Maternal Health: A Case Study of Rajasthan

This case study has used the results of a review of literature to understand the persistence of poor maternal health in Rajasthan, a large state of north India, and to make some conclusions on reasons for the same. The rate of reduction in Rajasthan's maternal mortality ratio (MMR) has been slow, and it has remained at 445 per 1000 livebirths in 2003. The government system provides the bulk of maternal health services. Although the service infrastructure has improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health (phase 1 and 2), have attempted to improve maternal health; however, they have not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. Thirty-two percent of women delivered in institutions in 2005-2006. A 2006 government scheme to give financial incentives for delivering in government institutions has led to substantial increase in the proportion of institutional deliveries. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The recent scheme of Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed

Comparison of Domiciliary and Institutional Delivery-care Practices in Rural Rajasthan, India

A retrospective cross-sectional survey was conducted to assess key practices and costs relating to home- and institutional delivery care in rural Rajasthan, India. One block from each of two sample districts was covered (estimated population–279,132). Field investigators listed women who had delivered in the past three months and contacted them for structured case interview. In total, 1,947 (96%) of 2,031 listed women were successfully interviewed. An average of 2.4 and 1.7 care providers attended each home- and institutional delivery respectively. While 34% of the women delivered in health facilities, modern care providers attended half of all the deliveries. Intramuscular injections, intravenous drips, and abdominal fundal pressure were widely used for hastening delivery in both homes and facilities while post-delivery injections for active management of the third stage were administered to a minority of women in both the venues. Most women were discharged prematurely after institutional delivery, especially by smaller health facilities. The cost of accessing home-delivery care was Rs 379 (US$8) while the mean costs in facilities for elective, difficult vaginal deliveries and for caesarean sections were Rs 1,336 (US$ 30), Rs 2,419 (US$54), and Rs 11,146 (US$ 248) respectively. Most families took loans at high interest rates to meet these costs. It is concluded that widespread irrational practices by a range of care providers in both homes and facilities can adversely affect women and newborns while inadequate observance of beneficial practices and high costs are likely to reduce the benefits of institutional delivery, especially for the poor. Government health agencies need to strengthen regulation of delivery care and, especially, monitor perinatal outcomes. Family preference for hastening delivery and early discharge also require educational efforts

Pregnancy-related Deaths in Rural Rajasthan, India: Exploring Causes, Context, and Care-seeking Through Verbal Autopsy

In 2002-2003, all deaths (n=156) of women aged 15-49 years in a block of southern Rajasthan were investigated to determine the cause of death and care-seeking behaviour. Family members of 156 (98%) of 160 deceased women were interviewed following the comprehensive listing of all deaths among women of reproductive age. Of the 156 deaths, 31 (20%) were pregnancy-related; 77% of these women died during the postpartum period, and 74% of the deaths occurred in the home. Direct and indirect obstetric causes were responsible for 58% and 29% of the deaths respectively; 12% were injury-related deaths. Medical care was sought for 65% of the women, and 29% were hospitalized. Family perception of not being able to afford treatment at distant hospitals was a major barrier to seeking care, and 60% of those who sought care had to borrow money for treatment. Lack of skilled attendance and immediate postpartum care were major factors contributing to deaths. Improved access to emergency obstetric care facilities in rural areas and steps to eliminate costs at public hospitals would be crucial to prevent pregnancy-related deaths

Early Postpartum Maternal Morbidity among Rural Women of Rajasthan, India: A Community-based Study

The first postpartum week is a high-risk period for mothers and newborns. Very few community-based studies have been conducted on patterns of maternal morbidity in resource-poor countries in that first week. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India. The intervention included a rigorous system of receiving reports of all deliveries in a defined population and providing home-level postpartum care to all women, irrespective of the place of delivery. Trained nurse-midwives used a structured checklist for detecting and managing maternal and neonatal conditions during postpartum-care visits. A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007 - December 2010. Haemoglobin was tested for 77.1% of women (n=3,836) who had a postnatal visit. The most common morbidity was postpartum anaemia - 7.4% of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Life-threatening postpartum morbidities were detected in 7.6% of women - 9.7% among those who had deliveries at home and 6.6% among those who had institutional deliveries. None had a fistula. Severe anaemia had a strong correlation with perinatal death [p<0.000, adjusted odds ratio (AOR)=1.99, 95% confidence interval (CI) 1.32-2.99], delivery at home [p<0.000, AOR=1.64 (95% CI 1.27-2.15)], socioeconomically-underprivileged scheduled caste or tribe [p<0.000, AOR=2.47 (95% CI 1.83-3.33)], and parity of three or more [p<0.000, AOR=1.52 (95% CI 1.18-1.97)]. The correlation with antenatal care was not significant. Perineal conditions were more frequent among women who had institutional deliveries while breast conditions were more common among those who had a perinatal death. This study adds valuable knowledge on postpartum morbidity affecting women in the first few days after delivery in a low-resource setting. Health programmes should invest to ensure that all women receive early postpartum visits after delivery at home and after discharge from institution to detect and manage maternal morbidity. Further, health programmes should also ensure that women are properly screened for complications before their discharge from hospitals after delivery

