|Year : 2020 | Volume
| Issue : 1 | Page : 1-6
Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study
Sarika Dakhode, Abhay Gaidhane, Sonali Choudhari, Pramita Muntode, Vasant Wagh, Quazi Syed Zahiruddin
Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
|Date of Submission||04-Dec-2019|
|Date of Decision||07-Jan-2020|
|Date of Acceptance||14-Jan-2020|
|Date of Web Publication||13-Oct-2020|
Dr. Sarika Dakhode
Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: In India, emergency obstetric care (EmOC) services were started under RCH-II program (2004) with the goal to reduce maternal mortality ratio <100/lakh live births and increase institutional deliveries to at least 80% by 2010. Implemented strategy was to enhance availability and accesses to EmOC services. Objective: This study was conducted in one of the blocks of Wardha district in Maharashtra to understand the accessibility for providing EmOC services at primary health center and rural hospital in the last 1 year. Materials and Methods: This cross-sectional qualitative study was conducted from May 2018 to October 2018. Data were collected by key informant interviews of service providers. Notes were transcribed and then translated into English. Respondents' verbatim that is significant and illustrative as per the theme of the study was used for analysis. Results: Equipment and drugs essential for EmOC were available; however, most of these were underutilized due to lack of skill in selected facilities. Basic EmOC training pattern was found inadequate in duration and practical skill. Training and recruitment of staff constantly were observed challenging for higher stakeholders. Of all EmOC signal functions, only parental antibiotics, oxytocics, and assisted vaginal delivery (episiotomy) were provided. Conclusion: Although building infrastructure, drugs, equipment, and transportation facilities were accessible, needy women may fail to receive timely and quality EmOC, due to lack of trained staff, low confidence, and lack of motivation in managing obstetric emergencies.
Keywords: Access, emergency obstetric care, qualitative study, training
|How to cite this article:|
Dakhode S, Gaidhane A, Choudhari S, Muntode P, Wagh V, Zahiruddin QS. Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study. J Datta Meghe Inst Med Sci Univ 2020;15:1-6
|How to cite this URL:|
Dakhode S, Gaidhane A, Choudhari S, Muntode P, Wagh V, Zahiruddin QS. Determinants for accessing emergency obstetric care services at peripheral health facilities in a block of Wardha district, Maharashtra: A qualitative study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Nov 27];15:1-6. Available from: http://www.journaldmims.com/text.asp?2020/15/1/1/297978
| Introduction|| |
Around 15% of pregnancies carry high risk of death due to unpredictable complications. In India, maternal mortality ratio (MMR) was 210 (2011), with a rate of decline of around 5.8%/year and projected to be 139 by 2015 and 123 by 2017. With this recent rate of decline, MMR was yet falling short by 30 points for Millennium Development Goals (MDG5). Reducing MMR to 109 by 2015 would require an acceleration of this current rate to achieve the target of 100 by 2017., MMR of Maharashtra was 68/lakh during 2011–2013.
Since the 1990s, WHO, UNICEF, and UNFPA have recognized that emergency obstetric care (EmOC) is one of the cost-effective strategies for the reduction of maternal deaths., In India, EmOC services were started under RCH-II program to reduce MMR <100 and increase institutional deliveries to at least 80% by 2010., Implemented strategy was to enhance availability of facilities and increase access to EmOC.
Carrying out of well-focused life-saving EmOC services requires effectively functioning health system. This includes clean delivery supplies, essential medicines, and equipment along with the presence of personnel qualified to provide it. Keeping in view the importance of EmOC services to avert unpredictable women's death during pregnancy and childbirth, we undertook this study to understand the accessibility of EmOC services at primary health centers (PHCs) and rural hospital (RH).
| Materials and Methods|| |
This cross-sectional study was conducted using qualitative techniques, in one of the blocks of Wardha District of Maharashtra from May 2018 to October 2018. Selected block has five PHCs and two RHs which were included in the study. Accessibility of EmOC was studied in terms of readiness of facilities, availability of competent human resources, training pattern, and EmOC signal functions provided at the facility.
