CHAPTER 3 LITERATURE REVIEW - Shodhganga : a...

CHAPTER 3

LITERATURE REVIEW

3. Literature review

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The domain of the term „Health‟ is as large and complex as the entire scope of human

activities.1 Healthcare may be viewed as the provision of a range of healthcare services

by professional, technical, and supportive health workers, with in-patient, out-patient and

home health facilities. The development of healthcare facilities is influenced not only by

the opening of hospitals or healthcare centers, but more so by their proper administration

and management.

Health care has been defined by the WHO as “A programme that should make available

to the individual and thereby to the community, all facilities and allied sciences necessary

to promote and maintain health of mind and body.2 Health care remains one of the most

important human endeavours to improve the quality of life. The main objective of any

healthcare system is to facilitate the achievement of optimal level of health to the

community through the delivery of services of appropriate quality and quantity.

Increasing the availability, accessibility and awareness about the services and

technological advances for the management of health problems, raising expectations of

the people, and the ever-escalating cost of healthcare are some of the challenges that the

healthcare systems have to cope up with. Health care delivery systems will have to gear

up to taking up necessary preventive, curative, promotive and rehabilitative healthcare for

the population. The challenge of building rural health services, state‟s responsibility in

providing these and training paramedical personnel to carry out limited curative and

preventive responsibilities were part of India‟s development thinking before and after

independence. The rising expectations of healthcare users mean that the way the services

are organized and delivered will become significant. It is therefore, essential to

understand how best to organize and deliver healthcare services.

The concept of health centre was first brought by Lord Dawson in England during 1920.

As early as 1928, Govt. of Mysore established the first health unit in the country at

Mandya (in Karnataka). Establishment of health centers at Nazafgarh, Singur,

Poonamallie, Trivandrum, Lucknow and at other places in collaboration with Rockefeller

1 Henrik L., Blumand Alvin, R. Leonard, Public Administration–A Public View Point, Macmillan and Co,. New York, 1963; 257–265. 2 Report of Expert Committee on hospital Administration, Geneva, WHO, 1968.


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foundation and Govt. of India between 1931 to 1939 was an important landmark in the

history of health care delivery system.3

3.1 Rural Health Care Services

3.1.1 Availability and Accessibility to health care

Community based primary health care is the mainstay of health care delivery to persons

in developing countries. In these countries, primary care must be accessible to the vast

majority of the population as poor access to primary health care is associated with

adverse pregnancy outcomes,4,5

infant mortality6 and decreased vaccination coverage.

7,8

In accessibility of health care facilities may also affect adherence to treatment regime.

Access to health services in the developing world is poor, but it gets significantly worse

in the rural areas.

World Health Organization (2009)9 in its study on increasing access to health workers in

remote and rural health areas found that there is more a problem of geographical mal

distribution rather than a lack of physicians. The movements of health workers in general,

such as turnover rates, absenteeism, unemployment or dual employment has a correlation

between the factors influencing the choices and decisions of health workers to practice in

remote and rural areas and the categories of interventions that could respond to those

factors. The deepest concerns of health workers when it comes to practicing in remote

and rural areas are those related to the socio-economic environment, such as working and

living conditions, access to education for children, availability of employment for

spouses, insecurity, and work overload.

3 Mukherjee PK. Public Health Administration in India. in Dr. B N Ghosh's a treatise on Preventive and social medicine, Academic

Publisher, Calcutta, 1987; 7-20. 4 Van den Broek NR, White SA, Ntonya C, Reproductive health in rural Malawi: a population based survey, a Brazial Journal of

Obstetrics and Gynecology 2003; 110: 902-8. 5 Thaddeus S, Maine D, Too far to walk: maternal mortality in context, Social Science and Medicine, 1994; 38(8): 1091-110. 6 Frankenberg E. The effects of access to health care on infant mortality in Indonesia, Health Transition Review, 1995; 5: 143-63. 7 Acharya LB, Cleland J., Maternal and Child health services in rural Nepal: does access or quality matter more?, Health Policy and Planning 2000; 15: 223 – 9, 8 Amil K, Bhuiya A Streatfield K, The immunization programme in Bangladesh: impressive gains in coverage, but gaps remain,

Health Policy Planning 1999; 14: 49 -58. 9 World Health Organisation 2009, Increasing access to health workers in remote and rural areas through improved retention,

Background paper for the first meeting to develop evidence based recommendations to increase access to health workers Geneva,

2009.


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Lewando Hundt et al (2012)10

found in their study that there are issues of accessibility in

terms of distance, and of acceptability in relation to the lack of local and female staff,

lack of cultural competencies and poor communication. Also they found that provision of

accessible acceptable health care in rural areas poses a challenge to health care providers

and these providers of health care have a developing partnership that could potentially

address the challenge of provision to this rural area.

Frank Tanser (2006)11

found out in their study that the population level increase in

accessibility that would be achieved by the construction of the test clinic (location

optimized by PHIT methodology) would be 3.6 times the increase in accessibility

achieved by the construction of the newest clinic The corresponding ratio for increasing

clinic coverage (% of population within 60 minutes of care) would be 4.7 and also

develop a model through Person Hours of Travel Time (PHIT) methodology for health

planners to identify potential localities for establishing new health care facilities by using

GIS technology to efficiently to site new facilities to achieve the maximum population

level increase in accessibility to primary health care.

Ray S.K. et al (2011)12

found in their study that large no of patients did not avail any

services when they fall sick especially in the tribal district where distance, poor

knowledge about the availability of the services and non-availability of the medicine in

addition to the cost of treatment and transport. Utilization of government health facilities

was around 38% followed by unqualified Practitioners and Private Practitioners. Referral

was mostly by self or by close relatives / families. Also attention is required with respect

to the cleanliness of the premises, safe drinking water, face-lift of PHCs and SCs, clean

toilet with privacy. Also they concluded that an attempt should be made to improve

utilization by cordial behavior, providing more time for patient care by the doctor, and

staff, explain their prescription and report, reducing time for registration as well as

waiting and finally cost of medicine they can afford.

10 Lewando Hundt G, Alzaroo S, Hasna F, Alsmerian M, The provision of accessible, acceptable health care in rural remote areas

and the right to health: Bedouin in the North East region of Jordan, Social Science and Medicine 2012; 74 (1): 36-43. 11 Frank Transer, Methodology for optimizing location of new primary health care facilities in rural communities: A case study in Kwazulunatal, South Africa, Journal of Epidemiology Community Health 2006; 60: 846 -50. 12 Ray SK, Basu SS, Basu AK, An assessment of rural health care delivery system in some areas of west Bengal – An overview, Indian

Journal of Public Health, 2011; 55(2): 70 -80.


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Srivastava R.K. et al (2009)13

study revealed that the utilization of RCH services in the

government facilities was higher among the backward classes than the general category;

and higher the level of education the lower was the utilization of the government

services. Also the users were not satisfied with the services provided by the governmental

health facilities especially with the behavior of medical officer and health workers and

non-satisfaction was highest among SC category. Also authors concluded that all the

health facilities need to be made functional according to the Indian Public Health

Standards (IPHS) of National Rural Health Mission (NRHM).

Meenakshi Gautham et al (2011)14

in their study found that most rural persons seek first

level of curative healthcare close to home, and pay for a composite convenient service of

consulting –cum-dispensing of medicines. Non Degree Allopathic Practitioners (NDAPs)

fill a huge demand for primary curative care which the public system does not satisfy and

are de facto first level access in most cases.

Kaveri Gill (2009)15

in their study concluded that the National Rural Health Mission is on

the right track of addressing the rural health care with the institutional changes it has

brought within the health system. But there are problems in implementation, so that

delivery is far from what it ought to be with respect to physical infrastructure, medicines

and funding. Whereas with respect to human resources and to the extent these impact

actual availability of services, structural issues of some complexity need careful resolving

with a definite long term investment in the training and education of paramedical and

medical staff.

Ager A. et al (2007)16

in their study examined the patterns of service utilization across the

rural population of four districts of Orissa, with special reference to perceptions of the

availability and quality of state services at the primary care level. Despite emphasis on

strengthening local health care provision, concern remains regarding the rates of

13 Srivastava RK, Kansal S, Tiwari VK, Piang L, Chand R, Nandan D, Assessment of utilization of RCH services and client

satisfaction at different levels of health facilities in Varanasi District, Indian Journal of Public Health, 2009; 53(3): 183 -189. 14 Meenashi Gautham, Erika Binnendik, Ruth Koren, David M. Dror, “First we go to the small doctor”:First contact for curative

health care sought by rural communities in Andhra Pradesh & Orissa, India, Indian Journal Medical Research 2011; 134(5): 627 -38. 15 Kaveri Gill, A Primary Evaluation of Service Delivery under the National Rural Health Mission (NRHM): Findings from a study in

Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan, Working Paper 1/2009-PEO, Planning Commission of India, 2009 16 Ager A, Pepper K, Patterns of health service utilization and perceptions of needs and services in rural Orissa, Health Policy and

Planning 2005; 20(3): 176 -84.


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utilization of state provided services. Households reported utilizing a wide range of

health care providers, although hospitals constituted the most frequently--and primary

health care centers (PHCs) the least frequently--accessed services. Private practitioners

(qualified and unqualified) represented a major sector of provision. This included high

rates of access by scheduled tribes and castes (running at approximately twice the rate of

access to both local and PHC provision). Key factors guiding patterns of utilization were

reputation of the provider, cost and physical accessibility. Local health provision through

assistant nurse midwives and male health workers was generally perceived of poor

quality, with the lowest rates of resolution of health problems of all service providers.

The location of a sub-centre base for assistant nurse midwives within a village had no

demonstrable impact on access to services. Acknowledging constraints on broader

generalization, the implications of the findings for informing health policy and

programming within Orissa are noted. This includes support for current efforts to

strengthen the capacity of PHC and sub-centre level provision within the state, and

acknowledgement of the potentially growing role of effectively regulated private

provision in meeting the needs of the rural poor.

