https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)60789-3.pdf

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India, with a particular focus on assessing the relative importance of community access and economic status. A descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (child/mother and community) random-effects logistical regression model using the second survey to investigate the determinants. In this investigation of institutional care seeking for child birth in rural India, economic status emerges as a more crucial determinant than access. Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births. Greater availability of obstetric services will not alone solve the problem of low institutional delivery rates. This is particularly true for the use of private-for-profit institutions, in which the distance to services does not have a significant adjusted effect. In the light of these findings a focus on increasing demand for existing services seems the most rational action. In particular, financial constraints need to be addressed, and results support current trials of demand side financing in India.

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Institutional delivery in rural India: the relative importance of accessibility and economic status

BACKGROUND: The use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980s. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India. METHODOLOGY/PRINCIPAL FINDINGS: Using data from three rounds of National Family Health Survey (NFHS) conducted during 1992-2006 we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers disaggregated by area of residence in India and three contrasting provinces namely Uttar Pradesh Maharashtra and Tamil Nadu. In addition we investigate the relative contribution of public and private health facilities in meeting the demand for SBA especially among poor mothers. We also examine the role of salient socioeconomic demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses concentration curve and concentration index logistic regression and multinomial logistic regression models are used to understand the trends patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992-2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups. CONCLUSIONS: The use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor it is clear that the poor (a) do not use SBA and (b) even if they had SBA they were more likely to use the private providers.

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Economic Inequalities in Maternal Health Care: Prenatal Care and Skilled Birth Attendance in India, 1992-2006

Background
Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider’s perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care.

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What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective

Background: Studies examining the intricate interplay between poverty female literacy child malnutrition and child mortality are rare in demographic literature. Given the recent focus on Millennium Development Goals 4 (child survival) and 5 (maternal health) we explored whether the geographic regions that were underprivileged in terms of wealth female literacy child nutrition or safe delivery were also grappling with the elevated risk of child mortality; whether there were any spatial outliers; whether these relationships have undergone any significant change over historical time periods. Methodology: The present paper attempted to investigate these critical questions using data from household surveys like NFHS 1992-1993 NFHS 1998-1999 and DLHS 2002-2004. For the first time we employed geo-spatial techniques like Morans-I univariate LISA bivariate LISA spatial error regression and spatiotemporal regression to address the research problem. For carrying out the geospatial analysis we classified India into 76 natural regions based on the agro-climatic scheme proposed by Bhat and Zavier (1999) following the Census of India Study and all estimates were generated for each of the geographic regions. Result/Conclusions: This study brings out the stark intra-state and inter-regional disparities in infant and under-five mortality in India over the past two decades. It further reveals for the first time that geographic regions that were underprivileged in child nutrition or wealth or female literacy were also likely to be disadvantaged in terms of infant and child survival irrespective of the state to which they belong. While the role of economic status in explaining child malnutrition and child survival has weakened the effect of mothers education has actually become stronger over time.

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Infant and Child Mortality in India in the Last Two Decades: A Geospatial Analysis

India has the largest number of births per year (27 million) in the world.1 With its high maternal mortality of about 300–500 per 100 000 births, about 75 000 to 150 000 maternal deaths occur every year in India.2,3 This is about 20% of the global burden hence India’s progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5 (MDG 5). Why is India’s maternal mortality high in spite of rapid economic growth? We believe the key reasons are political, administrative and managerial rather than a lack of technical knowledge.

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M. Prakasamma

Papers

Achieving Millennium Development Goal 5: is India serious?

Midwifery scope of practice among staff nurses: a grounded theory study in Gujarat, India.