EmOC has two types of services – basic EmOC (BEmOC) and comprehensive EmOC (CEmOC). BEmOC includes six medical interventions known as signal functions, such as parenteral administration of antibiotics, anticonvulsants, oxytocics, assisted vaginal delivery, manual removal of placenta, and removal of retained products of conception. CEmOC includes cesarean section and blood transfusion in addition to BEmOC services.
Emergency obstetric care service providers
Health provider's view plays a crucial role to understand accessibility, challenges, and facilitators for EmOC services at PHC and RH in the last 1 year. Key informant interviews (KIIs) of the following service providers/stakeholders were interviewed and are shown in [Table 1].
|Table 1: Study participants and sample size for key informant interviews|
Click here to view
- Facility level: Medical superintendent – two, medical officers (MOs) – five, nursing staff (one from each RH) – two, and specialists (gynecologist, anesthetist if available at RH) and auxiliary nursing midwife (ANM) – one from each PHC – five
- Sub-district level: Taluka health officer (THO)
- District level: Civil surgeon (CS), district health officer (DHO), and additional DHO (ADHO).
The study was approved by the Institutional Ethics Committee of DMIMS, Wardha, and permitted by DHO and CS of district hospital.
Separate KII guide was prepared for all categories of stakeholders to cover various issues related to EmOC: preparedness of facility for providing EmOC, availability of trained health personnel, content and quality of EmOC training, mode of care provided, and referral pattern and suggestions to improve accessibility of services. We conducted stakeholder's interview at respective facility or office in Marathi and English. Each interview lasted for around 45–60 min.
Interviews were audio-taped. Notes were transcribed and then translated into English. Respondents' verbatim that is significant and illustrative as per the theme of the study was used for analysis. These transcripts were coded using descriptive words and phrases and organized into the concerned subject, and themes that emerged were outlined. Qualitative data are presented in the text form with quotes to illustrate study findings and are organized under suitable headings and labels in accordance with the research objectives.
| Results|| |
Readiness of facility to provide emergency obstetric care
District- and subdistrict-level managers mentioned that maintaining cleanliness of the facility is challenging. They explored major reasons that lack of motivation of sanitary staff and supervision by facility in-charges; old buildings and premises that are difficult to maintain and require frequent repair. Out of two posts of sanitary worker, one post was vacant in two PHCs. DHO mentioned that in most of the facilities, biomedical waste disposal was essential to improve as per the guidelines. Out of two posts of MO, one post was vacant in two PHCs. In other three PHCs and in both RHs, although the second post of MO was filled, those were contractual or bonded candidate. MOs and nursing staff had stated that equipment essential for EmOC was available at facility; however, most of these were underutilized. MO of PHC mentioned they never used vacuum extractor or forceps for assisted vaginal delivery as most of them (five out of eight posted MOs) were yet to be trained to use it. Hence, patients with such complication are referred to higher center. Nurses stated that it was difficult to manage patients of obstructed labor or other complications at PHCs. On talk with facility in-charges, it was noted that equipment required for removal of retained products of conceptions were available in RHs and three PHCs in a bock. However, it was used in RH only on scheduled duty of gynecologist (not 24 h) and occasionally in one PHC for elective Medical Termination of Pregnancy (MTP) procedure by block health officer/THO who is trained and empaneled for MTP. DHO and CS mentioned that all necessary equipment was available and there was ample opportunity to improve the essential skills of MO and nurses for using this equipment in emergencies.
All facility health providers informed that almost all drugs essential for EmOC services were available or obtainable by purchasing it from NRHM/RKS funds. Oxytocin drug was used in almost all facilities as a routine procedure after expulsion of the placenta to prevent postpartum hemorrhage (PPH); however, only in few facilities, oxytocin was also used to control and treat the PPH. Patients of PPH were directly referred to higher center. Parenteral antibiotics and anticonvulsants were used by MOs who were trained in BEmOC. Magnesium sulfate was not used at all in any of the facilities.