3.1.2 Utilization, Perception and Patient Satisfaction

A critical challenge for health services in developing countries is to find ways to make

them more client-oriented. Indifferent treatment of patients, and inadequate provision of

medicines and supplies are common, Assessing patient perspectives gives users a voice,

which, if given systematic attention, offers the potential to make services more

responsive to people‟s needs and expectations, important elements of making health

systems more effective.17

Studies have shown that health care utilization, a long-standing

concern for many developing countries, is sensitive to user perceptions of

quality18,19,20,21,22,23

For these reasons, patient perceptions of health services are now an

17

The World Health Report 2000 – Health Systems: Improving Performance. Geneva: WHO, 2000. 18 Haddad S, Fournier P, Machouf N, Yatara F. What does quality mean to lay people? Community perceptions of primary care services in Guinea,. Social Science and Medicine, 1998; 47: 381–94. 19 Akin JS, Hutchinson P. Health-care facility choice and the phenomenon of bypassing, Health Policy and Planning, 1999; 14: 135–

51. 20 Acharya LB, Cleland J. Maternal and Child health services in rural Nepal: does access or quality matter more?, Health Policy and

Planning 2000; 15: 223 – 9. 21 Choi KS, ChoWH, Lee S, Lee H, Kim C. The relationships among quality, value, satisfaction and behavioral intention in health care provider choice: a South Korean study. Journal Business Research, 2004; 5: 913–921.


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important part of quality assessment in health care. The few studies on user perceptions

conducted in developing countries have shown that patients are able to evaluate

structural, process, and outcome measures of quality.23, 24

Patient perceptions of quality

have been a focus of research due to the increasing need to provide patient-centered care,

with the expectation that such care would lead to better patient outcomes and continued

use of care.24

Patient satisfaction was associated with providers‟ responsiveness,

assurance, communication, and discipline.25

In developing countries, where quality is one of the major challenges to be met under the

current health care reforms, the measurement of perceived quality is also justified by the

powerful influence that these perceptions have on utilization of services. Several studies

offer evidence on the growing interest in users‟ perception or satisfaction in developing

countries. Surprisingly, little research has been done on patient perceptions of quality in

India.

Orna Baron-Epel et al. (2001)26

found in their study that the degree to which expectations

of the interaction were perceived as fulfilled were more strongly associated with the

satisfaction especially attributes characterizing interactions and communication with the

physician like “explanation and discussion”, “answering questions”, and “listening to

problems”. When the patient expectations are met with respect to these characteristics,

patient satisfaction is greater. The perceived degree to which expectations with regards to

other characteristics, such as “Medical Certificate Provision”, “referral to specialist” or

“test referral” were fulfilled may be less critical in determining the patient satisfaction.

Margaret S.W. et al. (2003)27

study‟s findings provided support for Donabedian‟s

Structure, Process and Outcome Model28

and they demonstrated that attributers of

22 Alden DL, Hoa DM, Bhawuk D. Client satisfaction with reproductive health-care quality: integrating business approaches to

modeling and measurement. Social Science and Medicine, 2004; 59: 2219–2232. 23 Baltussen RM, Ye Y, Haddad S, Sauerborn R S. Perceived quality of care of primary health services in Burkina Faso. Health Policy and Planning, 2002; 17: 42–48. 24 Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annual Review of Public Health 2005; 26: 513–59. 25 Andaleeb SS. Service quality perceptions and patient satisfaction: a study of hospitals in a developing country. Social Science and Medicine, 2001; 52: 1359–70. 26 Orna Baron-Epel, Marina Dushenat, Nurit Friedman, Evaluation of the consumer model: relationship between patients’

expectations, perceptions and satisfaction with care, International Journal for Quality Health Care 2001; 13: 317-23. 27 Margaret SW, Paul R, Danie G Van Zyl, Ohn R. Seager, Interpersonal and Organisational dimensions of patient satisfaction: the

moderating effects of health status, International Journal for Quality in Health Care,2003; 15(4): 337-44. 28 Avedis Donabediean, The Quality of Care: How can it be assessed? Journal of American Medical Association 1988; 260: 1743-48.


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providers and settings are major components of patient‟s satisfaction and showed that the

patients in poor general health were significantly less satisfied with organizational factors

(like availability of a seat and toilet in the waiting area, and cleanliness) whereas the

patients in good general health but poor in mental health were significantly less satisfied

with the interpersonal quality of their care (like support, consideration, friendliness and

encouragement).

Krishna D. Rao et al (2006)29

found in their study that better staff and physician

interpersonal skills, facility infrastructure, and availability of drugs have the largest effect

in improving patient satisfaction at public health facilities. Also in their study they

concluded that, In India and many developing countries, the excessive emphasis on

service coverage and inputs in the provision of health services has ignored the needs of

the very people for whom these health services exist. Incorporating patient views into

quality assessment offers one way of making health services more responsive to people‟s

needs. It also gives users an opportunity to voice their opinion about their health services.

While conducting this study, we found many instances in which patients were eager to

record their concerns about the services they had received in the hope that some action

would be taken. It is likely that the very act involving patients in evaluating their health

services will make providers more sensitive and alert to patient needs.

Upali W. Jayasinghe et al. (2007)30

in their study showed that patient assessments of

quality of care and patient-centeredness were strongly associated with practice and

patient characteristics. Patients from smaller practices reported better access to care

compared with larger practices. Also patients from urban areas were more satisfied with

patient-centeredness than those from rural areas. Also females were more satisfied with

patient-centeredness.

29 Krishna Dipankar Rao, David H Peters and Karen Bandeed-Roche, Towards Patient-centered health services in India a scale to measure patient perceptions of quality, International Journal for Quality in Health Care 2006; 18(6): 414-21. 30 Upali W. Jayasinghe, Judy Proudfoot, Chris Holton, Gawaine Powell Davies, Cheryl Amoroso, Tanya Burbner, Chronically ill

Australians’ Satisfaction with accessibility and Patient centeredness, International Journal for Quality in Health Care, 2008; 20(2):

105–14.


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Many studies were made with regard to the patient‟s satisfaction and Patient‟s

characteristics such as age, health status and education.31

Usually, older patients are more

satisfied 32,33,34,35,36

and highly educated people are less satisfied with their health-care

services compared with their counterparts.37

Health status is another factor of importance.

A higher level of satisfaction is found in patients with better overall health33,35,36,38

Waiting time, real and perceived is often found to influence satisfaction of patients 38,39,40

Another aspect of quality is patient centeredness, inclusion of patients in the decision

making process, as well as the degree of such participation, has been found to be strongly

associated with overall satisfaction. 41,42,43

Patients time spent with their physician is also

strongly associated with overall satisfaction.44

Overall patient satisfaction is also

influenced by receiving information.45,46,47,48

31 Rahmqvist M. Patient satisfaction in relation to age, health status and other background factors: a model for comparisons of care

units. International Journal for Quality in Health Care 2001; 13: 385–90. 32 Sun BC, Adams J, Orav EJ Determinants of patient satisfaction and willingness to return with emergency care. Annals of

Emergency Medicine, 2000; 35: 426–34. 33 Young G Meterko M, Desai K, Patient satisfaction with hospital care: effects of demographic and institutional characteristics,

Medical care, 2001; 38: 325 – 34. 34 Crow R, Gage H, Hampson S The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. International Journal of Technology assessment in health care, 2002; 6: 1–244. 35 Sixma H, Spreeuwenberg P, van der Pasch M. Patient satisfaction with the general practitioner: a two-level analysis. Medical Care,

1998; 36: 212–29. 36 Jaipaul CK, Rosenthal GE. Are older patients more satisfied with hospital care than younger patients? Journal of General Internal

Medicine, 2003; 18: 23–30. 37 Bautista RE, Glen ET, Shetty NK. Factors associated with satisfaction with care among patients with epilepsy. Epilepsy Behaviour, 2007; 11: 518–24 38 Covinsky KE, Rosenthal GE, Chren MM et al. The relation between health status changes and patient satisfaction in older

hospitalized medical patients. Journal of General Internal Medicine, 1998; 13: 223–9. 39 Yildirim C, Kocoglu H, Goksu S et al. Patient satisfaction in a university hospital emergency department in Turkey. Acta medica

(Hradec Kra´love´), 2005; 48: 59–62. 40 Nerney M, Chin MH, Jin L et al. Factors associated with older patients’ satisfaction with care in an inner-city emergency

department. Annals of Emergency Medicine, 2001; 38: 140–45. 41 Bain J, Kelly H, Snadden D., Day surgery in Scotland: patient satisfaction and outcomes. Quality in Health Care 1999; 8: 86–91. 42 Kjeken I, Dagfinrud H, Mowinckel P.,Rheumatology care: involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis. Arthritis Rheum, 2006; 55: 394–

401. 43 Brekke M, Hjortdahl P, Kvien TK. Involvement and satisfaction:a Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain, Arthritis Care and Research, 2001; 45:

8–15. 44 Chen-Tan L, Albertson GA, Schilling LM., Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction? Arch Intern Med, 2001; 161: 1437–42. 45 Crow R, Gage H, Hampson S The measurement of satisfaction with healthcare: implications for practice from a systematic review

of the literature. International Journal of Technology assessment in health care, 2002; 6: 1–244. 46 Hall JA, Dornan MC. Patient socio demographic characteristics as predictors of satisfaction with medical care: a meta-analysis.

Social Science and Medicine, 1990; 6: 811–8. 47 Korsch BM, Gozzi EK, Francis V. Gaps in doctor patient communication. Part 1. Doctor patient interaction and patient satisfaction, Pediatrics 1968; 42: 855–71. 48 Thompson DA, Yarnold PR, Williams DR., Effects of actual waiting time, perceived waiting time, information delivery,and

expressive quality on patient satisfaction in the emergency department, Ann Eerg Med 1996; 6: 657-65.


