1. Investigators - Dr S Z Quazi
EMERGENCY OBSTETRIC CARE IN TWO COMMUNITY HEALTH CENTRES IN WARDHA DISTRICT, MAHARASHTRA A RAPID ASSESSMENT STUDY
Conducted by
Datta Meghe Institute of Medical Sciences
Sawangi (M) Wardha Maharashtra
Investigators Dr S Z Quazi
Dr Abhay Gaidhane

2. Background 5th MDG - reduction of the MMR by three quarters by 2015
MMR remained relatively unchanged since 1990
One woman dies every 5 min from a pregnancy related cause
India’s MMR 450 / live birth* (Regional differences)
Maharashtra MMR 145 / live birth**
The Challenge
15 % of all pregnancies will result in complications, which are extremely difficult to predict
most of these lives could be saved if affordable, good-quality emergency OB care available 24X7
* The State of World Children 2009, UNICEF
** State PIP & District PIP

3. Context
NRHM promises to provide EmOC through CHC conforming to minimum standard set by IPHS under NRHM
ensuring accessibility and quality of EmOC services
MMR of Wardha - 400/ live birth*
need for deeper enquiry into the accessibility & quality of EmOC
Therefore a rapid assessment was conducted to assess the EmOC services at CHCs in Wardha District
*source – Wardha District PIP 07-08

4. Specific Objectives
To assess the readiness of CHCs in Wardha (Maharashtra) in providing EmOC services with reference to the IPHS developed under the NRHM
To study the current referral and utilization pattern of EmOC
To identify ‘barriers’ and ‘facilitators’ for providing EmOC at CHCs from both, user as well as provider perspectives

5. Study Setting Health Infrastructure
Located in Central India, Maharashtra state, Blocks - 8
Population million
Rural %
Urban
Sex Ratio / 1000
Birth rate – 16.7 / 1000
IMR /1000 live birth
Health Infrastructure
Medical College Hospitals – 2
Civil Hospital – 1
CHCs – 8
PHCs - 27

6. Methods
Study design - A cross-sectional, qualitative study with facility assessment
Sampling – 2 (Arvi & Hinganghat) of 8 CHCs randomly chosen
Ethical Issues – IRB approval obtained
Tools of data collection –
in-depth Interviews
focus group discussions
observation using a standard checklist

7. Data Collection & stakeholders
Issues / objectives
Interviews
(Women – 16
CS – 1
MO CHC – 2
Local leader – 2
Private Provider - 2
Total – 23)
Observation (Both CHCs
Total -2 )
FGDs
(One at each CHC Total 2)
Record review
(Districts &
2 CHCs)
EmOC facilities at CHC as per the IPHS
Civil Surgeon
CHC MO
CHC
Review of district MIS and CHC data
Facilitators / barriers for providing EmOC
Private provider
Facilitators & barriers for accessing EmOC
Women (selected from CHC record)
Local leader
Women
Pattern of EmOC utilization
Women (selected randomly from CHC record)
Health provider
Review of MIS & CHC records

8. Definitions Basic EmOC Parenteral administration of antibiotics,
Parenteral administration of anticonvulsants,
Parenteral administration of oxytocics,
Assisted Vaginal delivery
Manual removal of placenta & retained products of conception
Comprehensive EmOC
Basic EmOC plus
Facility for caesarean deliveries and
Blood transfusion facilities

9. Scoring for facility assessment
Services Available
Max Score %
Manpower 15
28.85
Infrastructure 10
19.23
Drugs 8
15.38
Equipment 6
11.54
Emergency services (OB) 5
9.62
Training 4
7.69
Transport / Ambulance
All services (total score) 52
100
Ground realities considered for designing score

10. Percentage Scores for facility assessment - Hinganghat CHC
Poor
Needs improvement
Satisfactory
Good

11. Percentage Scores for facility assessment – Arvi CHC
Poor
Needs improvement
Satisfactory
Good

12. Findings Both CHC Functional 24X7
Adequate physical infrastructure for comprehensive EmOC
Average distance for women to CHC is 20 Km and money spent for travel – 20 to 200 Rs
Blood bank - functional at one CHC, supplies frequently out of stock
EmOC Drugs – frequently in short` supply.
Patients have to purchase from nearby 24X7 private pharmacy
usually all drugs are available)
Referral – ambulance in working condition at one CHC.

13. Findings Unavailability of full time specialist at both CHC
Two contractual specialists at Hinganghat CHC
Obstetrician from Hinganghat town
Anesthesiologist called from Wardha town (60 km / 2 hrs)
Other barriers
unawareness and lack of involvement of private provider
lack of EmOC training of available staff at one CHC
poor economic status of people

14. Referral / utilization pattern
From experiences of 10 women received EmOC in recent 6 months
Hinganghat CHC
Arvi CHC
Referral in to CHC
Self 2
PHC 1 GP
Services received at CHC
Delivered at CHC
1 (next day morning - assisted) Immediately referred to tertiary care hospital (low birth weight baby)
1 (normal)
Next day referred to tertiary care hospital for blood transfusion
LSCS
1 (anesthesiologist called from Wardha)
Reasons for out referral
Immediate referrals
Obstructed labour (1)
Hemorrhage (2)
Blood transfusion (2)
Hemorrhage (1)
Multiple pregnancy (1)

15. Referral / utilization pattern
Users prefer CHC - less time & cost for transportation
“... I went there (CHC) as it was nearest facility from my home” (mother – 8)
CHCs refer most EmOC cases to tertiary centers –
Specialist unavailable at CHC during emergency
“... we had to refer ...no other option.. as there are no specialist and blood is also not available most of time” (Medical Officer Arvi)
Caesarean delivery costs
CHC (elective CS) - Rs 1,500 to 12,000
Tertiary Centers - Rs 2,000 to 5,000
“.... we have to call the anaesthesiologist from Wardha (60 Km / 2 hrs distance) and he charged Rs 2500 ” (mother - 3)

16. Conclusions
Readiness for EmOC: Availability of physical infrastructure however no full time specialists
Hinganghat CHC - Mostly assisted deliveries & elective caesarean
Arvi CHC - only normal deliveries
Services at CHC expensive than at tertiary centers
Women seek EmOC care at CHC, but most referred to tertiary centers after supportive treatment
EmOC service delivery and utilization pattern highly skewed towards tertiary centers
Complicated deliveries are not receiving EmOC at CHCs in its true sense

17. Limitation of this study
Direct care seekers at tertiary centers possibly missed
Patients seeking services from the private provider were not studied, therefore we could not comment the pattern of EmOC services utilization from private providers
Findings may not be generalizable to other states or regions, however across Maharashtra State the infrastructure and health manpower problem is relatively similar.

18. Recommendations
Physical Health Infrastructure remains underutilized in absence of specialists
Therefore, need to address the health workforce crisis comprehensively to provide EmOC services at CHC level
Appointment of contractual specialists for EmOC
Preferably from the same town
Skill building of staff for EmOC
Better involvement of private providers in EmOC services (PPP)
Involvement of Medical College unto the level of CHC
Round the clock posting of specialist (24 X 7)

19. Thank you