Training pattern of health staff
Service providers were asked about training pattern, duration, topics covered, benefits, and improvement needed. Residential training of MOs was provided by a trained gynecologist at district hospital for 15 days. MOs who had undergone training stated that such training was extremely useful to identify some of the signal functions of the EmOC. Theoretical classes were conducted adequately in office hours only. As MOs usually did not stay in the hospital during evening or night hours, training on emergency case management and practical skill development remained untouched. Furthermore, MOs told that the trainers were mostly gynecologists and they were already busy with their routine clinical work and EmOC training was an additional responsibility for them. One of the MOs suggested that there should be a minimum of two trainers.
“…. Two gynecologists were present at the training institute, but the hospital workload was too much, and they said that you see yourself and you do……it (training) was not according to standards….both (gynecologist) were too much busy.”
Regarding the duration, content, and pattern of training, MOs expressed the need for more hands-on training than just theoretical part, especially for the cases of manual removal of placenta, removal of retained products of conception, and management of PPH and pregnancy-induced hypertension. MOs perceived that current training of 15-day duration was too short to provide enough opportunity for hands-on training and to cover complicated cases. One MO suggested that.
“….instead of theoretical, during training, clinical activities should be taken more as practical is easier to understand. In this small period of 15 days, all types of patients (complicated cases) are not cover…which can be covered in 1-month duration.”
In addition, district-level managers opined that there was a need of refresher training periodically and also agreed that management of obstetric complications was difficult to cover in the specified duration of training. Moreover, to perform these signal functions, separate training of medical termination of pregnancy or manual vacuum aspiration (MVA) or like this is required. The policy was only MBBS doctors were posted to EmOC training. MOs of two PHCs told that most of the PHCs had BAMS as a second MO and suggested that they should be trained in EmOC to provide consistent services.
Trained human resources at facility
Higher stakeholders (ADHO and THO) explained the situation of PHCs in district that, most of the time, single MO had to manage all the PHC work and so patients requiring BEmOC services might be referred. Block health officer/THO said –
“If second MO is sent for training or completed bond or resigned….then it is difficult to manage…how it is possible for a person to work for 24 h?…if emergency comes at night, MO has to attend and again has to be ready for next day routine work,…very hectic.so many times patients might be referred!”
The other important issue identified by the MOs of PHCs and RHs was related to posting of the recently passed undergraduates as a 1-year-bonded service. Such bonded MOs usually aspire for postgraduate (PG) education and are busy preparing for PG entrance and therefore show minimal involvement in service provision.
Inadequate specialist's services were available at RH. The gynecologist was available at only one RH, and private anesthetist was accessible there on-call basis for EmOC. Anesthetists were not available at the time of data collection even after two visits at the facility. CS shared the problem regarding availability of gynecologists at RH that –
“Specialists are hardly willing to reside in rural area and to make them available always and continuously at rural hospital is really difficult.”
Emergency obstetric care signal functions provided in recent last year
During discussion with MOs, we came to know that all untrained MOs were unsure about providing parenteral antibiotics whereas MO of the one PHC though trained still hesitates to provide this signal function. All of the facility MOs and ANMs informed that they never used parenteral anticonvulsant; according to them, no such case of severe hypertension or eclampsia occurred or arrived. Case of Retained Products of Conception (RPOCs) was managed by MO trained in MTP in one RH and gynecologist in other RH in their duty schedule which was 3 days/week only.
Under CEmOC, RH is expected to provide blood transfusion services. Of two RHs, only one had blood bank. The important gap identified by the providers in operationalizing the blood bank and transfusion services was lack of sufficient blood units as a flow of patients requiring transfusion was less; therefore, ample stock of blood units was not maintained in RH. As a result, emergency cases are referred to higher centers. This leads to delay in access to timely intervention and therefore may increase the risk for maternal mortality, especially in cases of PPH. However, planned blood transfusion was possible. Other part also seemed that complicated obstetric cases were referred for the requirement of life-saving interventions other than blood transfusion. Doctors usually do not keep such women in the facility for blood transfusion only. Hence, emergency blood transfusion was altogether avoided.
