The dominance of the private sector in the provision of emergency obstetric care: studies from Gujarat, India

Setting

Obstetric care in the state is provided by both public and private health facilities. While public facilities provide services that are formally free of charge, the private sector operates mainly on the basis of out-of-pocket payments [11]. The public sector consists of facilities organized at three levels of care: 1.a single district hospital providing specialist care located at the district headquarter city, 2. sub-district hospitals and community health centers located in smaller towns (some have few beds for admission) 3. primary health care centers and sub-centers further into the rural areas. Childbirth in public facilities is formally free of charge to the user.

The private health sector providing in-patient childbirth care comprises a number of independent facilities, of varying sizes, often owned and run by qualified obstetrician-gynecologists. While these are not formally organized into levels of care, they could be considered to provide secondary level obstetric care, i.e. have fully functional labor rooms and operating rooms for cesarean sections and other procedures. These private facilities operate on the basis of out-of-pocket payments made at the point of care.

Overall EmOC availability

The most common facility type was ‘Less-than-BemOC + CS’ facilities (45.3 %, 72/159). Almost all (95.8 %, 69/72) of the ‘Less-than-BemOC + CS’ were located in the private sector. “Less-than-BEmOC” were the second most common facility type, and most were located in the public sector (65 %, 40/61). CEmOC facilities were mostly private (20/23) (Table 2). There were only three BEmOC facilities in the districts, one of which was in the public sector. “Less-than-BEmOC facilities” were the predominant facilities in rural areas (30/35 - data not shown). The median number of signal functions was significantly higher in ‘Less-than-BemOC + CS’ facilities (7, IQR 6–8) than in ‘Less-than-BemOC’ facilities (3, IQR 2–4)(data not shown).

Basic and comprehensive obstetric care signal functions by facility ownership

Administration of parental antibiotics (96.2 %, 153/159), parenteral oxytocics (99.3 %, 158/159) and neonatal resuscitation (74.2 %, 118/159) were the three most often performed BEmOC functions. On the other hand, manual removal of placenta (37.7 %, 60/159), administration of parenteral anticonvulsants (50.3 %, 80/159) and assisted vaginal delivery (53.4 %, 85/159) were least performed (Fig. 1). Blood transfusions (93/159) and CS (95/159) were performed by six of every ten facilities (Fig. 1). Almost all functions (excluding neonatal resuscitation and administration of parenteral oxytocin) were significantly performed more often by private than public facilities (p < 0.001, Fig. 1).

Reasons for non-performance of EmOC care signal functions

In both public and private facilities, “no indication” was the most common answer for not performing parenteral administration of anticonvulsants, manual removal of placenta or neonatal resuscitation (Fig. 2). In the public sector, “not having enough manpower” was the main reason for not performing removal of retained product of conception or assisted vaginal delivery. On the other hand, in private facilities “no indication” and “policy issues” were the most frequent reasons for no performing removal of retained products of conception and assisted vaginal delivery respectively (Fig. 2). In the public sector, “lack of supplies” was the most common reason for not having given blood transfusions, whereas “no indication” was the most frequent reason cited by private facilities (data not shown). For all facilities, “inadequate manpower” was the main reason for not performing CS (data not shown).

Delivery loads and facility capacities

Inequalities in human resources distribution

Inequalities in the availability of human resources are shown in Fig. 3. The rate of obstetricians and anesthesiologists per 1000 births working in the private sector was higher than those working in the public sector. On the other hand, the rate of medical officers (non-specialist) and trained nurses per 1000 births was higher in the public than in the private sector (Fig. 3).

EmOC availability

EmOC availability and distribution

The availability and distribution of EmOC facilities in our study was different compared to reports from sub-Saharan Africa [14, 15] and other parts of India [16], i e. the location of facilities with a qualified obstetrician and the potential to do a CS is not just restricted to large district headquarter cities, but also goes down to the level of smaller towns in community development blocks (small urban centers surrounded by approximately 100–200 villages). Also, the availability of qualified human resources (qualified obstetricians) is much higher than in sub-Saharan Africa; though in India the majority of these are in the private sector [11].

Although the wide availability of CS could be a strength, given that it is often lifesaving, it does raise questions of possible overuse of cesareans in this setting. Although more in-depth examination is necessary to look into reasons for CS particularly in the private sector, aggregate figures suggest this is unlikely as sub-national community based surveys [17] have shown that overall CS rates in Gujarat are low (6 %) despite the dominant private provision of obstetric care.

