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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TRIAL REGISTRATION: Not applicable.

Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial.

INTRODUCTION: Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol with clinic misoprostol in a low-resource setting. MATERIAL AND METHODS: This was a secondary analysis of a randomized controlled trial conducted in six primary care clinics in India. Women seeking medical abortion within up to nine gestational weeks (n = 731) received mifepristone in the clinic and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days. RESULTS: Of 731 participants, 73% were from rural areas and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2 and 94.4%, respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion compared with clinic users (79.7%) who would opt for misoprostol at the clinic in a similar situation (p = 0.0002). Ninety-six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience. CONCLUSIONS: Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.

Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial.

BACKGROUND: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion. METHODS: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114). RESULTS: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use. CONCLUSIONS: Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods. TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995.

Improving access to safe abortion in a rural primary care setting in India: experience of a service delivery intervention.

BACKGROUND: Abortion services were legalized in India in 1972, however, the access to safe abortion services is restricted, especially in rural areas. In 2002, medical abortion using mifepristone- misoprostol was approved for termination of pregnancy, however, its use has been limited in primary care settings. METHODS: This paper describes a service delivery intervention for women attending with unwanted pregnancies over 14 years in four primary care clinics of Rajasthan, India. Prospective data was collected to document the profile of women, method of abortion provided, contraceptive use and follow-up rates after abortion. This analysis includes data collected during August 2001-March 2015. RESULTS: A total of 9076 women with unwanted pregnancies sought care from these clinics, and abortion services were provided to 70 % of these. Most abortion seekers were married, had one or more children. After 2003, the use of medical abortion increased over the years and ultimately accounted for 99 % of all abortions in 2014. About half the women returned for a follow-up visit, while the proportion using contraceptives declined from 74 % to 52 % from 2001 to 2014. CONCLUSIONS: The results of our intervention indicate that integrating medical abortion into primary care settings is feasible and has a potential to improve access to safe abortion services in rural areas. Our experience can be used to guide program managers and service providers about reducing barriers and making abortion services more accessible to women.

Huwa Rog, Parhej, and Desi Dawai: Women's Perceptions of Postpartum Maternal Morbidity and Care in Rajasthan, India.

Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of "medicinal dietary items" referred to as desi dawai, or "country medicine," and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples' beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.

Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India.

BACKGROUND: After the launch of Janani Suraksha Yojana, a conditional cash transfer scheme in India, the proportion of women giving birth in institutions has rapidly increased. However, there are important gaps in quality of childbirth services during institutional deliveries. The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan. This intervention titled "Parijaat" was designed by Action Research & Training for Health, in partnership with the state government and United Nations Population Fund. METHODS: The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan, India. These included district hospitals (9), community health centres (32) and primary health centres (3). The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment, feedback, training and action. The adherence to evidence based practices before, during and after this intervention were measured using structured checklists and scoring sheets. Main outcome measures included changes in practices during labour, delivery or immediate postpartum period. RESULTS: Use of several unnecessary or harmful practices reduced significantly. Most importantly, proportion of facilities using routine augmentation of labour reduced (p = 0), episiotomy for primigravidas (p = 0.0003), fundal pressure (p = 0.0003), and routine suction of newborns (0 = 0.0005). Among the beneficial practices, use of oxytocin after delivery increased (p = 0.0001) and the practice of listening foetal heart sounds during labour (p = 0.0001). Some practices did not show any improvements, such as dorsal position for delivery, use of partograph, and hand-washing. CONCLUSIONS: An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practices at health facilities.

Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India--study protocol and intervention adaptation of a randomised control trial.

BACKGROUND: The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. METHODS/DESIGN: This study protocol describes a study that is a randomised, controlled, non-superiority trial. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. The randomisation list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. Randomization of the study participants will occur after the first clinical encounter with the doctor. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study this study protocol describes is to evaluate the efficacy of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This resulted in an optimized, tailor-made intervention and in the development of the pictorial instruction sheet with a guide on how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion. DISCUSSION: In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor. TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995. Registered 04 May 2013.

Physical intimate partner violence in northern India.

