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Background: Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care. Objective: In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India. Design: A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined. Results: Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature. Conclusion: In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health. [ABSTRACT FROM AUTHOR]

Objectives: Only 40.7% women in India deliver in an institution; leaving many vulnerable to maternal morbidity and mortality (India has 22% of global maternal deaths). While limited accessibility to functioning institutions may account in part, a common reason why women deliver at home is poverty. A lack of readily available financial resources for families to draw upon at the time of labor to transport the mother to an institution, is often observed. This paper reports a yearlong collaborative intervention (between the University and Department of Health) to study if providing readily available and easily accessible funds for emergency transportation would reduce maternal deaths in a rural, low income, and high maternal mortality setting in central India. It aimed to obviate a deterrent to emergency obstetric care; the nonavailability of resources with mothers when most needed. Issues in implementation are also discussed. Methods: Maternal deaths were actively identified in block Amarpatan (0.2 million population) over a 2-year period. The project, with participation from local government and other groups, trained 482 local health care providers (public and private) to provide antenatal care. Emergency transport money (in cash) was placed with one provider in each village. Maternal mortality in the adjacent block (Maihar) was followed (as a 'control' block). Results: Maternal deaths in Amarpatan decreased during the project year relative to the previous year, or in the control block the same year. Discussion and conclusions: Issues in implementation of the cash incentive scheme are discussed. Although the intervention reduced maternal deaths in this low-income setting, chronic poverty and malnutrition are underlying structural problems that need to be addressed. [ABSTRACT FROM AUTHOR]

The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation. [ABSTRACT FROM AUTHOR]

Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India's low performing states (LPS), leading to a high burden of maternal mortality. This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities. A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India's nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings. Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women's education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a 'big problem' in accessing medical care had significantly lower odds of delivering at a health facility. The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage. [ABSTRACT FROM AUTHOR]

Background: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions. Objective: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar – a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country's blood transfusion system. Methods: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility. Results: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients' families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention. Conclusions: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought. [ABSTRACT FROM AUTHOR]

Background: Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth. The purpose of this study was to use district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planers to monitor equity in maternal care. Methods: Secondary data analyses were performed among 7,534 ever-married women who delivered since January 2004 in the District Level Household and Facility Survey (DLHS-3) carried out during 2007-2008 in Gujarat, India. Based on the conceptual framework designed by the Commission on the Social Determinants of Health, associations were assessed between three outcomes--Institutional delivery, antenatal care (ANC), and use of modern contraception--and selected intermediary and structural determinants of health using multiple logistic regression. Results: Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence. Discussion and conclusions: Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services. [ABSTRACT FROM AUTHOR]

Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens. Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality. [ABSTRACT FROM AUTHOR]