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Rahmqvisti Mikael et al (2010)49

found in their study of two-dimensional outcome in the

QSP model: „Importance‟ (to satisfaction) and „Quality‟ (grade of satisfaction) that

younger patients in emergency were least satisfied group and older patient with excellent

health status were the most satisfied group. Patients with perceived better health status

and those with less education were more satisfied than those with more education or

poorer health status. The two dimensions most strongly associated with global

satisfaction were “receiving the expected medical help” and “being treated well by the

doctor”. To wait at the reception without getting information correlated negatively to

patient satisfaction. Also participation in the medical decision making is correlated

positively.

Aldana J.M. et al (2001)50

in their study showed that client satisfaction is determined by

the cultural background of the people. It shows the dilemma that, though optimally care

should be capable of meeting both medical and psychosocial needs, in reality care that

meets all medical needs may fail to meet the client‟s emotional or social needs.

Conversely, care that meets psychosocial needs may leave the clients medically at risk.

Dongre A.R. (2008)51

in their study found gap between mothers' knowledge and their

health seeking behavior for sick newborn and explored their deep perceptions, constraints

and various traditional treatments. Most of the mothers of sick newborns knew that sick

child should be immediately taken to the doctor and only around 50% of such sick

newborns got treatment either from government hospital or from private hospital and

almost rest 50% of sick babies received no treatment. The reasons for not taking actions

even in presence of danger signs/ symptoms were ignorance of parents, lack of money,

faith in supernatural causes, non availability of transport, home remedy, non availability

of doctor and absence of responsible person at home. For almost all the danger signs /

symptoms supernatural causes were suspected and remedy was sought from Traditional

Faith Healer (Vaidu) followed by doctor of primary health centre and private doctor.

Comprehensive intervention strategies are required to change behavior of caregivers

49 Rahmqvisti M, Ana-Claudia Bara, Patient characteristics and quality dimensions related to patient satisfaction, International

Journal for Quality in Health Care 2010; 22 (2): 86–92. 50 Aldana Jorge Mendoza, Helga Piechulek & Ahmed Al-Sabir,Cclient satisfaction and quality of health care in rural Bangladesh,

Bulletin of World Health Organisation 2001; 79(6): 512 -517. 51 Dongre AR, Deshmukh PR, Garg BS, Perceptions and health care seeing about newborn danger signs among mothers in rural Wardha, Indian Journal of Pediatrics, 2008; 75 (4): 325-9.


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along with improvement in capacity of Government health care services and National

Health Programs to ensure newborn survival in rural area.

Nath L.M. (1994)52

study shows that in rural areas where the government centers are

particularly desolate, the community has chosen to erect its own health care system of

private practitioners of all sorts and qualifications. Even in rural areas where a

comprehensive health service is provided, with each household visited regularly by health

workers, people depend upon practitioners of various types. Upon analysis, it was

discovered that the reason for using this multiplicity of practitioners had nothing to do

with the level of satisfaction with the government service or with the accessibility of the

services. Rather, when ill, the people make a diagnosis and then go to the proper place for

treatment. If, for instance, they believe their malady was caused by the evil eye, they

consult a magico-religious practitioner. These various types of practitioners flourish in

areas with the best primary health care because they fulfill a need not met by the primary

health care staff.

Acharya L.B. et al. (2000)53

in their study with regard to the access–quality trade-offs, the

evidence strongly suggests that basic improvement to Health Facility quality, (which are

measured through availability of trained staff, equipment, supplies and facilities) is a

more important priority than increase the number of Health Facilities to improve the

access.(measured in terms of travel time based on a normal mode of transport)

All of these are user-perspective studies, that is, they predominantly aim to measure

perceived quality of care of those people who actually visit the health facilities. The

resulting information is then used as a basis to further improve quality of care with the

ultimate goal to improve the effectiveness of care, and/or to increase utilization.

However, in assessing community preferences on modern health facilities, it is important

not only to be informed about the preferences of those who actually use the facilities but

also of those who do not use them.

52 Nath L M, Health care in rural areas, Health for the millions, 1994; 2(1): 17-8. 53 Acharya LB, Cleland J. Maternal and Child health services in rural Nepal: does access or quality matter more?, Health Policy and

Planning 2000; 15: 223 – 9.


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Rob Baltussen et al (2006)54

found in their study that a documentation of the perceptions

of these „non-users‟ is necessary for policy makers and may shed light on the factors that

influence peoples‟ choice of health care services. To remove barriers to increase

utilization, policy makers may do good to target their attention to improve financial

accessibility of modern health services and improve drugs availability. These factors

seem most persistent in decisions of ill people to stay with home-based care and/or

traditional medicine, or go to consult modern health services.

3.1.3 Health care services delivery

In much of the developing world, access to quality health care is limited, and people

depend on providers who have limited training or supervision, often from the private

sector 55,56

A number of studies have suggested that improving quality of services can

increase utilization in low-income countries. In some contexts even in the face of higher

user fees 57,58,59

. But public providers often lack the resources and systems to encourage

high quality services; while insufficient attention is paid to the preferences of the people,

the interventions are intended to benefit. The poor may prefer private and unqualified

providers because they may be more accessible, affordable, and responsive to their needs,

even if the technical quality of care is questionable. 60,61,62

The outcome is that many

people‟s health conditions are inappropriately treated. Various studies have been made in

developed and developing country health delivery systems to try to assess whether health

services meet acceptable levels of quality.

54 Rob Baltussen, Yazume Ye, Quality of care of modern health services as perceived by users and non-users in Burkina Faso,

International Journal for Quality in Health Care, 2006; 18(1): 30-34. 55 Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries?, Bulletin of

World Health Organisation, 2002; 80: 325–330 56 Peters DH, Yazbeck AS, Sharma RR, Ramana GNV, Pritchett LH, Wag staff A. Better Health Systems for India’s Poor: Findings, Analysis, and Options. Washington D.C.: The World Bank, 2002. 57 Mariko M. Quality of care and the demand for health services in Bamako, Mali: the specific roles of structural, process, and

outcome component, Social Science and Medicine, 2003; 56: 1183–96 58 Chawla M, Ellis RP. The impact of financing and quality changes on health care demand in Niger. Health Policy and Planning,

2000; 15: 76–84. 59 Haddad S, Fournier P. Quality, cost and utilization of health services in developing countries. A longitudinal study in Zaire. Social Science Medicine 1995; 40: 743–53. 60 Peters DH, Yazbeck AS, Sharma RR, Ramana GNV, Pritchett LH, Wag staff A. Better Health Systems for India’s Poor: Findings,

Analysis, and Options. Washington D.C.: The World Bank, 2002. 61 Chawla M, Ellis RP. The impact of financing and quality changes on health care demand in Niger. Health Policy and Planning,

2000; 15: 76–84. 62 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet 2003; 362: 65–71.


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Duggal R.(1994)63

in his study on the utilization of health care in India, revealed that

India has a plurality of health care systems as well as different systems of medicine. The

government and local administrations provide public health care in hospitals and clinics.

Public health care in rural areas is concentrated on prevention and promotion services to

the detriment of curative services. The rural primary health centers are woefully

underutilized because they fail to provide their clients with the desired amount of

attention and medication and because they have inconvenient locations and long waiting

times. Public hospitals provide 60% of all hospitalizations, while the private sector

provides 75% of all routine care. The private sector is composed of an equal number of

qualified doctors and unqualified practitioners, with a greater ratio of unqualified to

qualified existing in less developed states. In rural areas, qualified doctors are clustered in

areas where government services are available. With a population barely able to meet its

nutritional needs, India needs universalization of health care provision to assure equity in

health care access and availability instead of a large number of doctors who are profiting

from the sicknesses of the poor.

Khare R.S. (1996)64

in his study explicates "practiced medicine" as an operative cross-

cultural analytic concept by locating it within previous major developments and

directions of study within anthropological studies of medicine in India, and medical

anthropology more generally. Practiced medicine in India, for example, allows us to see

better how India manages not only multiple traditional and modern medical approaches,

languages, therapeutic regimens, and material medica, but it also leads us to a sustained

moral, social and material criticism from within. Author concludes that, as India today

grapples with issues of availability, affordability, equity, and distributive justice in

medical care, its practiced medicine raises issues of "critical consciousness" for modern

(and traditional), state supported medicine.

Sheehan H.E.(2009)65

in his research on Indian health care described that the mal

distribution of biomedical services creating a dilemma for Indian patients encountering a

bewildering arrangements of medical services, ranging from qualified traditional medical

63 Duggal R, Health care utilization in India, Health for the Millions, 1994; 2(1): 10-2. 64 Khare RS, Dava, Daktar and Dua: anthropology of practiced medicine in India, Social Science and medicine, 1996; 43(5): 837-48. 65 Sheehan HE, Medical Pluralism in India: Patient choice or no other options?, Indian Journal of Medical Ethics, 2009; 6(3): 138-

41.


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practitioners to untrained, self taught purveyors of medicines and cures. The study

revealed the ground reality of the consequences of limited choices for patients,

characterized as “forced pluralism”, with no state of regulation of type of care, quality of

care or credentials of practitioners.

Rohde J. et al (1994)66

in their research on the profile and practice of the private

practitioners revealed that majority of India‟s rural population is being provided by

private practitioners. It was found that the private practitioners are almost always male,

practice in or close to their birth place, and have attended school, of which only 25% of

them graduates and almost 50% have no formal training. Regardless of training, nearly

90% practice allopathy. Medications, including antibiotics are given in small doses (a

practice which is certainly harmful). The practitioners refer difficult cases to the

government centers. Most of the practitioners however, practice alone with their only

professional contact being the town chemist. Another important finding is that the

patients were satisfied with the care they received because the private practitioners paid

more attention to them than they were accustomed to receive from primary health care

doctors. Further study also reveals that analysis of the cost of this health care shows that

it accounts for a substantial portion of rural expenditure and constitutes a sizeable

“hidden industry”. And authors have suggested that In order to respond to this situation,

the government must ban the untrained rural private practitioner, promote the quality of

care provided by the government network, or acknowledge the existence of the private

practitioners and provide them with support and training.