In this article, we examine perceptions about the definition of physical intimate partner violence (IPV) in northern India utilizing feminist perspectives as a framework. We interviewed 56 women and 52 men affiliated with a health services nongovernmental organization in the Udaipur district of Rajasthan. We transcribed, coded, and analyzed the interviews utilizing grounded theory. We found that perceptions regarding physical IPV were associated with both structural and ideological patriarchal beliefs and microlevel constructs such as alcohol use. We discovered multiple types of physical IPV in the study region, including rationalized violence (socially condoned violence perpetrated by a husband against his wife), unjustified violence (socially prohibited violence perpetrated by a husband against his wife), and majboori violence (violence perpetrated by a wife against her husband). Our results add to the breadth of research available about IPV in India and create a framework for future research and IPV prevention initiatives.

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.

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.

Observational study of feasibility and acceptability of the levonorgestrel-releasing intrauterine device as a long-acting reversible contraceptive in a primary care setting in India.

Objectives: The levonorgestrel-releasing intrauterine device (LNG-IUD) is a well-accepted contraceptive across developed countries, yet there is limited experience in use and acceptance amongst women living in low-resource, developing country settings. We studied the feasibility of providing the LNG-IUD through a primary care service, and its acceptability amongst women living in a low-income, rural-tribal community in India. Study design: We conducted an observational study of feasibility and acceptability at four health facilities (three rural, and one urban) in Rajasthan, India. Women seeking contraception were offered the LNG-IUD in addition to existing contraceptive methods. We followed all those who adopted LNG-IUD from August 2015 to September 2019 (n= 1266) till discontinuation or 12 months, whichever was earlier. The primary outcome was continuation rate and acceptability, and the secondary outcome was change in hemoglobin levels, which we measured before insertion and at 12-month follow-up, using Sahli's method. Results: Most users lived in villages, were illiterate, belonged to marginalized groups, had 2 or more children, and wished to limit births when they adopted the method. The 12-month continuation rate was 87.6%. Amongst all users, 7.4% of women sought removal for side effects and 2% for change in reproductive intention, while another 2% reported spontaneous expulsion. Most continuing users reported hypomenorrhea (54%) or amenorrhea (42%) by 12 months of use. User satisfaction was high at 91.6%, with 92% of women rating their experience as equaling or exceeding expectations. Moderate and severe anemia reduced, and mean hemoglobin levels increased by 0.7 g/dL (p < 0.01). Conclusion: Primary care clinics can feasibly deliver LNG-IUD, with high acceptability amongst women living in low resource settings. Given the paucity of long-acting reversible contraceptive options and high prevalence of anemia among women in India and similar countries, the method should be piloted through the public health system. Implications: Long duration of contraceptive action, ability to reduce menstrual bleeding and reduce anemia, reversibility, and easy removal, combine to make LNG-IUD acceptable to women, especially in regions with high prevalence of anemia. This study demonstrates the feasibility and acceptability of introducing LNG-IUD in a low resource, primary care setting.

Relative risk of postpartum maternal morbidity among cesarean-delivered women: A multisite prospective cohort study in a large district, India.

Introduction: Family doctors manage mild to moderate postpartum morbidities that do not receive attention. The morbidities are higher after cesareans, which are increasing in number. The aim was to calculate the relative risk of various maternal morbidities occurring during 6 months postpartum among cesarean-delivered women in Pune District, India. Material and Methods: This was a large multisite study, which included all 11 non-teaching government hospitals performing at least five cesarean sections per month, one teaching government hospital, and one private teaching hospital. All eligible cesarean delivered and an equal number of age and parity matched vaginally delivered women were the participants. The obstetricians interrogated women before discharge, after 4 weeks, 6 weeks, and 6 months. Results: In this study 3,112 women participated. At any visit and among any group lost to follow-up proportion was <10%. There was no major intra-operative complication among vaginally delivered women. The relative risks of acute and severe morbidity as intensive care unit admission and blood transfusion among cesarean-delivered women were 2.59 [95% confidence interval (CI) = 1.96 to 3.44], 4.33 (95% CI = 2.17 to 8.92), respectively. The adjusted relative risk of surgical site pain and infection at 4 weeks; surgical site pain at 6 weeks; and lower abdominal pain, breast engorgement/mastitis, urinary incontinence, and weakness at 6 months among cesarean-delivered women was higher (P < 0.05). Vaginally delivered women resumed family activities earlier. Conclusion: Health care workers, including family doctors, during follow-up of cesarean-delivered women, must assess for pain, induration/discharge at the surgical site, urinary incontinence, and breast engorgement/mastitis.

