Provision of Emergency Obstetric Services in Rural Gujarat, India: Challenges and Solutions

Abstract

Background: The importance of emergency obstetric services in saving mothers’ lives and the inadequacy of these services in less developed regions of the world has been documented by many agencies. The development of private health services in recent decades in many of these regions has opened up the possibility of public-private-partnerships as an approach to make emergency obstetric services available to vulnerable women. The Chiranjeevi Yojana is a Public Private Partnership between the state of Gujarat and private obstetricians in the state. It was started in 2006-7 because of lack of adequate numbers of public facilities which could provide emergency obstetric care in the state. This program addresses the inequity in access to obstetric care among vulnerable households in the state due to financial barrier. The state government directly pays a capitation fee to accredited private obstetricians so that mothers from vulnerable households can access free institutional delivery and emergency obstetric care from them. This study examines the distribution of obstetric care in three districts of Gujarat as well as characteristics of private providers who participate in the Chiranjeevi program. Methodology: We conducted a facility survey of three districts; Sabarkantha, Dahod and Surendranagar. All public facilities and all private facilities which had conducted a delivery in last one year were visited and a modified version of the Averting Maternal Death and Disability (AMDD) questionnaire was administered. Results: In the three districts 151 private and 149 public facilities had conducted any delivery in the previous year. Of these, 111 private and 47 public conducted more than 30 deliveries in last three months (high load). Forty-five percent of high load public facilities and only 5% of private high load facilities were situated at rural/peripheral locations. Of all high load private facilities, 30% were located in the three district headquarter towns while the remaining 65% were clustered in 14 of 27 district and sub-district headquarter towns. Nine blocks had neither private nor public caesarean section facility. Of these high load facilities, 13% (6/47) public and 81% (90/111) private had performed the crucial functions of caesarean sections (CS) with or without blood transfusion in the past three months. Further analysis showed that 36 of the 90 facilities participated in the CY program. Facilities which participated in the Chiranjeevi program tended to have obstetricians with less than 5 years’ experience and conducted more than 75 normal deliveries in a month. Discussion: Half of the high load public facilities were located in rural areas. They provided normal delivery services and referral services to the rural populations of these three districts which have as yet not been reached by private obstetricians. But they did not provide life-saving caesarean and blood transfusion facilities. Strengthening of public sector needs to be targeted at these performing public facilities rather than general plans for expansion of the health infrastructure. The crowding of private services in district and block towns may be used to advantage by the state to recruit young partners who are new in practice. Authorities need to design more nuanced partnerships with select providers, based on locations of providers. This will provide more effective EmOC coverage for a given expenditure. Conclusions: The total absence of life-saving services in remote blocks and their clustering in 18 towns indicates a need for a central policy to encourage more even distribution of life saving services through the public and private sectors.