Singh P. et al (2005)67

in their study on the usage and acceptability of indigenous systems

of medicine to provide estimate of utilization of different indigenous systems of medicine

in the country showed that very small proportion (around 14% ) of sick persons utilizing

indigenous system of medicine. Also those who preferred Indian System of Medicine &

Homeopathy, the reasons were mainly “no side effects” and low cost treatment. Slow

progress and non availability of practitioners were the main reasons for not preferring the

ISM &H treatment.

66 Rohde J, Viswanathan H, The rural private practitioner, Health for the millions, 1994; 2(1): 13-6. 67 Singh P, Yadav RJ, Pandey A, Utilization of Indigenous systems of medicine and homeopathy in India, Indian Journal of Medical Research, 2005; 122 (2): 137-42.


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Yadav R.J. et al (2007)68

found in their study on acceptability of Indian System of

Medicine that very small proportion of sick persons actually availed ISM&H treatment.

Majority availed Homeopathy followed by Ayurvedic medicines and use of Unani and

Siddha is almost negligible. ISM&H are preferred only in case of minor ailments. In case

of serious illness, like Jaundice, snake bite, dog bite and „bone setting‟, sick persons

sought treatment from traditional healers. Sizable proportion of sic persons used various

“kitchen remedies” for conditions lie indigestion, fever, body ache, sprain, cough and

cold.

Gogtay N.J. et al (2002)69

concluded in their study on use and safety of non – allopathic

Indian medicines that non-allopathic Indian medicines, Ayurveda, Siddha, Unani and

Homeopathy , referred to elsewhere in the world as complementary and alternative

medicine have gathered increasing recognition in recent years with regard to both

treatment options and health hazards. The challenges in these non-allopathic systems

relate to the patient, physician, regulatory authorities, the abuse/misuse of these

medicines, quality and purity issues. Safety monitoring is mandated by a changing

ecological environment, the use of insecticides, new manufacturing techniques, in yet

unregulated pharmaceutical industry. The Indian traditional medicine industry has come a

long way from the times when it was considered unnecessary to test these formulations

prior to use, to the introduction of Good Manufacturing Practice guidelines for the

industry. There is an urgent need for the practitioners of the allopathic and non-allopathic

systems to work together to optimize the risk-benefit profile of these medicines.

Tourigny A. et all (2010)70

found in their study to evaluate how a primary care reform,

which aimed to promote interpersonal and inter organizational collaborative practices,

affected patients‟ experiences of the core dimension of primary care that perceptions of

relational and informational continuity increased significantly whereas organizational and

first- contact accessibility and service responsiveness did not change significantly.

Perception of physician-nurse coordination remained unchanged, but perception of

68 Yadav RJ, Pandey A, Singh P, A study on acceptability of Indian system of medicine and homeopathy in India: results from the state

of West Bengal, Indian Journal of Public Health, 2007; 51(1): 47-9. 69 Gogtay NJ, Bhatt HA, Dalvi SS, Kshirsagar NA, The use and Safety of Non allopathic Indian medicines, Drug safety: International

Journal of medical toxicology and drug experience, 2002; 25(14): 1005-19. 70 Tourigny A, Aubin M, Haggerty J, Bonin L Morin D, Reinharz D, Leduc Y, St. Pierre M, Houle N et al, Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec, Canadian Family Medicine, 2010; 56(7): 273 -82.


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primary care physician-specialist coordination decreased significantly. And also authors

concluded in their study that the reorganization of primary care services resulted in

considerable changes in care practices, which led to improvements in patients‟

experiences of the continuity of care but not improvements in their experiences of the

accessibility of care.

De Costa A. et all (2007)71

empirically demonstrates the domain heterogeneous private

health sector and the overall disparity in health care provision in rural and urban areas

with 75.6% of the qualified doctors work in the private sector, 80% of these private

physicians work in urban areas and 72.1% of all qualified paramedical staff work in the

private sector mostly in rural areas. It argues for a new role for the public health sector,

one of constructive oversight over the entire health sector (public and private) balanced

with direct provision of services where necessary. It emphasizes the need to build strong

public private partnerships to ensure equitable access to healthcare for all.

Laurant M. et al (2005)72

in their findings suggest that appropriately trained nurses can

produce as high quality care as primary care doctors and achieve as good health outcomes

for patients, process of care, resource utilization or cost. While doctor-nurse substitution

has the potential to reduce doctors' workload and direct healthcare costs, achieving such

reductions depends on the particular context of care. Doctors' workload may remain

unchanged either because nurses are deployed to meet previously unmet patient need or

because nurses generate demand for care where previously there was none. Savings in

cost depend on the magnitude of the salary differential between doctors and nurses, and

may be offset by the lower productivity of nurses compared to doctors. However, this

conclusion should be viewed with caution given that only one study was powered to

assess equivalence of care, many studies had methodological limitations, and patient

follow-up was generally 12 months or less.

71 De Costa A, Diwan V, “Where is the public health sector?”Public and private sector health care provision in Madhya Pradesh,

India, Health Policy 2007; 84(2-3): 269 -76. 72 Laurant M, reeves D, Braspenning J, grol R, Sibbald B, Substitution of doctors by nurses in primary care, Cochrane database of systematic reviews, 2005; 18(2): CD001217.


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Syed S.A. et al (2007)73

conclude from their study that improving medical care requires

attention to service features that are regularly rated by patients. These features include

doctors, nurses, tangibles, process features. However, additional organizational and extra

organizational issues that play a vital role must also be addressed to improve the health

care system.

Raz Samandari et al (2001)74

conclude from their study that a specialized private health

care institute, its funding, organization, delivery of care and measures to ensure quality of

care. Further, the authors also claiming that privately funded quality health care could be

a sustainable and equitable model „for the developing world‟

Hanan AL-Ahmadi et al (2005)75

found out from their study that the factors that are

determining the high quality care are management & organizational factors,

implementation of evidence-based practices, professional development, use of referrals to

secondary care and organizational culture. The other factors that are required in order to

improve quality are the knowledge and skills of staff.

McDonald J. et al (2002)76

discuss in their study how the present health funding models

can place onerous pressures on rural health services. Staff may lack the time, resources,

access to data, and the expertise needed to complete complex and lengthy funding

submissions. This present study describes an innovative capacity-building approach to

working with Victorian rural communities seeking to access health care funding through

the Regional Health Services Program. This approach used several strategies: engaging

stakeholders in targeted rural communities, developing an information kit and running a

workshop on preparing submissions to the Regional Health Services Program, facilitating

community consultations, and providing ongoing support with submissions. This

capacity-building approach is both effective and replicable to other health funding

opportunities.

73 Syed Saad Andaleeb, Nazlee Siddiqui, Shahjahan Khandakar, Patient satisfaction with health services in Bangladesh, Health Policy

and Planning, 2007; 22: 263–73. 74 Raz Samandari Sahron Kleefield, Jim Hammel and Robert crone, Privately funded quality health care in India: a sustainable and

equitable model, International Journal for Quality in Health Care, 2001; 13(4): 283 -88. 75 Hanan ALAhmadi, Martin Roland, Quality of primary health care in Saudi Arabia: a comprehensive view, International Journal for

Quality in Health Care 2005; 17(4): 331-46 76 Mcdonald J, Brown L, Murphy A., Strengthening primary health care: building the capacity of rural communities to access health funding, Australian Journal of rural health, 2002; 10(3): 173–7.


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Peters D.H. et al (2006)77

showed in their study that Decision Support Technologies

(DST) have considerable potential to improve coverage and quality of health care for the

poor and where there is no doctor, but the unreceptive attitude of public health workers

would need to be overcome. Application of these technologies should take advantage of

their popularity with patients and the opportunity to work through the private sector.

Various methods have been used in developed and developing country health delivery

systems to try to assess whether health services meet acceptable levels of quality. These

include record review or audit, interview with health care providers, written and oral

examinations, interviews and focus groups with patient patients, direct observation of the

delivery of the services. Although these methods are used frequently, there has been little

empirical research on their validity in measuring the quality of health worker‟s

performance in delivering primary health care services.

Jorge H. et al (1999)78

in their study they found that the method of reviewing medical

records has low specificity for the detection of the performance, but is recommended for

the evaluation of quality in prescription of drugs. Study also found that exit interview of

the mother has a better specificity with respect to the performance of health workers than

that of medical record review.

Avedis Donabedian (1988)79

developed a popular Donabedian model of Structure – Process -

Outcome, which is widely validated and applied in implementing quality in health care services.

In his work he advocated that before assessment can begin we must decide how quality is

to be defined and that depends on whether one assesses only the performance of

practitioners or also the contributions of patients and of the health care system; on how

broadly health and responsibility for health are defined; on whether the maximally

effective or optimally effective care is sought; and on whether individual or social

preferences define the optimum. We also need detailed information about the causal

linkages among the structural attributes of the settings in which care occurs, the

77 Peters DH, Kohli Manish, Maya Mascarenhas, Rao Krishna, Can computers improve patient care by primary health care workers in

India?, International Journal for Quality in Health care, 2006; 18(6): 437-45 78 Jorge Hermida, David D Nicholas and Stewart N Blumenfeld, Comparative validity of three methods for assessment of the quality

of primary health care, International Journal for Quality in Health Care, 1999; 11(5): 429-33 79 Avedis Donabediean, The Quality of Care: How can it be assessed?, Journal of American Medical Association 1988; 260: 1743-48.

http://jama.ama-assn.org/search?author1=Avedis+Donabedian&sortspec=date&submit=Submit


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processes of care, and the outcomes of care. Specifying the components or outcomes of

care to be sampled, formulating the appropriate criteria and standards, and obtaining the

necessary information are the steps that follow. Though we know much about assessing

quality, much remains to be known.

3.2 Maternal and Child health

3.2.1 Maternal and Child healthcare

Maternal health refers to the health of women during pregnancy, childbirth and the

postpartum period. While motherhood is often a positive and fulfilling experience, for too

many women it is associated with suffering, ill-health and even death. Most maternal

deaths and pregnancy complications can be prevented by quality ante-natal, care during

delivery period and post natal care.