Low performance of functions requiring manual skills in the public and private sectors

BEmOC functions requiring advanced manual skills (manual removal of placenta and assisted vaginal delivery) were among the least performed functions; this is in line with reports from South India [16] and Africa [15]. Several reasons might explain these findings. As reported in our results, there may not be enough cases seen in each facility to keep these skills alive. Staff may also lack training to perform these procedures [18] or may replace them with procedures they are more comfortable with performing (i.e. CS). For example, the inverse relation between CS and instrumental childbirth rates has been reported elsewhere [19]. Nevertheless, the attrition of skills from non-performance of procedures is of concern. Further studies are needed to identify the reasons behind the poor performance of these skills in this setting.

The use of WHR 2005 benchmarks to assess the adequacy of EmOC

Different benchmarks have described and used to evaluate the sufficiency of the supply side of childbirth care for women [13]. Among those are the UN 2009 [1] and the WHR 2005 [8] benchmarks. Most studies looking at EmOC availability have used the UN 2009 benchmarks to assess the adequacy of facilities and staff in a given setting [20–22]. However, it has been argued that the WHR 2005 benchmarks are more useful than the UN 2009 benchmarks for planning and providing health services. The WHR 2005 benchmarks correlate better with maternal mortality and provide more consistent estimates across different levels of crude birth rates [13].

In our study, we have used the WHR 2005 benchmarks and we found that the numbers of BEmOC and CEmOC facilities were below these benchmarks [8], with the largest gap in BEmOC facilities. Our use of the WHR 2005 benchmarks make our findings difficult to compare with studies using the UN 2009 benchmarks. Nevertheless, the insufficient number of BEmOC facilities found in these studies and in ours is a consistent finding across many settings regardless of the benchmarking standard used [20, 21].

The inadequate number of BEmOC found in this setting is an issue of concern since it has negative consequences for mothers and health systems. Facilities that are unable to provide key obstetric services are more likely to be bypassed resulting in wasteful expenditure for the health system, delays in EmOC access, and overcrowding of higher level facilities [23]. Our study highlights that in this setting, EmOC care in the hinterland is provided mainly by less-than-BEmOC public facilities which restricts rural women’s access to adequate standards of obstetric care.

The insufficient number of CEmOC facilities in our study contrasts with studies conducted elsewhere reporting the opposite [14, 20, 22]. This might be explained by our use of the more strict WHR 2005 benchmarks [8] than UN 2009 benchmarks [1]. Thus, it is possible that studies reporting sufficient number of CEmOC facilities might have contrary findings if WHR 2005 standards were used [14].

The role of Less-than BeMOC + CS facilities

Our study identified that in this setting the majority of births occurred at private facilities with the ability to do CS but unable to provide all other emergency obstetric care signal functions. Although these facilities did not perform all signal functions, they provided a median of seven comprehensive and key basic emergency obstetric care services (i.e., CS, blood transfusions, parenteral anticonvulsants, parenteral oxytocin, etc.) which cover the most frequently reported complications associated with maternal mortality in India [24]. Thus, these facilities can to some extent, compensate for the lack of fully functional BEmOC or CEmOC facilities in these districts.

Human resources for EmOC

Our findings show that the rate of obstetricians and anesthesiologists per 100 births was significantly higher in the private than in the public sector. These numbers were lowest in the poorest (and more rural) district studied. This is cause for concern given that rural women in our study settings receive EmOC services mainly from the public sector. The shortage of specialized obstetric care in rural settings in India is commonplace [25] and highlights the deep inequalities in access to comprehensive care that rural women face.

All study districts met the WHR 2005 benchmarks [8] for doctors, but this was largely because of the presence of medical officers, a large majority of whom perform administrative tasks and are not necessarily practicing skilled birth attendants.

In our setting, nurses are often front line skilled birth attendants though their skills have been questioned [26]. It is also an issue of concern that their numbers fall below the WHR 2005 benchmarks, especially as they provide most intrapartum care in the public sector.

Limitations

The generalizability of our findings to other parts the country should be done with caution given the heterogeneity that exists in other parts of Gujarat and the Indian Union. The level and availability of EmOC services even in our study districts varied widely. One important limitation of this and other studies evaluating the performance of signal functions at the facility level is that we cannot assert whether these services were provided to all women who needed them. Another possible limitation of our study is that we did not inquire into dual practice (public and private) by physicians and anesthesiologists. Nevertheless, given the large disparities in the distribution of these cadres between public and private facilities, it is unlikely that any overlap might significantly change the figures reported in our findings.