Baseline Assessment of Evidence-Based Intrapartum Care Practices in Medical Schools in 3 States in India: A Mixed-Methods Study.

INTRODUCTION: Implementation research with pre- and post-comparison was planned to improve the quality of evidence-based intrapartum care services in Indian medical schools. We present the baseline study results to assess the status of adherence to intrapartum evidence-based practices (IP-EBP) in study schools in 3 states in India and the perception of the faculty. METHODS: A concurrent mixed-methods approach was used to conduct the baseline assessment in 9 medical schools in Rajasthan, Gujarat, and Union Territory from October 2018 to June 2019. IP-EBP among pregnant women in uncomplicated first (n=135), second (n=120), and third stage (n=120) of labor were observed using a predesigned, pretested checklist quantitatively. We conducted in-depth interviews with 33 obstetrics and gynecology faculty to understand their perceptions of intrapartum practices. Quantitative data were analyzed using SPSS (version 22). COM-B (Capability, Opportunity, and Motivation Behavior) model was used to understand the behaviors, and thematic analysis was done for the qualitative data. FINDINGS: Unindicated augmentation of labor was done in 64.4%, fundal pressure applied in 50.8%, episiotomy done in 58.3%, and delivery in lithotomy position was performed in 86.7% of women in labor. CONCLUSIONS: Intrapartum practices that are not recommended were routinely practiced in the study medical schools due to a lack of staff awareness of evidence-based practices and incorrect beliefs about their impact.

Violence Perpetrated by Mothers-in-Law in Northern India: Perceived Frequency, Acceptability, and Options for Survivors.

In India, physical and psychological abuse perpetrated by a mother-in-law against a daughter-in-law is well documented. However, there is a dearth of literature exploring the perceived frequency and acceptability of mother-in-law abuse or options available for survivors of this type of abuse. The goal of this qualitative study was to add to the in-law abuse literature by exploring men's and women's perspectives about physical and psychological abuse perpetrated by mothers-in-law against daughters-in-law in northern India. Forty-four women and 34 men residing in rural and urban areas of the Udaipur district in the northwest state of Rajasthan participated in semistructured interviews. Women, but not men, thought mother-in-law abuse was common in their communities. Psychological abuse was accepted in certain situations; however, few male or female participants agreed with physical mother-in-law abuse. Men were described as mediators in the context of mother-in-law abuse, and male participants thought that disrespecting a mother-in-law was a justifiable reason for a man to hit his wife. Both male and female participants described few options available for a woman experiencing mother-in-law abuse, apart from asking her husband to intervene or living as a separate, nuclear family. Grassroots initiatives and legislative policy should focus on addressing the immediate needs of women experiencing mother-in-law abuse and developing intergenerational interventions to educate men and women about the dynamics of law abuse.

Emergency obstetric care and referral: experience of two midwife-led health centres in rural Rajasthan, India.

This paper documents the experience of two health centres in a primary health service located in interior rural areas of southern Rajasthan, northern India, where trained nurse-midwives are providing skilled maternal and newborn care round the clock daily. The nurse-midwives independently detect and manage complications and decide when to refer women to the nearest hospital for emergency care, in telephonic consultation with a doctor if required. From 2000-2008, 2,771 women in labour and 202 women with maternal emergencies who were not in labour were attended by nurse-midwives. Of women in labour, 21% had a life-threatening complication or its antecedent condition and 16% were advised referral, of which two-thirds complied. Compliance with referral was higher for maternal conditions than fetal conditions. Among the 202 women who came with complications antenatally, post-abortion or post-partum, referral was advised for 70%, of whom 72% complied. The referral system included counselling, arranging transport, accompanying women, facilitating admission and supporting inpatient care, and led to higher referral compliance rates. There was only one maternal death in nine years. We conclude that trained nurse-midwives can significantly improve access to skilled maternal and neonatal care in rural areas, and manage maternal complications with and without the need for referral. Protocols must acknowledge that some families might not comply with referral advice, and also that initial care by nurse-midwives can reverse progression of certain complications and thereby avert the need for referral.

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.

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.

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, 1947 (96%) of 2031 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, modem 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 1336 (US$ 30), Rs 2419 (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.

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.