It appeared that MOs did not want to take risk to treat with the complicated cases even at minor stage for the sake of patient's safety, if suppose the condition worsens, MO will be the sole responsible person for everything. One MO said that –
“At district hospital, there is a team of specialists, they together can manage complications…how can I alone do it!.and that too here! what will happen if it gets more serious!…after all patient's life is more important?”
Other MO stated that –
“Here one MO…there (district hospital) numerous doctors are present at a time, they can discuss the case, and if patient's condition worsens, then all of them would be responsible…here one-man shows!…here nobody will take the risk.”
Regarding this, THO said that –
“Previously, maternal deaths were too high…now, single death is a major issue for the family as well as for health department and MO received letters…memo (from DHO office)…then death audits.”
The [Figure 1] reflects overall observed determinants for accessing Emergency Obstetric Care services at peripheral health facilities in a block of Wardha District.
|Figure 1: Determinants for accessing emergency obstetric care services in selected health facilities (primary health center and rural hospital) of one block of Wardha district|
Click here to view
| Discussion|| |
Sepsis is one of the leading causes of maternal deaths in developing countries. It is also one of the most preventable conditions of all postpartum morbidities.,, Cleanliness and asepsis were quite variable between present study facilities. Most of the facilities were clean, but some required improvement in cleanliness. This may be due to lack of motivation among staff or shortage of sanitary workers/sweepers as only one was available for these facilities to do work for 24 h. All higher stakeholders suggested that more post of sweepers must be sanctioned as NRHM/RKS fund was not sufficient to hire contractual sweepers. MO at the PHC can sensitize their staff for BMW, provide them with guidelines and training for the same can be arranged at district level or block level. Civil work might be required for those facilities where old infrastructure was observed.
As per the ADHO and DHO, to improve cleanliness, calendar activity had already started for 1 year back at PHC level. Responsibilities were distributed among staff and workers. MO in-charge has to monitor this activity and; district-level supervisors and district-level officers have to supervise one PHC monthly.
Once major obstetric complications develop, it requires parenteral drugs, surgical interventions, blood transfusion, and other potent treatment to handle effectively and reduce maternal deaths substantially. Therefore, one of the cost-effective approaches is to ensure high-quality EmOC. As per the National Program Implementation Plan for RCH-II, operational strategies are making PHCs functional 24 × 7 to provide the full range of RCH services including management of common obstetric complications that do not need major surgical intervention. Most of the equipment was available and was being used at almost all studied facilities, except vacuum extractor and MVA. This might be because of lack of adequate training, especially hands-on experience/exposure. Only availability of equipment is not enough to provide services but staff must be skilled as well.
The WHO technical consultation (November 2008) to develop guidelines for interventions for PPH identified parenteral oxytocin and misoprostol as a recommended drug of choice for the prevention of PPH. To manage PIH and severe hypertension, injection diazepam, and to control eclampsia, magnesium sulfate should be available., In studied facility, although these drugs were available, its appropriate use needs to be improved. In-charge MOs would have to be equipped enough to handle common obstetric emergencies and provide the required care such as administration of parenteral oxytocics, antibiotics, and anti-convulsant drugs, along with MRP and conduction of assisted vaginal deliveries.
To provide quality of care, two MOs must be available at PHC as per the guidelines. It emerged that usually, single MO remains available in most of the PHCs of the district. There is need of two MOs to provide 24-h EmOC services, and if second MO is posted, the person might be contractual and/or preparing for PG entrance and may show less motivation or involvement in PHCs services.
Training model has been developed to teach some of the manual skills to replace classroom training. Initially, duration of training was 15 days, and then it was increased to 21 days since April 2009. As per information received from the district training center, training duration is 10 days for BEmOC and 16 weeks for CEmOC.
