Our findings show that facilities and qualified obstetricians were largely in the private sector; which also accounted for three-quarters of all institutional births in our study. Facilities were clustered at two levels of function; (i) at CEmOC level and (ii) at less than BEmOC + CS level (71 % of all births occurred here). While the availability of CS was high, what was notable was the non-availability of BEmOC level facilities in either the private or public sectors.
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.
