India, Maharashtra state, Blocks - 8 • Population - 1.2 million • Rural - 73.6% • Urban - 22.4 • Sex Ratio - 935 / 1000 • Birth rate – 16.7 / 1000 • IMR - 35.8/1000 live birth Health Infrastructure • Medical College Hospitals – 2 • Civil Hospital – 1 • CHCs – 8 • PHCs - 27

6. Methods • Study design - A cross-sectional, qualitative study with facility assessment • Sampling – 2 (Arvi & Hinganghat) of 8 CHCs randomly chosen • Ethical Issues – IRB approval obtained • Tools of data collection – • in-depth Interviews • focus group discussions • observation using a standard checklist

7. Data Collection & stakeholders

8. Definitions • 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

9. Scoring for facility assessment Ground realities considered for designing score

10. Percentage Scores for facility assessment - Hinganghat CHC

11. Percentage Scores for facility assessment – Arvi CHC

12. Findings • 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.

13. Findings • Unavailability of full time specialist at both CHC • Two contractual specialists at Hinganghat CHC • Obstetrician from Hinganghat town • Anesthesiologist called from Wardha town (60 km / 2 hrs) • 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

14. Referral / utilization pattern From experiences of 10 women received EmOC in recent 6 months

15. Referral / utilization pattern • Users prefer CHC - less time & cost for transportation “... I went there (CHC) as it was nearest facility from my home” (mother – 8) • 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) • 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)

16. Conclusions • 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

17. Limitation of this study • 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.

18. Recommendations • 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)

19. Thank you