Quality of obstetric referral services in India's JSY cash transfer programme for institutional births: a study from Madhya Pradesh province

Abstract

Background: India launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30%in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter- facility referrals and study quality of referral services in JSY.

Methods and results: Women accessing intra natal care (n = 1182) at facilities (reporting >10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR- 2.6, 95% CI: 1.0-6.6 p = 0.04). Maternal death record review (April 10-March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from <2 hours. Median time between arrival and death was 6.75 hours.

Conclusions: High odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.

Figure 1. Model of referral chain, adapted from Jahn A and De Brouwer V 2001.

Figure 2. Mothers who reached study facilities for intra-partum care by referral status.

Figure 3. Referrals by facility levels among referred in mothers.

(Arrows point to receiving facilities, encircled numbers on arrows indicate numbers of mothers who went to the receiving facility.)

Figure 4. Referrals by facility levels among referred out mothers.

Figure 5. Buffer analysis of distance between CEmOC facility and facilities that referred the 55 mothers who died at CEmOC facility.

(Circles in the figure are buffers with radius of 50 Km and 100 Km around the CEmOC facility.)