Antenatal care is the „care before birth‟ to promote the well-being of mother and fetus,

and is essential to reduce maternal morbidity and mortality, low-weight births and peri

natal mortality. However, the content and quality of antenatal care and the availability of

effective referral and essential obstetric care are important for antenatal care to be

effective.80

Ante natal care is generally aimed at producing healthy mother and baby at the end of any

pregnancy.81

It presents important opportunities for reaching pregnant women with a

number of interventions that may be vital to their health and well being and that of their

infants. The antenatal care period also provides a forum to supply information may

positively influence maternal and child outcomes. Thus, it has been suggested that the

antenatal care could play a role in reducing maternal mortality rate82

and that it could

ensure that pregnant woman deliver with the assistance of a skilled attendant.83

Most

maternal deaths and pregnancy complications can be prevented by quality antenatal, natal

and post-natal care.

80 World Health Organsiation, The World Health Report 2005: Make every Mother and Child Count, Geneva, World Health

Organisation, 2005. 81 Lindmark G, Cnattingius S., The scientific basis of antenatal care. Acta obstetricia et gynaecologica scandinavica, 1991; 70: 105-9 82 Pandit RD . Role of antenatal care in reducing maternal mortality. Asia Oceania Journal of Obstetrics and Gynaecology, 1992;18:

1-6. 83 McDonagh M . Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning, 1996; 11: 1-15.


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Stokoe U. (1991)84

concludes that maternal mortality is the culmination of a series of

detrimental events in a woman's life, pregnancy being the last one. And found in their

study that the underlying pathology is the lack of education, sanitation,

accessible health care, as well as poor nutrition and poverty. These affect women during

pregnancy and childbirth when they are more vulnerable.

Pillai G. (1993)85

in their study found that the immediate causes of maternal mortality

include pregnancy and delivery and the management of complications such as

hemorrhage, toxic and bacterial infections (sepsis), eclampsia, and obstructed labor. The

poor health, nutrition, and socioeconomic status of women are the underlying causes

of maternal death. Gender bias in the allocation of meager food supplies results in the

poor health and nutritional status of women, rendering a woman's pelvis too small, which

causes obstructed labor and even death. Socioeconomic status is linked to access the

family planning and health services which affect mortality and reproductive health

Fazili F. et al (1999)86

found their research that peri-natal mortality reflects the amount of

pregnancy wastage due to fetal and neonatal deaths, and is considered a sensitive

indicator of maternal and child health status in particular and community health status in

general. Peri-Natal Mortality Rate (PNMR) was significantly higher among illiterate

mothers, in extremes of age, among those living in joint families, and those having

incomplete antenatal care. PNMR was low among the higher socioeconomic

classes. Maternal weight had a significant effect upon peri natal loss.

Nirmala Murthy et al (2004)87

was carried out a study to explore non-medical factors

responsible for the persistently high maternal mortality in India showed that most deaths

occurred at home and during the postnatal period. Most 'death cases' belonged to high-

risk age groups, had high parity (3+), were socially disadvantaged, had not received

prenatal care and advice to go to hospital as compared to women with complications.

Consequently, they either had not gone to hospital or had gone too late. Delay in care was

84 Stokoe U, Determinants of maternal mortality in the developing world, Australian and Newzealand, Journal of Obstretric and

Gynecology, 1991; 31(1): 8-16. 85 Pillai G, Reducing deaths from pregnancy and childbirth: Asia, Links, NewYork,1993; 9(5): 11-3. 86 Fazili F, Mattoo GM., Epidemiology of Peri-natal mortality: a hospital based study, JK Practitioner, Journal of current clinical

medicine and surgery, 1999; 6(1): 41-5. 87 Nirmala Murthy, Alka Barua, Non-medical Determinants of Maternal Death in India, Journal of Health Management, 2004; 6(1):

47-61.


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also because of lack of transport facilities, inappropriate referrals or poor emergency

preparedness of referral facilities. Data suggested that about half the deaths could have

been avoided if the health system had been alert and accessible. The critical determinants

of avoidable death were families' awareness about complications, emergency transport

and preparedness of referral facilities. The study highlighted the need for health workers

to stress on health education, care during the third trimester and postnatal period, and

referral to appropriate and accessible facilities, even bypassing the hierarchical referral

system if necessary.

Susmita Bharati et al (2007)88

showed in their study that the status of literacy of mothers

and standard of living of the family are of prime importance in improving the obstetric

health care practices. The study indicates that the educated women with high standards of

living have an emphasized role in the practice of more maternal health care. The study

shows that rural antenatal care is still mostly based on Indian traditional system. It is the

women who need to be educated and must be made aware about the importance of the

health care for ensuring healthy pregnancy and safe delivery.

Kayode Osungbade et al (2008)89

in their study to assess the content of antenatal care and

adequacy of maternal health care concluded that the antenatal care service has reasonable

capacity for intervention against pre-eclampsia and some foetal problems and could

contribute to delivery in a health facility and by a health worker and also health care

centers are to be equipped with the capacity to detect anemia and proteinunia in order to

improve the ante natal care service. Furthermore, iron and foliate supplements in

pregnancy should be intensified.

Sadiqua et al (2009)90

in their study of finding the medical and socio economic causes of

maternal deaths, found out that high risk groups are women with low socioeconomic

status, illiteracy, low-earnings jobs, parity and bad obstetric history. The sixty-nine

percent of deaths occurred in the postpartum period, 51% took place within 24 hours of

88 Susmita Bharati, Manoranjan Pal, Premananda Bharati, Obstetric care practice in Birbhum District, West Bengal, India,

International Journal for Quality in Health Care, 2007; 19(4): 244–249. 89 Kayode Osungbade, Samuel Oginni, Aseronke Olunide, Content of antenatal care services in secondary health care facilities in

Nigeria: implication for quality of maternal health care, International Journal for Quality in Health Care, 2008; 20(5): 346– 351. 90 Sadiqua N. Jafarey, Talat Rizvi, Marge Koblinsky, and Nazo Kureshy, Verbal Autopsy of Maternal Deaths in Two Districts of Pakistan Filling information Gaps, Journal of Health, Population and Nutrition 2009; 27(2): 170-183.

http://intqhc.oxfordjournals.org/search?author1=Kayode+Osungbade&sortspec=date&submit=Submit


3-21

delivery. Also study identified gaps in reporting of maternal deaths and profile of the

dead women and causes of death.

Ravendra K. et al (2010)91

in their study demonstrates that utilization of maternal and

child health services is very poor among the tribes of central India. Clinically acceptable

maternal and newborn care practices for delivery, cord cutting and care, bathing of

mother and newborn and skin massage are uncommon. Therefore, newborns remain at

high risk of hypothermia, sepsis and other infections. Prelacteals, supplementary feeding

practices and delay in breastfeeding are very common, although colostrum is less

frequently discarded. Malnutrition is a severe problem among tribes and many tribal

children and women are severely malnourished as well as anemic.

Upadhyay R.P. et al (2012)92

in their study of role of prevalent culturally driven beliefs

and practices in influencing the home based new born care, found that significant portion

of mothers have some beliefs/ practices with respect to care of the cord, taking the baby

out of the house for the first time. Also around 11% of the mothers did not prefer their

baby to be weighed at frequent intervals because according to them, doing so could lead

to slowing of the growth of the baby. Further researchers concluded that Traditional

knowledge and practices must be considered before developing neonatal health care

intervention strategies.

Iron deficiency is the most prevalent nutrient deficiency during pregnancy. According to

the literature, anemia, particularly severe anemia, is associated with increased risk

of maternal mortality. It also puts mothers at risk of multiple perinatal complications.

Numerous studies in the past have evaluated the impact of supplementation with iron-

folic acid 93,94,95,96

and multi nutrient supplements 97,94,98,99

and effectiveness of these

91 Ravendra K. Sharma, Newborn Care among Tribes of Central India Experiences from Micro Level Studies, Social Change

2010; 40(2): 117-137. 92 Upadhyay RP, Singh B, Rao SK, Anand K, Role of cultural beliefs in influencing selected Newborn care Practices in rural

Haryana, Journal of tropical Pediatrics, 2012, Jan 20, advance access [E pub ahead of print] 93 Pathak P, Kapil U, Yainik CS, Kapoor SK, Dwivedi SN, Singh R, Iron, foliate and Vitamin B12 stores among pregnant women in a rural area of Haryana State, India, Food and Nutrition Bulletin, 2007; 28(4): 435-8. 94 Allen LH, person JM, Impact of multiple micronutrient versus iron-folic acid supplements on maternal anemia and micronutrient

status in pregnancy, Food and Nutrition bulletin, 2009; 30(4): 527-32. 95 Sanghavi TG, Harvey Pw, Wainwright E., Maternal iron folic acid supplementation programs: evidence of impact and

implementation, Food and Nutrition bulletin, 2010; 31(2): 100-7. 96 Yakoob MY, Bhutta ZA, Effect of iron supplementation with or without folic acid on anemia during pregnancy, BMC Public

Health, 2011; 11(3): S21.


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interventions on maternal anemia and maternal mortality. The studies have shown that

these supplements improve anemia status and have other benefits for maternal96

and child

nutritional status and birth outcomes.97,100, 99

Collin S.M. et al (2007)101

in their study through model-based analysis by adopting the

effective interventions which have demonstrated potential to prevent maternal deaths

showed that Maternal mortality could be reduced by a combination of micronutrient

supplementation and presumptive treatment of infection during pregnancy. Such an

approach could be adopted in resource-poor settings where visits to antenatal clinics are

infrequent and would complement existing Safe Motherhood activities.

Pena-Rosas J.P. et al (2009)102

found in their study that universal prenatal

supplementation with iron or iron+folic acid provided either daily or weekly is effective

to prevent anemia and iron deficiency at term. We found no evidence, however, of the

significant reduction in substantive maternal and neonatal adverse clinical outcomes (low

birth weight, delayed development, preterm birth, infection, postpartum hemorrhage).

Associated side effects and particularly haemo concentration during pregnancy may

suggest the need for revising iron doses and schemes of supplementation during

pregnancy and adjust preventive iron supplementation recommendations.

