Background
Methods
Conceptual Framework
Maternal health policy objectives
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Register all maternal deaths: whether MAPEDIR contributed to the un-hiding and investigation of maternal deaths;
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Evidence based planning: whether the information on causes and circumstances of maternal deaths generated by MAPEDIR led to the development of new interventions or strategies within the state plans;
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Decentralized Planning: whether the exercise led to the development and planning of district-specific interventions; and
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Community Participation: whether local communities participated in the development of new maternal health interventions based on the MAPEDIR-generated evidence.
Contextual factors
Community factors
Public health systems factors
Governance factors
Analytic Approach
Ethical Review
Results
Contextual factors
Community factors
State | ||||
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Contextual factor | Indicators | Rajasthan | Madhya Pradesh | West Bengal |
Community
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Economic status | % population BPL (rural/urban) [26] | 14.3/28.1 | 29.8/39.3 | 24.2/11.2 |
Community cohesiveness | % skilled birth attendance, by caste (SC/ST/other backward class/other) | 27.0/23.9/37.3/42.8 | 25.7/13.9/32.6/49.5 | 46.2/24.5/64.5/44.5 |
Status of women | % female age 15-49 literacy | 39.0 | 50.0 | 64.0 |
Civil society networks and influence | WSHGs: engagement in health activities; breadth of coverage* | Limited health activities (mostly involved in livelihood generation and micro-financing) | Assist with birth preparedness and arrange transport for normal or complicated labour; some districts | Promote MH and provide loans for medical emergencies; 300, 000+ WSHGs throughout WB |
Public health systems
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Responsiveness and accountability | 1. % CHCs with obstetrician posted | 1. 32.2 (105/326) | 1. 5.7 (13/229) | 1. 43.2 (41/95) |
2. % women contacted in last 3 months by community health or nutrition worker | 2. 11.7 | 2. 16.9 | 2. 23.3 | |
Capacity | % blocks with a PH nurse* | 0.0 (0/237 blocks) | 0.0 (0/313 blocks) | > 80% (> 348/436 blocks) |
Governance
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Decentralization | Decentralization index score [31] | 0.35 | 0.59 | 0.75 |
Responsiveness and accountability | % health expenditure from public resources/out-of-pocket | 30.0/70.0 | 16.6/83.4 | 21.6/78.4 |
Public health systems factors
Governance factors
MAPEDIR implementation (including key findings) and up-scaling
Implementation
Key findings
District, State | |||
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Maternal health indicator | Dholpur, Rajasthan N = 35 n (%) or median (range) | Guna/Shivpuri, Madhya Pradesh N = 92 n (%) or median (range) | Purulia, West Bengal N = 102 n (%) or median (range) |
Type of death (Ab, AN, LD [> 24 hours post delivery]) | 2, 6, 27 [14] (5.7, 17.1, 77.1, [40.0]) | 2, 1, 89 [28] (2.2, 1.0, 96.7 [30.4]) | 13 [7], 21, 68 [31] (12.7, 20.6, 66.7 [30.4]) |
Cause of death (H, S, E, Ob, A, O, U)* | 10, 7, 6, 2, 5, 4, 1 (28.6, 20.0, 17.1, 5.7, 14.3, 11.4, 2.9) | 27, 8, 25, 7, 9, 11, 5 (29.3, 8.7, 27.2, 7.6, 9.8, 12.0, 5.4) | 23, 4, 19, 1, 9, 13, 33 (22.5, 3.9, 18.6, 1.0, 8.8, 12.7, 32.4) |
Infant outcome in LD deaths: IUFD, stillbirth, born alive and died, alive | 1, 12, 4, 10 (3.7, 44.4, 14.8, 37.0) | 3, 17, 49, 20 (3.4, 19.1, 55.1, 22.5) | 9, 11, 15, 33 (13.2, 16.2, 22.1, 48.5) |
Age in years | 26 (16-40) | 25 (15-49) | 24 (15-35) |
Caste (SC/ST) | 17 (48.6) | 51 (55.4) | 61/100 (61.0) |
Kutcha house | 15 (42.9) | 66/92 (71.7) | 83 (81.4) |
Below Poverty Line card holder | 11 (31.4) | 58/91 (63.7) | 39/95 (41.1) |
Years of schooling | 0 (1-10) | 0 (0-12) | 0 (0-10) |
Age in years at marriage | 16 (7-20) | 17 (12-24) | 17 (11-24) |
Skilled birth attendance (LD deaths) | 14/27 (51.9) | 58/89 (65.2) | 27/60 (45.0) |
Sought formal care for the fatal illness: never, not first, first | 15, 7, 13 (42.9, 20.0, 37.1) | 28, 9, 52 (31.5, 10.1, 58.4) | 17, 38, 47 (16.6, 37.3, 46.1) |
Delay 1--time (hours) to decide to seek care | 2 (0-32) | 1 (0-15) (N = 44) | 4 (0-216) |
Delay 2a--time (hours) to arrange to seek care | 2 (1-5) (N = 11) | 0.5 (0.1-24) (N = 78) | 1.0 (0-12.0) |
Delay 2b--transport time (hours) | 0.5 (0.5-2.0) (N = 8) | 1 (0.2-3.0) (N = 82) | 0.5 (0-4.2) |
Reasons for not seeking formal care or not seeking formal care first: (perception, cost/transport, other) (multiple responses allowed) | 4, 5, 9 (22.2, 27.8, 50.0) (18 reasons/18 women) | 21, 19, 16 (37.5, 33.9, 28.6) (56 reasons/37 women) | 24, 22, 6 (46.2, 42.3, 11.5) (52 reasons/34 women) |
1st action decision maker: (W, H, O)†
(% of all decision makers) | 1, 9, 23 (3.0, 27.3, 69.7) | 7, 41, 44 (7.6, 44.6, 47.8) | 11, 68, 117‡
(5.6, 34.7, 59.7) |
Referred from F1 to F2 | 11/17 (64.7) | 42/61 (68.9) | 48/67 (71.6) |
Reasons for referral from F1 to F2 (complication, medicine, blood, procedure, specialist, equipment) (multiple responses allowed) | 4, 1, 3, 0, 0, 3 (36.4, 9.0, 27.3, 0, 0, 27.3) | 18, 14, 17, --, 23, 14 (20.9, 16.3, 19.8, --, 26.7, 16.3) | 31, 6, 9, 23, 15, 8 (33.7, 6.5, 9.8, 25.0, 16.3, 8.7) |
Out-of-pocket transport and treatment expenditure (rupees) at F1 and F2 | 1280 (150-13000) 2950 (350-11000) | 300 (0-1500) 500 (0-3000) | 800 (0-7100) 1860 (0-26500) |
Up-scaling
MAPEDIR utilization and achievement of maternal health policy objectives
State (District) Outcomes | ||||
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National RCH policy
| District maternal health policy objectives and indicators | Rajasthan (Dholpur) N (%) | Madhya Pradesh (Guna and Shivpuri) N (%) | West Bengal (Purulia) N (%) |
Register all maternal deaths |
"Unhide" maternal deaths:
% of expected maternal deaths* reported by district before//after MAPEDIR implementation | Apr, 04-Mar, 05: 4% (5/116 deaths in 4 blocks)//Apr, 05-Mar, 06: 60% (35/58 deaths in 2 blocks) | Feb-Dec, 05: 47% (113/239)//Feb-Dec, 06: 57% (136/239) | July, 04-June, 05: 119% (114/96)//July, 05-June, 06: 127% (122/96) |
Investigate all (or a sample of) reported maternal deaths |
Gather new evidence:
% of reported maternal deaths investigated by district before//after MAPEDIR implementation | Apr, 04-Mar, 05: 0% (0/5)//Apr, 05-Mar, 06: 100% (35/35) | Feb-Dec, 05: 0% (0/113)//Feb-Dec, 06: 100% (136/136) | July, 04-June, 05: 0% (0/114)//July, 05-June, 06: 86% (105/122) |
Implement RCH programme planning and management: • Evidence-based |
The state uses the new evidence:
New maternal health interventions developed by/with the state health system based on MAPEDIR data | Statewide obstetric help line (implementation delayed); 141 FRU blood storage units equipped | None | Made all public maternity beds non-paying; expanded JSY to all SC/ST and BPL women; implemented new rural referral transport system |
• Decentralized |
Decentralized MH planning:
New maternal health interventions initiated at district level based on MAPEDIR data | District health society planned and mobilized obstetric helpline and referral transport system by partnering with civil society | Guna: mapped maternal deaths to prioritize & upgrade remote SHCs for 24 × 7 safe delivery services; Guna and Shivpuri: ensured 24 × 7 referral transport to all PHCs via call center and secured vehicles | None |
• Bottom-up |
Community participation:
New maternal health interventions developed by or with communities based on MAPEDIR data | Taxi union & NGO collaborated with district in implementing and running the obstetric help line and referral transport system | Guna: block PRI ensured referral transport for remote villages to upgraded SHC; Guna: communities donated 6 of 22 referral vehicles | GP-initiated 8 van rickshaws in 4 remote GPs of 4 Purulia blocks |