Can community health workers play a greater role in increasing access to medical abortion services? A qualitative study

Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals.; In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed.; Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation.; Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women's concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting.; Not applicable

Maternal Health: A Case Study of Rajasthan

This case study has used the results of a review of literature to understand the persistence of poor maternal health in Rajasthan, a large state of north India, and to make some conclusions on reasons for the same. The rate of reduction in Rajasthan\u2019s maternal mortality ratio (MMR) has been slow, and it has remained at 445 per 1000 livebirths in 2003. The government system provides the bulk of maternal health services. Although the service infrastructure has improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health (phase 1 and 2), have attempted to improve maternal health; however, they have not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. Thirty-two percent of women delivered in institutions in 2005-2006. A 2006 government scheme to give financial incentives for delivering in government institutions has led to substantial increase in the proportion of institutional deliveries. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The recent scheme of Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed

Le modèle de 'l'État-stratège':Genèse d'une forme organisationnelle dans l'administration française

Cet article retrace la genèse d'une nouvelle forme d'organisation du système administratif en France, désignée sous le nom d'« État-stratège », qui redessine, dans les années 1990, les relations entre administrations centrales et services territoriaux de l'État. La séparation entre les fonctions stratégiques de pilotage et de contrôle de l'État et les fonctions opérationnelles d'exécution et de mise en œuvre des politiques publiques est au cœur de ce changement. Cette transformation suit deux processus. D'un côté, l'adoption de mesures concrètes de « gouvernement à distance » fait l'objet de luttes de pouvoir entre trois acteurs ministériels majeurs (ministère de l'Intérieur, du Budget et de la Fonction publique). De l'autre, est produite une nouvelle « catégorisation » légitime de l'État, portée par des hauts fonctionnaires généralistes, dans le cadre de grandes commissions de réforme, et inspirée des idées du New Public Management. La fabrique d'une nouvelle forme d'organisation étatique renvoie ainsi à deux dynamiques et deux dimensions, politique et idéelle. — Numéro spécial : Les nouveaux formats de l'institution.Since the 1990s, a new organisational form of the administrative system in France has been steadily redefining relations between central administrations and local state units. Labelled “the steering state” or the “managerial state”, this new paradigm hinges on separating the strategic functions of steering and controlling the state from the operational functions of execution and policy implementation. The making of this new form of state organization involves two parallel processes: political and cognitive. For one thing, the adoption of concrete measures for “government at distance” results from power struggles between three major ministries (Home Office, Budget and Civil Service). For another, a new legitimate “categorization of the state” is being formed in the major committees involved in the reform process of the 1990s; it is borne by top civil servants and inspired by the ideas of New Public Management. — Special issue: New patterns of institutions

Consequences of Maternal Complications in Women's Lives in the First Postpartum Year: A Prospective Cohort Study

Maternal complications are common during and following childbirth. However, little information is available on the psychological, social and economic consequences of maternal complications on women's lives, especially in a rural setting. A prospective cohort study was conducted in southern Rajasthan, India, among rural women who had a severe or less-severe, or no complication at the time of delivery or in the immediate postpartum period. In total, 1,542 women, representing 93% of all women who delivered in the field area over a 15-month period and were examined in the first week postpartum by nurse-midwives, were followed up to 12 months to record maternal and child survival. Of them, a subset of 430 women was followed up at 6-8 weeks and 12 months to capture data on the physical, psychological, social, or economic consequences. Women with severe maternal complications around the time of delivery and in the immediate postpartum period experienced an increased risk of mortality and morbidity in the first postpartum year: 2.8% of the women with severe complications died within one year compared to none with uncomplicated delivery. Women with severe complications also had higher rates of perinatal mortality [adjusted odds ratio (AOR)=3.98, confidence interval (CI) 1.96-8.1, p=0.000] and mortality of babies aged eight days to 12 months (AOR=3.14, CI 1.4-7.06, p=0.004). Compared to women in the uncomplicated group, women with severe complications were at a higher risk of depression at eight weeks and 12 months with perceived physical symptoms, had a greater difficulty in completing daily household work, and had important financial repercussions. The results suggest that women with severe complications at the time of delivery need to be provided regular follow-up services for their physical and psychological problems till about 12 months after childbirth. They also might benefit from financial support during several months in the postpartum period to prevent severe economic consequences. Further research is needed to identify an effective package of services for women in the first year after delivery

Maternal Health Situation in India: A Case Study

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India's goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health