Readiness of public health facilities to provide quality maternal and newborn care across the state of Bihar, India: a cross-sectional study of district hospitals and primary health centres

Abstract

Introduction: Poor access to quality healthcare is one of the most important reasons of high maternal and neonatal mortality in India, particularly in poorer states like Bihar. India has implemented initiatives to promote institutional maternal deliveries. It is important to ensure that health facilities are adequately equipped and staffed to provide quality care for mothers and newborns.

Methods: We conducted a cross-sectional study of 190 primary health centres (PHCs) and 36 district hospitals (DHs) across all districts in Bihar to assess the readiness of facilities to provide quality maternal and neonatal care. Infrastructure, equipment and supplies and staffing were assessed using the WHO service availability and readiness assessment and Indian public health standard guidelines. Additionally, we used household survey data to assess the quality of care reported by mothers delivering at study facilities.

Results: PHCs and DHs were found to have 61% and 67% of the mandated structural components to provide maternal and neonatal care, on average, respectively. DHs were, on average, slightly better equipped in terms of infrastructure, equipment and supplies by comparison to PHCs. DHs were found to be inadequately prepared to provide neonatal care. Lack of recommended handwashing stations and bins at both DHs and PHCs suggested low levels of hygiene. Only half of the essential drugs were available in both DHs and PHCs. While no association was revealed between structural capacity and patient-reported quality of care, adequacy of staffing was positively associated with the quality of care in DHs.

Conclusion: Examining all DHs and a representative sample of PHCs in Bihar, this study revealed the gaps in structural components that need to be filled to provide quality care to mothers and newborns. Access to quality care is essential if progress in reducing maternal and neonatal mortality is to be achieved in this high-burden state.

Keywords: health economics; health policy; quality in health care.

Figure 1

Reasons for unavailability of services in (A) primary health centres (PHCs) and (B) district hospitals (DHs). Multiple answers were allowed. Figures in parentheses of x axis report the total unavailability. ANC, antenatal care; ECP, emergency contraceptive pill; MTP, medical termination of pregnancy; PPIUCD, postpartum intrauterine contraceptive device; VDRL, venereal disease research laboratory.

Figure 2

Structural readiness scores across district hospitals (DHs) and primary health centres (PHCs). Scores are presented as box plots representing the median and IQR (box and whiskers, respectively) and outliers (dots).

Figure 3

Structural capacity, staffing and quality of care relationship for primary health centres (PHC) (blue) and district hospitals (DH) (orange). Each point represents the indexes for each facility (PHC or DH). The trend line shows the relationship between the staffing and quality of care across the PHCs (blue) and DHs (orange). Note that axis scales vary.