Socio-Economic Status or Caste? Inequities in Maternal and Newborn Health Care in Rural Uttar Pradesh, India

Many inequities in the coverage of essential interventions in pregnancy, childbirth and newborn and child health, especially those that require contact with the health system, persist within countries. Although economic inequities may be the most visible and profound, there can be other sources of social disadvantage. Poverty and caste are important determinants of health, including maternal healthcare. IDEAS conducted a descriptive analysis of socio-economic and caste-based inequities in the coverage of: a) Interactions between women and front-line health staff b) Interventions for antenatal, intrapartum and postanatal care Conclusions There were more socioeconomic than caste based inequities and more inequities in interactions between women and the health system than in the coverage of interventions

IDEAS project - Data Informed Platform for Health feasibility study in Uttar Pradesh

The IDEAS project sought to improve the health and survival of mothers and babies through generating evidence to inform policy and practice. This data collection contains topic guides and other research tools used to assess the feasibility of introducing a Data Informed Platform for Health (DIPH), in order to bring together key data from the public and private health sector on inputs and processes that may influence maternal and newborn health. The DIPH was intended to promote the use of local data for decision-making and priority setting at local health administration level, and for programme appraisal and comparison at regional and zonal level

Quality of care for reproductive tract morbidities by rural private practitioners in North India

Reproductive tract morbidities are reported by more than a third of the population in India. In rural areas, practitioners without a formal medical qualification are likely to be the first point of care seeking for these. The aim of this PhD thesis was to contribute to the body of knowledge on quality of care by rural private providers in India. The main objectives were to 1) examine care-seeking for genito-urinary symptoms and community perceptions of provider quality, 2) evaluate rural providers' quality of care, and, 3) examine associations between symptoms, infections and psychological health of care seekers. A combination of qualitative and quantitative methods were used: focus group discussions, household interviews, observations of patient-provider interactions (60 providers; 367 patients) and laboratory investigations for common reproductive tract infections. Patients were also screened for possible psychological distress. The study found that around 90 % providers did not possess a formal qualification but were a significant source of care provision. Providers' overall knowledge and practice of syndromic management was inadequate but these guidelines alone were inappropriate in relation to the care seekers's epidemiological and socio-cultural profile. Prevalence of infections in this population was low and some symptoms were associated with possible psychological distress. Communities' perceptions of genito-urinary illnesses were imbued with culturally influenced anxieties, that could potentially confound a clinical diagnosis. Providers too, commonly attributed symptoms to non-biomedical causes but persisted in dispensing biomedical drugs including antibiotics. Providers with a recognized qualification in an indigenous system of medicine displayed greater average technical skills than informally qualified ones, but both groups displayed similar knowledge levels. Knowledge was associated with technical performance at middle but not higher levels. All providers demonstrated moderate to high levels of interpersonal skills and these were strongly associated with increasing treatment charges. Providers were more likely to provide better technical quality to men and better interpersonal quality to women. As private providers with diverse qualifications meet a vast proportion of basic health care needs in rural areas, they all must be strengthened to provide an optimum quality of basic health care. The public health system needs to recognize private providers as an important first rung of primary health care in rural areas and establish strong referral and other supportive links with them. Providers' knowledge and skills upgradation needs to be combined with concerted behaviour change communication targeted at rural communities and regulation of the pahramaceutical industry for providers' drug dispensing to be rationalized. Health services for genito-urinary problems need to be expanded to cover pathological as well as psycho-sexual etiologies and management guidelines revised and evaluated. Health related IEC campaigns must allay fears and anxieties related to masturbation and loss of genital fluids in men and local secondary schools must intitiate comperehensive reproductive health education for adolescents at the earliest.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

IDEAS project - Scaling-up innovations to improve maternal and newborn health - Uttar Pradesh case study resources

The IDEAS project sought to improve the health and survival of mothers and babies through generating evidence to inform policy and practice in Ethiopia, northeast Nigeria and Uttar Pradesh, India. This data collection contains interview field notes and supporting information produced as part of a case study to document and assess the process by which the State Government of Uttar Pradesh introduced and scaled-up mSehat, a mobile phone application used by community health workers (Accredited Social Health Activists (ASHAs)) to create and maintain electronic health records

Informal rural healthcare providers in North and South India.

Rural households in India rely extensively on informal biomedical providers, who lack valid medical qualifications. Their numbers far exceed those of formal providers. Our study reports on the education, knowledge, practices and relationships of informal providers (IPs) in two very different districts: Tehri Garhwal in Uttarakhand (north) and Guntur in Andhra Pradesh (south). We mapped and interviewed IPs in all nine blocks of Tehri and in nine out of 57 blocks in Guntur, and then interviewed a smaller sample in depth (90 IPs in Tehri, 100 in Guntur) about market practices, relationships with the formal sector, and their knowledge of protocol-based management of fever, diarrhoea and respiratory conditions. We evaluated IPs' performance by observing their interactions with three patients per condition; nine patients per provider. IPs in the two districts had very different educational backgrounds-more years of schooling followed by various informal diplomas in Tehri and more apprenticeships in Guntur, yet their knowledge of management of the three conditions was similar and reasonably high (71% Tehri and 73% Guntur). IPs in Tehri were mostly clinic-based and dispensed a blend of allopathic and indigenous drugs. IPs in Guntur mostly provided door-to-door services and prescribed and dispensed mainly allopathic drugs. In Guntur, formal private doctors were important referral providers (with commissions) and source of new knowledge for IPs. At both sites, IPs prescribed inappropriate drugs, but the use of injections and antibiotics was higher in Guntur. Guntur IPs were well organized in state and block level associations that had successfully lobbied for a state government registration and training for themselves. We find that IPs are firmly established in rural India but their role has grown and evolved differently in different market settings. Interventions need to be tailored differently keeping in view these unique features

"It's About the Idea Hitting the Bull's Eye": How Aid Effectiveness Can Catalyse the Scale-up of Health Innovations.

