EmOC –Indian context EmOC provision a policy priority JSY to promote institutional births, thus provide access to EmOC Three tiered health system with referral services Free referral transport in some states-Janani Express in MP

Figure 1. Model of referral chain, adapted from Jahn A and De Brouwer V Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e doi: /journal.pone

Objectives To study quality of referral services in JSY by examining 1. association between maternal referral and adverse birth outcomes 2. spatial access to Emergency obstetric care (EmOC) among mothers referred to and died at referral facility

Objective 1: Methods Nested matched case control design Three heterogenous districts of Madhya Pradesh Cross sectional facility based study at facilities reporting >10 deliveries/month (n=96), 5 days at each facility Interviews with mothers delivered at the facility (n= 1182)

Table 2. Study facilities by level and distribution of mothers who accessed intra-partum care at these levels. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e doi: /journal.pone

Figure 2. Mothers who reached study facilities for intra-partum care by referral status. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e doi: /journal.pone

Design Cases: mothers with adverse birth outcome at term delivery (n=34) Controls : mothers with live neonates at 48 hours postpartum (n=68) Controls matched individually to cases for type of complication and place of delivery Adverse birth outcome: Intra partum foetal death /early in facility neonatal death

Sample characteristics Cases (n==34)Controls (n=68) Age in years, median (range)22 (18-35)23 (18-40) Below poverty line *65%41% Illiterate32% Referred*50%25% Primiparous50%44% Caesarean section delivery15%28% ANC visits < 238%25% Delivery care by doctor21%30% * Significant at p<0.05

Association bet maternal referral & adverse birth outcome VariableOdds ratio (95% CI)P value Maternal referral2.61 (1.08; 6.6)0.04 Age1.83 (0.60, 5.51)0.28 Education1.2 ( )0.70 Below poverty line2.06 ( )0.13 Parity 0.63 ( )0.43 ANC visit1.19 (0.57, 2.48)0.63 Provider0.30 (0.07, 1.25)0.10 Maternal referral associated with significantly higher odds of adverse birth outcomes

Objective2 -Methods Application of Geographical Information System (GIS) tools Two hours travel time to CEmOC facility- UN standard for geographical access to EmOC Used two hours as desired time travel time to determine spatial access to EmOC services

Objective 2 -Methods 1.Identification of CEmOC facilities by survey using UN signal functions Digitization of district map with roads and maternity facilities

Shahdol District: Delivery facilities and major roads Delivery facilities- 63 CEmOC facility-1 (Dist Hospital)

Objective 2 -Methods ctd……. 2. Review of maternal death records at CEmOC facility (April2010-March 2012) : 124 deaths 3. Identification of deaths among mothers referred to CEmOC facility : 55 referred in mothers 4.Referring facility locations plotted on GIS map

Facilities that referred the 55 mothers who died

Objective 2 -Methods ctd… 5.Buffer analysis of referring facility locations in Arc Info 10  Average speed for a van in the study area is 50 Km/hr  Buffers with a radius of 50 Km and 100 Km constructed around CEmOC facility

100 km Buffer from CEmOC facility Almost all were referred from within 2 hours travel time

50 km Buffer from CEmOC facility Most were referred from within 1 hour travel time

Objective 2- Results Almost all mothers referred from within 2 hours distance Most (82%) referred from within one hour distance Median time between arrival and death hours (IQR hours)

Summary results High odds of adverse birth outcome associated with maternal referral Maternal deaths despite spatial access to EmOC

Conclusions Inefficiencies in referral services resulting in loss of life saving opportunities Failure to provide successful EmOC Possible deficiencies at sender, transfer and receiver levels of referral system Poor quality of referral services in JSY in MP

Acknowledgements EU FP 7 grant to project MATIND Government of Madhya Pradesh, India Thank You!