Abhay T.B. et al (1999)103

found in their study that home-based neonatal care, including

management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality

by nearly 50% among malnourished, illiterate, rural study population. This approach

would reduce neonatal mortality substantially in developing countries.

97 Sunawang, Utomo B, Hidavat A, Kusharisupeni, Subarkh, Preventing low birth weight through maternal multiple micronutrient supplementation: a cluster randomized, controlled trial in Indramayu, West Java, Food and Nutrition Bulletin, 2009; 30(4l): 488-95. 98 Christian P, Micronutrients, birth weight, and survival, Annual Review of nutrition, 2010; 30: 83-104. 99 Haider BA, Yakoob MY, Bhutta ZA, Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes, BMC Public Health, 2011; 13(11): 3-19. 100 Christian P, Stewart CP, LeClerg SC, Wu L, Katz J, West KP Jr, Khatry SK, Antenatal and Postnatal iron supplementation and

childhood mortality in rural Nepal: a prospective follow-up in a randomized, controlled community trial, American Journal Epidemiology, 2009; 170(9): 1127-36. 101 Collin SM, Baggaley RF, Pittorf R, Filippi V., Could a simple antenatal package combining micronutritional supplementation with

presumptive treatment of infection prevent maternal deaths in sub Saharan African? BMC Pregnancy and Child Birth, 2007; 23(7): 6 102 Pena-Rosas JP, Viteri FE, Effects and safety of preventive oral iron or iron+folic acid supplementation for women during

pregnancy, Cochrane database of systematic review 2009; 7(4): CD004736. 103 Abhay T Bang, Rani A Bang, Sanjay B Baitule, M Hanimi Reddy, Mahesh D Deshmukh, Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India, Lancet 1999; 354: 1955–61.


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Partha De et al (2002)104

study‟s results showed that children are more likely to receive

immunization if their parents are a couple, with the father literate and the mother with at

least a middle-school-education level who received antenatal care or delivered in an

institutional environment.

Gokhale M.K. et al (2002)105

showed in their study that Illiteracy of females had a more

detrimental impact on rural than on urban areas. In the event of high female illiteracy,

male literacy was beneficial for improving the use of services for reducing infant

mortality rate. The micro-level study supported all major findings obtained for the

national-level aggregate data. Programmes, like providing free education to girls, will

yield long-term health benefits.

Adam Wagstaff et al (2004)106

evidently showed in their study that in most countries,

rates of mortality and malnutrition among children continue to decline, but large

inequalities between poor and better-off children exist, both between and within

countries.

Anita Raj et al (2010)107

showed in their study that infant and child malnutrition is

significantly more likely among the children born to mothers married as minors than in

those born to women married as adults. Also study concludes that, association between

the maternal child marriage and low infant birth weight as well as infant and child

mortality seem to be a consequence of early motherhood, low maternal education, and

other indicators of poor maternal health and socioeconomic status factors all significantly

linked to early marriage of girls.

104 Partha De, B.N. Bhattacharya, Determinants of child immunization in four less developed states of North India, Journal of Child

Health Care, 2002, 6: 134-50. 105 Gokhale MK, Rao SS, Garole VR, Infant mortality in India: use of maternal and child health services in relation to literacy,

Journal of Health, Population and Nutrition, 2002; 20(2): 138-47. 106 Adam Wagstaff, , Flavia Bustreo, , Jennifer Bryce, , Mariam Claeson, , Child Health: Reaching the poor, Worls Health Organisation–World Bank Child Health and Poverty Working Group, American Journal of Public Health, 2004; 94(5): 726–736. 107 Anita Raj, Niranjan Saggurti, Michael Winter, Alan Labonte, Michele R Decker, Donta Balaiah, Jay G Silverman, The effect of

maternal child marriage on morbidity and mortality of under 5 in India: cross sectional study of a nationally representative sample,

BMJ 2010; 340: b4258.


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3.2.2 Utilization of services, Perception and Patients Satisfaction

Health care services are not reaching their programme goals because of poor utilization.

Provision and utilization can only be brought into balance if there is an understanding of

people‟s health seeking behaviour and the felt needs of communities

Bhardwaj N. et all (1990)108

shows that there is a wide gap between provision and

utilization of maternal care services. Since most of the deliveries are conducted at home

by untrained traditional birth attendants, the people must be educated to utilize

the services of trained personnel.

Huebner et al (2001)109

showed that expanded services during the prenatal period will

lead to increase in reported patient satisfaction, provider satisfaction and organizational

efficiency within the health care delivery system.

Dilip T.R. (2002)110

found from their study that the preference of public / private sector

depends on nature of service in demand. The role of private providers in health care was

found to be limited in the case of family planning services, but almost 50 per cent availed

delivery care services from the private sector. A majority of women were found to prefer

treatment from the private medical service providers if their children were suffering from

fever or cough. Class differentials were severe, with the public sector being the major

provider of Reproductive and Child Health care services for the poorer sections of

society. People with a higher potential to pay preferred the private sector irrespective of

the nature of service they required.

Rani M. et al (2003)111

use the data from the India National Family and Health Survey-2

conducted in 1998-99 to investigate the level and correlation of care-seeking and choice

of provider for gynecological symptoms among currently married women in rural India.

Of the symptomatic women surveyed, Care-seeking behavior and type of providers

108 Bhardwaj N, Yunus M, Hasan SB, Zaheer M, Role of birth attendants in maternal care services a rural study, Indian Journal of Maternal and Child Health, 1990; 1: 29-30. 109 C.E.Huebner, L.Tyll, Luallen, B.D.Johnston and R.S. Thompson, PrePare: a program of enhanced prenatal services within health

maintenance organization settings, Health Education Research, 2001; 16(1): 71–80. 110 Dilip,T.R. Utilisation of Reproductive and Child Health Care Services: Some Observations from Kerala, Journal of Health

Management, 2002; 4(1): 19-30. 111 Rani M, Bonu S, Rural Indian Womens Care–Seeking Behaviour and choice of provider for gynecological symptoms, Studies in

Family Planning, 2003; 34(3): 173 -85.


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consulted varied significantly across different Indian states. Significant differentials in

care-seeking by age, caste, religion, education, household wealth, and women's autonomy

suggest the existence of multiple cultural, economic, and demand-side barriers to care-

seeking. Although socially disadvantaged women were less likely than better-off women

to consult private providers, the majority of even the poorest, uneducated, and lower-

caste women consulted private providers. Geographical access to public health facilities

had no significant association with choice of provider, whereas access to private

providers had only a moderately significant association with that choice. The

predominance of use of private services for self-perceived gynecological morbidity

warrants the inclusion of private providers in the national reproductive health strategy to

enhance its effectiveness.

Harriott E.M. et al (2005)112

found in their study that women‟s satisfaction with delivery

care was associated with aspects of quality of care, including courtesy and availability of

staff, confidence in providers, being treated with respect, receiving information and

physical comfort.

Senarath et al (2006)113

in their study on delivery care, showed that, women‟s satisfaction

was associated with their characteristics of parity, ethnic group and income level, as well

as hospital type, immediate mother newborn contact and receipt of information after

examination

Ram F. et al (2006)114

through Multilevel analysis shows that after controlling for other

socioeconomic and demographic factors, utilization of antenatal care services may lead to

the utilization of other maternal health related services such as institutional delivery,

delivery assisted by trained professionals, seeking advice for pregnancy complications,

and seeking advice for post-delivery complications. There is strong clustering of

utilization of services within the primary sampling units (i.e. villages) and districts.

112 Harriott EM, Williams TV, Peterson MR. Childbearing in US military hospitals: dimensions of care affecting women’s perceptions

of quality and satisfaction. Birth 2005; 32: 4–10. 113 Senarath U, Fernando DN, Rodrigo I. Factors determining client satisfaction with hospital-based perinatal care in Sri Lanka,

Tropical Medicine and International Health, 2006; 11: 1442–51. 114 Ram F, Singh A., Is antenatal care effective in improving maternal health in rural Uttar Pradesh? Evidence from a district level household survey, Journal of Biosocial Sciences, 2006; 38(4): 433-48.


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Guha Mazumdar P. et al (2007)115

in their study shows that, for the majority of women's

health problems biomedicine is regarded as the first choice, failure of which leads clients

to seek treatment from Indian System of Medicine (ISM) as a final resort. Nevertheless,

women showed a preference for ISM treatment for certain specific health problems,

strongly backed by a belief in their efficacy. Of the predictors that positively influenced

women's choice of ISM treatment, 'strong evidenced-based results' was found to be the

most important. Women's preference for ISM is dependent on the availability of

competent providers.

Collin S.M. et al (2007)116

found in their study that the trend in professional attendance

was entirely confounded by socioeconomic and demographic changes, but education of

the woman and her husband remained important determinants of utilization of

obstetric services. Despite commendable progress in improving uptake of antenatal care,

and in equipping health facilities to provide emergency obstetric care, the very low

utilization of these facilities, especially by poor women, is a major impediment to

meeting MDG-5.

Simkhada B. et al (2008)117

found in their study that the factors affecting antenatal care

uptake: maternal education, husband's education, marital status, availability, cost,

household income, women's employment, media exposure and having a history of

obstetric complications. Cultural beliefs and ideas about pregnancy also had an influence

on antenatal care use. Parity had a statistically significant negative effect on adequate

attendance. Whilst women of higher parity tend to use antenatal care less, there is

interaction with women's age and religion. Only one study examined the effect of the

quality of antenatal services on utilization. None identified an association between the

utilization of such services and satisfaction with them.

115 Guha Mazumdar P., Gupta K., Indian system of medicine and women’s health: a client’s perspective, Journal of Biosocial Science,

2007; 39 (6): 819-41. 116 Collin SM, Anwar I, Ronsmans C, A decade of inequality in maternity care: antenatal care, professional attendance at delivery

and caesarean section in Bangladesh (1991 – 2004), International Journal of equity in health, 2007; 6: 19-23. 117 Simkhada B, Teijlingen ER, Porter M, Simkhada P., Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature, Journal of Advanced Nursing, 2008; 61(3): 244-60.


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Eva S. Basant et al (2009)118

showed in their study that women‟s satisfaction with

delivery care was associated with greater provider empathy. Women delivering at private

facilities in the settlement near the industrial area were more satisfied than women

delivering at private facilities in the more distant and marginalized settlement. The

association of women‟s satisfaction and provider empathy was stronger among women

who experienced complications compared to those who did not. Maternal health

programmes should focus on increasing provider empathy, especially for women who

experience complications, in both private and government health facilities.

Das P. et al (2010)119

in their study of client satisfaction receiving some components of

maternal and child health services at health centers and sub centers in a rural area, found

that the degree of patient satisfaction was closely related to the services given, recipients'

perception on care providers. The deficiency that remained might be overcome by

generating awareness among the community by holding mothers' meetings and extensive

IEC program, inviting opinions and suggestions from the clients and encouraging

enhanced community participation.

Singh M.K. et al (2010)120

showed in their study that educated Recently Delivered

Women (RDW), those belonging to higher socio-economic class, Hindus in reference to

Muslims, young RDW and those with low parity were more likely to utilize ASHA

services for early registration, adequate ANC and postnatal check-up. On the other hand,

contrary to previous studies, women from lower castes were more likely to avail antenatal

and postnatal care. The reason for discordance is better approach of ASHA and her

ability to connect and convince the women belonging to lower caste.

118 Eva S. Bazant, Michael A. Koenig, Women’s satisfaction with delivery care in Nairobi’s informal settlements, International Journal

for Quality in Health Care 2009; 21(2): 79–86 119 Das P, Basu M, Tikadar T, Biswas GC, Mridha P, Pal R., Client satisfaction on maternal and child health services in rural Bengal. Indian Journal of Community Medicine, 2010; 35: 478-81. 120 Singh MK, Singh JV, Ahmad N, Kumari R, Khanna A., Factors influencing utilization of ASHA services under NRHM in relation

to maternal health in rural Lucknow. Indian Journal of Community Medicine, 2010; 35: 414-419.


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3.2.3 Maternal and Child Health Care Services delivery

In recent years developing countries, influenced heavily by findings in developed

countries, have become increasingly interested in assessing the quality of their health

care. Outcomes have received special emphasis as a measure of quality. Assessing

outcomes has merit both as an indicator of the effectiveness of different interventions and

as part of a monitoring system directed to improving quality of Care. Quality assessment

studies usually measure one of three types of outcomes: medical outcomes, costs, and

client satisfaction. For the last mentioned, clients are asked to assess not their own health

status after receiving care but their satisfaction with the services delivered.

Most maternal deaths are avoidable, as the health-care solutions to prevent or manage

complications are well known. All women need access to antenatal care in pregnancy,

skilled care during childbirth, and care and support in the weeks after childbirth. It is

particularly important that all births are attended by skilled health professionals, as timely

management and treatment can make the difference between life and death.

Facuveau V. et al (1991)121

showed in their study that maternal survival can be improved

by the posting of midwives at village level, if they are given proper training, means,

supervision, and back-up. The inputs for such a programme to succeed and the

constraints of its replication on a large scale should not be underestimated.

Sundari T.K. (1992)122

in their study put together evidence from maternal mortality

studies in developing countries of how an inadequate health care systems characterized

by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of

essential health information to the women most affected, and the physical as well as

economic and socio-cultural distance separating health services from the vast majority of

women, are only part of the problem. Even when the woman reaches a health facility,

there are a number of obstacles to her receiving adequate and appropriate care. These are

121 Fauveau V, Stewart K., Khan SA., Chakraborty J., Effect on mortality of community-based maternity care programme in rural Bangladesh, 1991; 38(6): 1183-6. 122 Sundari TK, The untold story: how the health care systems in developing countries contribute to maternal mortality, International

Journal of health services, Planning, Administration and Evaluation,1992; 22(3): 513-28


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a result of failures in the health services delivery system: the lack of minimal life-saving

equipment at the first referral level; the lack of equipment, personnel, and know-how

even in referral hospitals; and worst of all, faulty patient management. Prevention of

maternal deaths requires fundamental changes not only in resource allocation, but in the

very structures of health services delivery. Further, they concluded that most of the

maternal mortality is due to “avoidable factors” either patient factors or structural factors.

Patient factors are defined as those actions by the patient that are faulty: delayed arrival

or non arrival at a health facility, failure to seek legal abortion or interference with

pregnancy, nonuse of prenatal care, and transportation problems. Structural factors are

inaccessible health services and failures in the health services delivery system with

shortage of trained personnel, lack of equipment and supplies, and poor patient

management.

Thaddeus S. et al (1994)123

research on the factors that: (1) delay the decision to seek

care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care,

findings from their study indicates that while distance and cost are major obstacles in the

decision to seek care, the relationships are not simple. There is evidence that people often

consider the quality of care more important than cost. These three factors--distance, cost

and quality--alone do not give a full understanding of decision-making process. Their

salience as obstacles is ultimately defined by illness-related factors, such as severity. Also

they found in their study that shortages of qualified staff, essential drugs and supplies,

coupled with administrative delays and clinical mismanagement, become documentable

contributors to maternal deaths.

Martey J.O. et al (1994)124

found in their study that prenatal care alone is not sufficient to

prevent some deaths. The high mortality rate during delivery is a justification to improve

the quality of care during delivery at all levels of the district health system. Causes

of maternal death were postpartum hemorrhage (45.5%), jaundice in pregnancy (22.7%),

obstructed labor (6.8%), eclampsia (6.8%), and fever (4.6%). 2.3% of deaths were

attributed to ante partum hemorrhage, ectopic pregnancy, and septic abortion.

123 Thaddeus S, Maine D, Too far to walk: maternal mortality in context, Social Science and Medicine, 1994; 38(8): 1091-110. 124 Martey JO, Dian JO, Twum S, Browne EN, Opoku SA, Maternal mortality and related factors in Eisu District, Ghana, East

African Medical Journal, 1994; 71(10): 656-60.


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Kwast B.E. (1996) 125

found in their study that access was improved through training of

traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery

/neonatal complications, while quality of care in health facilities was improved through

modifying health professionals' attitude towards TBAs and clients, and implementation of

management protocols.

Bloom S.S. et al (1999)126

in their study of evidence to support that antenatal screening

and interventions are effective in reducing maternal mortality found out through Logistic

Regression that the women with relatively high level of care had an estimated odds of

using trained assistance at delivery than that was almost four times higher than women

with low level of care. And similar results were shown for the women delivering in health

facility versus home. This strong positive association between level of care obtained

during pregnancy and the use of safe delivery care may help explain why antenatal care

could also be associated with reduced maternal mortality.

Drazancic A. (2001) 127

in their study found that the bad socioeconomic background and

a lack of organized antenatal and perinatal health care system are the reasons for high

maternal and perinatal mortality. Authors concluded that the policy with respect to

improvement of antenatal booking, the number of prenatal visits of pregnant women,

their childbearing under professional assistance to be adopted to decrease maternal and

perinatal mortality.

Majumdar A. et al (2004)128

found in their study that doctors are technically more

resourceful than any other supporting, Paramedical personnel. However, in rural India the

people are more dependent on the latter which play a dominant role. If we consider the

elasticity coefficients as a measure of productivity then in the rural health care system

Paramedical Staff are more productive than the Doctors. Geographical factors, social

structure, family characteristics, and quality of care also work as the main determinants

125 Kwast BE, Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works? European journal of

Obstetrics, Gynecology and reproductive biology, 1996; 69(1): 47-53. 126 Bloom SS, Lippeveld. T., Wypli D., does antenatal care make a difference to safe delivery? A study in Urban Uttar Pradesh, India, Health Policy and Planning, 1999; 14(1): 38-48. 127 Drazancic A,Antenatal care in developing countries: what should be done?, Journal of Perinatal Medicine, 2001; 29(3): 188-98. 128 Majumdar Aman , V. Upadhyay, An Analysis of the Primary Health Care system in India with focus on reproductive health care services, Artha Beekshan 2004, 12(4): 29 -38.


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of the utilization of health care services. Education of the acceptors is also an important

factor. Our study reveals that as education increases people are likely to avoid public

health facilities for reproductive health related services. This may be due to poor quality

of services provided at the health centers.

Moran A.C. et al (2006)129

highlight their findings from their study that how birth-

preparedness and complication readiness may be useful in increasing the use of skilled

providers at birth, especially for women with a plan for saving money during pregnancy.

Controlling for education, parity, average distance to health facility, and the number of

antenatal care visits, planning to save money was associated with giving birth with the

assistance of a skilled provider.

Hossain J. et all (2006)130

found in their study of impact of interventions on use of

obstetric services in government facilities that the best results are achieved through a

combination of facility improvement, quality of care activities and targeted community

mobilization activities.

Margaret E.K. (2007)131

found in their study that greater government participation in

health financing and higher levels of health spending are associated with increased

utilization of two maternal health services: skilled birth attendants and Caesarean section.

While government financing is associated with better access to some essential maternal

health services, greater absolute levels of health spending will be required if developing

countries are to achieve the Millennium Development Goal on maternal mortality.

Abdullah H.B. et al (2008)132

found in their study that NGO facilitation of government

programmes is a feasible strategy to improve equity of maternal and neonatal health

programmes. Improvements in equity were most pronounced for household practices, and

129 Moran AC, Sangli G, Dineen R, Rawlins B, Yameogo M, Bava B, Birth-preparedness for maternal health: findings from Koupela

District, Burkina Faso, Journal of Health, Population and Nutrition, 2006; 24(4): 489-97. 130 Hossain J, Ross SR, The effect of addressing demand for as well as supply of emergency obstetric care in Dinapur, Bangladesh, Human Resources for Health, 2006, 92 (3) : 320 – 8. 131 Margaret E Kruk, Sandro Galea, Marta Prescott and Lynn P. Freedman, Health care financing and utilization of maternal health

services in developing countries, Health Policy and Planning 2007; 22: 303–310. 132 Abdullah H Baqui, Amanda M Rosecrans, Emma K Williams, Praween K Agrawal, Saifuddin Ahmed, Gary L Darmstadt,

Vishwajeet Kumar, Usha Kiran, Dharmendra Panwar, Ramesh C Ahuja, Vinod K Srivastava, Robert E Black and Mathuram

Santosham , NGO facilitation of a government community-based maternal and neonatal health programme in rural India: improvements in equity, Health Policy and Planning 2008; 23: 234–243.


