Background
Despite the Registrar General reporting recently that the maternal mortality rate in India declined to 301 per 100,00 live births, India still accounts for the largest contribution to maternal deaths worldwide, related directly to or exacerbated by pregnancy. [
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3] Reducing the maternal mortality rate is a key goal of government, and this is enshrined in the National Population Policy, which aims to "provide.... universal access to, and make available good quality maternal and child health care services".[
4] One strategy advocated by the National Population Policy to reduce maternal mortality is to increase access to institutional deliveries in India.
The choice of delivery locations in India can be broadly be classified into three mutually exclusive categories. A woman can deliver her baby at home, with or without the presence of a birth attendant, who may be trained or untrained. Home delivery is usually the cheapest option, but is associated with attendant risks of infection and lack of available equipment should complications occur. Institutional deliveries can occur at private or public facilities. Public facilities are usually owned and financed by the government, and while costs are usually minimal, available amenities often leave much to be desired. Although private facilities are the most expensive, they are often perceived as having the best amenities and offering the best standard of care in India.
Most research has focused on understanding the determinants of home vs. institutional deliveries. [
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8] With rapid economic growth, there has been a concomitant expansion of the private sector in health care delivery in India. It is thus important to tease out the two types of institutions – public and private – as research has shown that each sector may provide different sets of services. For example, public hospitals provide a majority of hospitalizations, while the private sector provides most of the out-patient care.[
9] Till date, there is no research that delineates the differences (if any) among these sectors in the provision of delivery care.
The purpose of the present study is to understand the determinants of delivery location (home, public or private facility) in one state of India (Maharashtra), using data from the Second National Family Health Survey (NFHS-2).
Discussion
The National Population Policy provides "a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the population of India".[
4] The strategy involves focusing on the issues of child survival, maternal health, and contraception by increasing outreach, and addressing the unmet needs for care, infrastructure, and health personnel. Of the set of 14 socio – demographic goals for 2010, the chief reproductive and child health (RCH) related targets are reduction of the Infant Mortality Rate to below 30 per 1000 live births, and reduction of Maternal Mortality Ratio to below 100 per 100,000 live births. One strategy outlined in the NPP to reduce maternal mortality is to promote institutional delivery by strengthening the public system from the peripheral sub-center level to the referral unit level. Another strategy is to increase the numbers and diversify the categories of health care providers, promoting the involvement of, and developing partnerships with, the private health care industry and voluntary non-government sector.[
4]
India spends approximately 5% of its GDP on health care.[
21] Despite the rapid growth of its economy in the recent years, public funding for the health care sector has not kept pace. According to a recent report of the National Commission on Macroeconomics and Health, households accounted for nearly 75% of all health care expenditures, with the government accounting for only 22%.[
22] Even in the state of Maharashtra, considered to be one of the more socially and economically progressive states in India, the state health budget has not increased commensurate with the increase in population and demand. Maharashtra's annual rate of growth of total expenditures on health grew from 3.8% in 1993 – 98 to 6.5% in 1999 – 2003, yet the per capita health expenditure averaged only Rupees 1576 in 2001 – 02 (1 Rupee = approx. 0.022 USD), and only 24% of pregnant women had received adequate antenatal care (defined as 3 antenatal care visits).[
21]
There is increasing concern regarding the unmet need for care, especially among the destitute and the rural population. Consequently, the dependence on private sector for health care is increasing, more by default rather than by design. This is reflected in the fact that households in Maharashtra account for 73.3% of all health care spending, and the government accounted for 22.1% – percentages that mimic the all-India averages.[
22] The dependence on household expenditures is equally significant in the reproductive and child health care segment, which is one of the high priority sectors of health care services in India.
The 63% institutional delivery rate in Maharashtra is much higher than the all India average for institutional deliveries, which is around a third.[
8,
10] Of the institutional deliveries in Maharashtra, almost equal numbers took place in public and private facilities, same as the national percentages. The discrepancy in the number of institutional deliveries can partly be explained by the fact that Maharashtra is one of the more economically developed states in India, and has relatively higher levels education, industrialization, and private sector growth. Moreover, the private sector share of the health care market in Maharashtra has been high. Its publicly funded rural health care delivery infrastructure is much better than that of many other states.
Our analyses show that among the predisposing factors, birth order, maternal education and religion affect the choice between home and public/private deliveries. It is plausible that after the uneventful birth of the first child at home, subsequent deliveries are perceived to be of low risk, thus increasing the likelihood of delivering subsequent babies at home. Increasing maternal age may, on the other hand, may increase the perception of risk, thus increasing the likelihood of institutional (public or private) delivery. Further research is need to understand why Muslims are less likely than Hindus' to deliver at home in Maharashtra.
Maternal and paternal education, and scheduled caste status are the predisposing factors that determine the choice between private facilities and public/home deliveries. The direction of the education effect is in the expected direction – increasing education leading to increased probability of using private facilities. Education leads to better health awareness, and this may sensitize the family to the quality of health care provided at various facilities.[
5,
23] It is a common perception in many parts of the country that private facilities provide better care than public facilities.[
6,
8] Unfortunately, the lack of quality indicators in the present data set precludes further analyses of this issue. Women from scheduled caste/scheduled tribes were less likely to use private sector facilities, which may be am indication of the continued exclusion of these groups from the mainstream. Despite vigorous efforts to integrate these dispossessed into society, much work needs to be done especially in the rural parts of the country.
Among the enabling factors, media exposure, number of antenatal visits and location affected the choice between home and private/public facilities, while a higher standard of living affected the choice between private and home/public facilities. The rich have the wherewithal to pay for the price of private care, and given the perception of better quality at private facilities, it is no surprise that they utilize them.
We did not find need to be a significant determinant of public versus private sector use. The Andersen Model posits that need is the most proximate determinant of health services utilization. Need can be conceptualized as perceived (by the individual woman) or evaluated (by an expert, such as a physician); our construction of need is more evaluative than perceived. It is possible that perceived need may be the appropriate variable to use, however, the NFHS-2 lacks sufficient data to construct such a variable.
Policy recommendations from our analyses are threefold. First, given the preponderance of home deliveries in the state, especially in the rural areas, every attempt should be made to ensure that these are attended to by a trained birth attendant. Efforts should also be made to ensure that every pregnant women receives at least 3 antenatal visits, with each visit being used as an educational opportunity. This requires strengthening the public health and outreach components of the publicly funded health care system.
Second, private sector health care delivery system is a fact of life in Maharashtra. As the India's economy continues to grow, its effects will filter down to all levels of society, thus raising the household income. As this occurs, the likelihood of increased utilization of the private sector will increase, leading to a further expansion of this sector. If we take the importance of education and standard of living as determinants of private sector use, we need to set up mechanisms that will prevent impoverishment of families as they seek care from this sector. Given the percentage of household expenditures devoted to health care, it is important that insurance schemes be set up to financially protect the consumers. This is already happening in the country, and needs to be strengthened more.
Third, quality of care in the public sector should be improved, so that it becomes an attractive place to obtain care. This is especially important for households of low and middle income, who maybe using the private sector due to a perceived lack of quality, and may reach financial distress quicker than households with higher standards to living. In other words, the public sector needs to return to its mission of being the safety net for the vulnerable. The government has recognized the limitations of its Family Welfare program in providing services, and has implemented a new Reproductive and Child health program to deliver and even wider range of services.[
24] The National Rural Health Mission and the 'Janani Suraksha Yojana' which aims to strengthen the community health centers are steps in the right direction, especially as they aim to devolve decision making to the panchayat level, which is closest to the users. [
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A few caveats should be kept in mind regarding our study. It is limited to Maharashtra, and may not be generalizable to other states in the country, especially poorer states such as Bihar, where the context and environment may be quite different. Our analytic model does not take into account factors such as distance and travel time, which may affect the decision to use a particular facility. We do not explicitly control for the perceived quality of care in our model. Lastly, we categorize all private and all public providers into one category each, when in fact each group encompasses a heterogeneous range of providers, each of which may have distinct clientele.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
AT was responsible for conceptualizing the research question, data acquisition and analyses, and drafting the manuscript. AM assisted in data analysis and manuscript drafting. KB assisted in data analyses and provided contextual and policy input. FH contributed to study design and help in manuscript drafting. All authors read and approved the final document.