Policy development and implementation : maternal health in India

Background: The progress to improve maternal health in India is characterized by a wide spread of success stories as well as failures. Policies and programs have been developed and implemented to reduce maternal mortality; however, many women stil lack access to health care during pregnancy and delivery and approximately 68 000 women die in pregnancy related complication each year. The capacity of the health system in India is considered to be weak and this is likely to influence the access to and use of maternal health care services. Aim: The overall aim of the work presented in this thesis was to explore and describe the topic of maternal health policy in the context of India, focusing on the states of Madhya Pradesh and Gujarat. Methods: To approach the topic of maternal health in India both qualitative (paper I) and quantitative (paper II) methods were used. In paper I, the implementation of maternal health policies in the state of Gujarat were explored by conducting in-depth interviews that were analyzed using qualitative content analysis. In paper II, a prospective cross-sectional design was used to study how antibiotics were prescribed during vaginal delivery and cesarean sections in a hospital setting in Madhya Pradesh. Main Findings: The findings presented in paper I indicate that limitations in the health system have implications for the capacity to implement maternal health interventions in Gujarat. Findings presented in paper II, show high levels of antibiotic prescribing during vaginal delivery and cesarean sections during hospital stay and at discharge. Conclusions: Improved maternal health is dependent on good policies and the functioning of the health systems. To further strengthen the capacity of the health system to implement maternal health policies in the state of Gujarat the findings presented in paper I indicate that improved coordination between actors and between single interventions, long-term and improved monitoring systems are key factors essential to strengthen capacity. To ensure evidence-based practice in terms of the prescribing of antibiotics during delivery in health facilities the development of a policy providing guidelines on best practices is important

Regional inequity in complete antenatal services and public emergency obstetric care is associated with greater burden of maternal deaths: analysis from consecutive district level facility survey of Karnataka, India.

BACKGROUND: This equity focused evaluation analyses change in inter-district inequity of maternal health services (MHS) in Karnataka state between 2006-07 & 2012-13, alongside association of MHS inequity with distribution of maternal deaths. METHODS: Repeated cross-sectional analysis of inequity and decomposition was done on nine district level MHS indicators using Theil's T index. Data was obtained from population linked district level facility surveys and health information systems. RESULTS: Inequity in births attended by skill birth attendants decreased the most (83.16%) among six other MHS indicators. Community provision of comprehensive emergency obstetric care strategy remained stagnant. Districts with higher complete antenatal care share and C-sections in public settings had lesser share of state's maternal deaths (R2 = 0.29, p = 0.004). 5 districts suffered perpetual inequity of MHS with relatively greater burden of maternal deaths. CONCLUSION: First 6 years of national rural health mission increased coverage of MHS and decreased regional inequity albeit non-uniformly. Distribution of system driven interventions of complete ANC and C-sections appear to determine decrease of maternal mortality in Karnataka

Health system capacity: maternal health policy implementation in the state of Gujarat, India

Introduction: The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007–2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services. Objective: To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat. Method: Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis. Result: Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health. Conclusions: The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes