Academic journal article Bulletin of the World Health Organization

Quality of Routine Essential Care during Childbirth: Clinical Observations of Uncomplicated Births in Uttar Pradesh, India/Qualite Des Soins Essentiels De Routine a L'accouchement et a la Naissance: Observations Cliniques Des Naissances Sans Complications Dans l'Uttar Pradesh/Calidad De la Atencion Esencial Rutinaria Durante El Parto: Observaciones Clinicas De Nacimientos Sin Complicaciones En Uttar Pradesh, India (Inde)

Academic journal article Bulletin of the World Health Organization

Quality of Routine Essential Care during Childbirth: Clinical Observations of Uncomplicated Births in Uttar Pradesh, India/Qualite Des Soins Essentiels De Routine a L'accouchement et a la Naissance: Observations Cliniques Des Naissances Sans Complications Dans l'Uttar Pradesh/Calidad De la Atencion Esencial Rutinaria Durante El Parto: Observaciones Clinicas De Nacimientos Sin Complicaciones En Uttar Pradesh, India (Inde)

Article excerpt

Introduction

The quality of care offered at maternity facilities not only affects pregnant women--both emotionally and physically--but also has an impact on the long-term health and survival of mothers and neonates. (1, 2) An increased focus on care during childbirth can lead to reductions in disability, maternal and neonatal mortality and stillbirths. (2, 3)

An estimated 72% of all deliveries--including 69% of those in South Asia--now occur in health facilities. (4) Even in health facilities, however, failures in the processes of care can result in bad obstetric and neonatal outcomes (5, 6) and care of poor quality often leads to low demand for maternal health services. (7, 8) Some routine interventions can be ineffective or even harmful. (9)

Despite substantial efforts to promote evidence-based obstetrics, the uptake of recommended interventions into clinical practice has been limited. (10-12) Clinical practices can be difficult to change because they are influenced by health worker and patient characteristics, the complexity of the tasks involved and the institutional and sociocultural environments. (13, 14)

In 2015, the estimated number of maternal deaths in India was higher than that in any other country apart from Nigeria. (15) India has to make rapid improvements in its levels of maternal mortality if the Global Strategy for Women's, Children's and Adolescents' Health's targets are to be met by 2030. (16) Maternity services in India are available from an enormous range of health providers. Maternity care in the public sector is provided through a network of primary, secondary and tertiary facilities that, in principle, provide routine care, basic emergency obstetric care and comprehensive emergency obstetric care, respectively. (17) In the private sector, maternity care is provided by a heterogeneous collection of facilities that range from small maternity homes to large multispecialty medical colleges and tertiary hospitals.

An analysis of the results of Demographic and Health Surveys conducted in 57 countries between 2000 and 2013 revealed that, in the various regions of the world, the private sector accounted for 9-56% of deliveries. (18) In 2003-2005, an estimated 22% of all deliveries in India occurred in the private sector.19 Among Indian women, previous negative pregnancy outcomes and relatively high socioeconomic status are positively associated with use of private facilities (19) whereas belonging to a so-called scheduled caste or tribe is negatively associated with such use. (20) The private sector is more expensive than the public sector but most Indians associate the private sector with better amenities and a higher standard of care. (20)

Although much information exists on the quality of emergency obstetric care in India, (21, 22) there appears to have been little research on the quality of normal labour and childbirth care, particularly in private facilities. The results of a few relevant qualitative studies on the public sector have generally revealed care of poor quality, often characterized by high rates of labour augmentation, routine episiotomies, no choice of position, non-adherence to protocols, limited monitoring, early discharge from the hospital and poor neonatal care. (23-25) In most areas of the world, deliveries in the private sector are much more likely to be by caesarean section than deliveries in the public sector. (26-29) This paper reports findings from clinical observations that were used to describe and investigate the quality of care provided routinely, for uncomplicated labour and childbirth, in maternity facilities in Uttar Pradesh, India.

Methods

Study setting

This study was conducted in three districts of Uttar Pradesh: Kannauj, Kanpur Dehat and Kanpur Nagar. (30) In 2012-2013, Uttar Pradesh was the Indian state with the largest population and the second and third highest levels of maternal and neonatal mortality, respectively. …

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