BACKGROUND: Since the global economic crisis, a harsher economic climate and global commitments to address the problems of global health and poverty have led to increased donor interest to fund effective health innovations that offer value for money. Simultaneously, further aid effectiveness is being sought through encouraging governments in low- and middle-income countries (LMICs) to strengthen their capacity to be self-supporting, rather than donor reliant. In practice, this often means donors fund pilot innovations for three to five years to demonstrate effectiveness and then advocate to the national government to adopt them for scale-up within country-wide health systems. We aim to connect the literature on scaling-up health innovations in LMICs with six key principles of aid effectiveness: country ownership; alignment; harmonisation; transparency and accountability; predictability; and civil society engagement and participation, based on our analysis of interviewees' accounts of scale-up in such settings. METHODS: We analysed 150 semi-structured qualitative interviews, to explore the factors catalysing and inhibiting the scale-up of maternal and newborn health (MNH) innovations in Ethiopia, northeast Nigeria and the State of Uttar Pradesh, India and identified links with the aid effectiveness principles. Our interviewees were purposively selected for their knowledge of scale-up in these settings, and represented a range of constituencies. We conducted a systematic analysis of the expanded field notes, using a framework approach to code a priori themes and identify emerging themes in NVivo 10. RESULTS: Our analysis revealed that actions by donors, implementers and recipient governments to promote the scale-up of innovations strongly reflected many of the aid effectiveness principles embraced by well-known international agreements - including the Paris Declaration of Aid Effectiveness. Our findings show variations in the extent to which these six principles have been adopted in what are three diverse geographical settings, raising important implications for scaling health innovations in low- and middle-income countries. CONCLUSION: Our findings suggest that if donors, implementers and recipient governments were better able to put these principles into practice, the prospects for scaling externally funded health innovations as part of country health policies and programmes would be enhanced

'If I do 10-15 normal deliveries in a month I hardly ever sleep at home.' A qualitative study of health providers' reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India.

BACKGROUND: Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. We present providers' perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend. METHODS: Fourteen in-depth interviews were conducted with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad. RESULTS: Respondents were of the common view that private sector caesarean rates were unreasonably high and perceived time and doctors' convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more support, from either well-trained midwives and junior staff or using a 'shared practice' model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers' caesarean rates. CONCLUSIONS: Commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the 'safe' option have re-defined caesareans as the new 'normal', even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates

Contextual factors in maternal and newborn health evaluation: a protocol applied in Nigeria, India and Ethiopia.

BACKGROUND: Understanding the context of a health programme is important in interpreting evaluation findings and in considering the external validity for other settings. Public health researchers can be imprecise and inconsistent in their usage of the word "context" and its application to their work. This paper presents an approach to defining context, to capturing relevant contextual information and to using such information to help interpret findings from the perspective of a research group evaluating the effect of diverse innovations on coverage of evidence-based, life-saving interventions for maternal and newborn health in Ethiopia, Nigeria, and India. METHODS: We define "context" as the background environment or setting of any program, and "contextual factors" as those elements of context that could affect implementation of a programme. Through a structured, consultative process, contextual factors were identified while trying to strike a balance between comprehensiveness and feasibility. Thematic areas included demographics and socio-economics, epidemiological profile, health systems and service uptake, infrastructure, education, environment, politics, policy and governance. We outline an approach for capturing and using contextual factors while maximizing use of existing data. Methods include desk reviews, secondary data extraction and key informant interviews. Outputs include databases of contextual factors and summaries of existing maternal and newborn health policies and their implementation. Use of contextual data will be qualitative in nature and may assist in interpreting findings in both quantitative and qualitative aspects of programme evaluation. DISCUSSION: Applying this approach was more resource intensive than expected, in part because routinely available information was not consistently available across settings and more primary data collection was required than anticipated. Data was used only minimally, partly due to a lack of evaluation results that needed further explanation, but also because contextual data was not available for the precise units of analysis or time periods of interest. We would advise others to consider integrating contextual factors within other data collection activities, and to conduct regular reviews of maternal and newborn health policies. This approach and the learnings from its application could help inform the development of guidelines for the collection and use of contextual factors in public health evaluation

IDEAS project - Private sector health data sharing study in West Bengal

The IDEAS project sought to improve the health and survival of mothers and babies through generating evidence to inform policy and practice. This data collection is part of the formative research for the creation of a Data Informed Platform (DIPH) for Health in West Bengal to strengthen the public sector’s capacity for data-based decision-making. It consists of a rapid situational analysis of the private health sector in West Bengal to gain insights and understand the private sector’s role and relevance in maternal, newborn and child health services and data sharing. A field study of private health facilities providing maternal and newborn health services was undertaken in two districts – North 24 Parganas and South 24 Parganas. Face-to-face interviews with key informants from these facilities were conducted to identify existing private/public partnerships for health; the maternal and newborn health services provided by them; and the related data that private facilities shared with the public sector