WHO technical group reported that auxiliary midwives at rural health posts could save lives with injectable oxytocin or ergometrine. Oxytocics are a drug of choice to prevent and treat PPH, and parenteral antibiotics play an important role in puerperal sepsis.,
This study observed that only to train was not sufficient; although untrained MO was hardly providing any EmOC in studied facility, newly trained MO was also hesitant. Hence, it is also important to have regular and experienced staff at the facility. None of the facility-level providers mentioned that they had performed removal of retained products of conceptions as they lack the desired skills. Manual removal of the placenta and removal of retained products of conception are rarely required at PHC level. Therefore, skills of these procedures though learned during training could not be retained or recollected when required. There is need of re-sensitization or refresh training, CME to update and enhance the skills.
| Conclusion|| |
The assessment of studied facilities was conducted for infrastructure readiness and availability of trained staff to provide EmOC at specific time. Although building infrastructure is adequate, drugs and equipment are accessible, and transportation facilities are available, still it is observed that needy women may fail to receive the timely and quality EmOC services at periphery due to lack of trained staff, low confidence, and lack of motivation in managing obstetric emergencies.
We would like to thank Civil Surgeon, District Health Officer, of Wardha for giving permission to conduct the study in the selected block and share the valuable information, suggestions with us.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The Millennium Development Goals Report 2012. United Nations, New York; June, 2012. Available from: http://www.un.org/millenniumgoals
. [Last accessed on 2014 Sep 08].
Ministry of Statistics and Programme Implementation, Government of India. Millennium Development Goals: India Country Report; 2014. Available from: Htpp://www.in.undp.org/content/dam/india/docs/MDG%20-%20India%20Report%202014.pdf. [Last accessed on 2013 Mar 13].
World Health Organization, United Nations Population Fund, United Nations Children's Fund. Guidelines for Monitoring the Availability and Use of Obstetric Services. 2nd
ed. New York: United Nations Children's Fund; 1997. Available from: http://www.unicef.org
. [Last accessed on 2013 Mar 23].
Government of India, Ministry of Health and Family Welfare. Project Implementation Plans, RCH II Program: RCH II Document 1, Policy Framework. Government of India, Ministry of Health and Family Welfare; 2004. p. 1-58.
Ronsmans C, Graham WJ; Lancet Maternal Survival Series Steering Group. Maternal mortality: Who, when, where, and why. Lancet 2006;368:1189-200.
Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: The key to maternal mortality. Int J Gynaecol Obstet 1996;54:1-10.
Casey SE, Mitchell KT, Amisi IM, Haliza MM, Aveledi B, Kalenga P, et al
. Use of facility assessment data to improve reproductive health service delivery in the Democratic Republic of the Congo. Confl Health 2009;3:12.
Ministry of Health and Family Welfare, Government of India, Directorate General of Health Services. Indian Public Health Standards (IPHS), Guidelines for Community Health Centers/Rural Hospital. Ministry of Health and Family Welfare, Government of India, Directorate General of Health Services; 2012. Available from: http://tripuranrhm.gov.in/Guidlines/IPHS_Guidelines_Health_Centres.pdf
. [Last accessed on 2013 Apr 09].
World Health Organization. The Prevention and Management of Post-Partum Haemorrhage: Report of a Technical Working Group. Geneva: World Health Organization; 3-6 July, 1989. Available from: http://www.who.int/iris/handle/10665/61409
. [Last accessed on 2015 Apr 09].
Loudon Irvine. Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800-1950. Oxford, England: Oxford University Clarendon Press; October, 2011. Available from: https://searchworks.stanford.edu/view/2471343
[Last accessed on 2017 Jan 12].
World Health Organization/United Nations Population Fund/United Nations Children's Fund/World Bank. Integrated Management of Pregnancy and Childbirth (IMPAC): Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and doctors. World Health Organization; 2000. Available from: http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf
. [Last accessed on 2016 Apr 05].
Aglawe PB, Jha RK, Mishra V, Sakore KM, Chetan A, Shrivastava DS. Appraisal of Core Therapy, Supportive Therapy, and Alternative Therapy in a Tertiary Care Rural Hospital of Vidarbha Region in Correlation to Plethora of Menopausal Problems. J Midlife Health 2019;10:14-21. Available from: https://doi.org/10.4103/jmh.JMH-131-18
.[Last accessed on 2019 Nov 12].