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inequities were still apparent in health care utilization. The equity of programme

coverage and antenatal and newborn care practices improved from baseline to end line in

the intervention district while showing little change in the comparison district. Equity in

health care utilization for mothers and newborns also showed some improvements in the

intervention district, but notable socio-economic differentials remained, with the poor

demonstrating less ability to access health services.

Manju Rani et al (2008)133

showed through their study on differentials in the quality of

antenatal care that poor quality of antenatal care is likely to reduce its utilization. Policy

and program interventions to improve the quality of care of antenatal care, especially for

the poor and other disadvantaged population groups.

Anwar et al (2009)134

concluded in their research that the human-resource constraints are

the major barrier for maternal health. Sanctioned posts for nurses are inadequate in rural

areas of both the divisions; however, deployment and retention of trained human

resources are more problematic in rural areas. To improve maternal healthcare, there is a

need for a human-resource plan that increases the number of posts in rural areas and

ensures availability. All categories of maternal healthcare providers also need training on

evidence-based techniques. The authors recommend special strategies for improving the

response in the low-performing areas is urgently warranted.

Chowdhury Mahbub Elahi et al (2009)135

showed through their study that access to and

use of comprehensive Emergency Obstetric Care (EmOC) services possibly is the major

contributor to the reduction in maternal mortality. Policies that bring expansion of female

education, later childbearing, better financial access to the poor, and poverty alleviation

are also essential to sustain the success achieved to date.

133 Manju Rani, Sekhar Bonu, Steve Harvey, Differentials in the quality of antenatal care in India, International Journal for Quality in

Health Care 2008; 20(1): 62 –71. 134 Anwar I, Kalim N. and Koblinsky M. Quality of obstetric care in public-sector facilities and constraints to implementing emergency obstetric care services: evidence from high- and low-performing districts of Bangladesh, 2009. Report of Centre for Health

and Population Research (ICDDR), Bangladesh. 135 Chowdhury Mahbub Elahi, Anisuddin Ahmed, Nahid Kalim, and Marge Koblinsky, Causes of Maternal Mortality Decline in Matlab, Bangladesh, Journal of Health, Population and Nutrition, 2009; 27(2): 108-123.


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Mrisho M. et al (2009)136

found in their study that efforts to improve antenatal and

postnatal care should focus on addressing geographical and economic access while

striving to make services more culturally sensitive. Antenatal and postnatal care can offer

important opportunities for linking the health system and the community by encouraging

women to deliver with a skilled attendant. Addressing staff shortages through expanding

training opportunities and incentives to health care providers and developing postnatal

care guidelines are key steps to improve maternal and newborn health.

Lawn J.E. et al (2009)137

showed in their study that even in high-performance settings,

there is scope to improve intra partum care and especially reduce impairment and

disability. Addressing missed opportunities for births already occurring in facilities could

avert 36% of intra partum-related deaths. Improved quality of care through drills and

audit are promising strategies. However, the majority of deaths occur in poorly

performing health systems requiring urgent strategic planning and investment to scale up

effective care at birth, neonatal resuscitation, and community mobilization as well as to

develop, adapt, and introduce tools, technologies, and task shifting to reach the poorest.

Sharad D. Iyengar et al (2009)138

study‟s findings indicate that several factors had

contributed to maternal mortality. Lack of skilled attendance and immediate postpartum

care were major factors contributing to deaths. Improved access to emergency obstetric

care facilities in rural areas and steps to eliminate costs at public hospitals would be

crucial to prevent pregnancy-related deaths. Although the high prevalence of health

conditions and diseases, including TB and anemia, are identifiable as direct or indirect

causes of death, important societal and health systems factors constrain women from

accessing quality health services. If reduction in maternal mortality is to become a reality,

women in rural regions will require more efficient access to high-quality delivery and

emergency services at an affordable cost.

136 Mrisho M, Obrist B, Schellenberg JA, Haws RA, Mushi AK, Mshinda H, Tanner M, Schellenberg D, The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy and

Childbirth, 2009; 9: 10-22. 137 Lawn JE, Kinney M, Lee AC, Chopra M, Donnay F, Paul VK, Bhutta ZA, Bateman M, Darmstadt GL, Reducing intra partum-related deaths and disability: can the health system deliver?, International Journal of Gynecology and Obstetrics, (The official

organ of the International Federation of Gynecology and Obstetrics), 2009; 107: 123-40, 140-2. 138 Sharad D. Iyengar, Kirti Iyengar, Virendra Suhalka, and Kumaril Agarwal, Comparison of Domiciliary and Institutional Delivery care Pracices in Rural Rajastan, India, Journal of Health, Population and Nutrition 2009; 27(2): 293-312.


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Further they concluded that widespread irrational practices by a range of care providers

in both homes and facilities can adversely affect women and newborns while inadequate

observance of beneficial practices and high costs are likely to reduce the benefits of

institutional delivery, especially for the poor. Government health agencies need to

strengthen regulation of delivery care and, especially, monitor perinatal outcomes.

Family preference for hastening delivery and early discharge also require educational

efforts.

Sharma M.P. et al (2009)139

found in their study on assessment of institutional deliveries

under Janani SurakshaYojana ((JSY) that the quality aspects of institutional deliveries are

far from desired level mostly because of lack of resources, both manpower and materials;

non achievement of Indian Public Health Standards etc. The service quality related to

antenatal, intra natal and postnatal care need to be improved. The Janani SurakshaYojana

is perceived as an effective scheme by the beneficiaries but gaps in resources and lack of

quality of services needs to be adequately dealt with. It is found that the necessary drugs

were in short supply and use of partogaraph was absent in health facilities. Also the

quality of emergency obstetric care services (EmOC) was still poor due to the lack of

blood storage units and anesthetists. Further they found out that private accredited

hospitals fared better as they had the manpower and managed more complicated cases as

compared to government facilities.

Dogba M. et al (2009)140

in their study concluded that (a) staff shortages are a major

obstacle to providing good quality EmOC, (b) women are often dissatisfied with the care

they receive during child birth and (c) the technical quality of EmOC has not been

adequately studied.

Sharad D. Iyengar et al (2009)141

concluded in their study that there is a lack of doctors

in the PHCs, especially in tribal districts, and the availability of specialists at higher

levels is even worse. Their review further shows that human-resource capacity, especially

139 Sharma MP, Soni SC, Bhattacharya M, Datta U, Gupta S, Nanadan D, An assessment of institutional deliveries under JSY at

different levels of health care in Jaipur district, Rajasthan, Indian Journal of Public Health, 2009, 53 (3) : 177-82. 140 Dogba M, Fournier P, Human resources and the quality of emergency obstetric care in developing countries: a systematic review

of the literature, Human Resource for Health, 2009: 7:7 141 Sharad D. Iyengar1, Kirti Iyengar1, and Vikram Gupta, Maternal Health – A case study of Rajasthan, Journal of Health,

Population and Nutrition 2009; 27(2): 271-292.


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of specialists and skilled midwives, has been deficient, and referral arrangements

continue to be weak. Non-residence on part of field staff, such as ANMs, whose personal

mobility, security, and family needs have not been met, seriously impedes access to

round-the-clock services. Efforts, such as raising salaries or contracting private

practitioners, have failed to boost the availability of specialists adequately. The reasons

for lack of staff are multiple. While anecdotal evidence points to the apparent perception

of lack of safety, especially for female staff in some areas, there is little to attract

specialists to government service. Several specialists posted at the CHCs manage to get

themselves posted in peri-urban CHCs or „on-deputation‟ in district hospitals. Given the

unwillingness of specialists to provide services at rural CHCs, the Government should

train and empower much greater numbers of graduate doctors to provide EmOC services.

Amarit Singh et al (2009)142

showed that it is possible to develop large-scale partnerships

with the private sector to provide skilled birth attendants and emergency obstetric care to

poor women at a relatively small cost. Poor women will take up the benefit of skilled

delivery care rapidly, if they do not have to pay for it.

Bhatta Z.A. et al (2010)143

amply demonstrated in their review that opportunities for

assessing outcomes for both mothers and newborns have been poorly realized and

documented. Most of the interventions reviewed will require more greater-quality

evidence before solid programmatic recommendations can be made.

However, on the basis of our review they conclude that, birth spacing, prevention of

indoor air pollution, prevention of intimate partner violence before and during pregnancy,

antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy,

insecticide-treated mosquito nets, birth and newborn care preparedness via community-

based intervention packages, emergency obstetrical care, elective induction for post term

delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in

preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth

142 Amarjit Singh, Dileep V Mavalankar, Ramesh Bhat, Ajesh Desai, SR Patel, Prabal V Singh, and Neelu Singh, Providing skilled birth attendants and emergency obstetric care to the poor through partnership with private sector obstetricians in Gujarat, India,

Bulletin of World Health Organisation, 2009; 87(12): 960–964. 143 Bhutta ZA, Lassi ZS, Blanc A, Donnay F, Linkages among the reproductive health, maternal health and perinatal outcomes, seminar in Perinatology, 2010; 34(6): 434-45.


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and newborn care preparedness through community-based intervention packages reduce

neonatal mortality.

Further Their review demonstrates that Reproductive, Maternal and Newborn Health

(RMNH) are inextricably linked, and that, therefore, health policies and programs should

link them together. Such potential integration of strategies would not only help improve

outcomes for millions of mothers and newborns but would also save scant resources. This

would also allow for greater efficiency in training, monitoring, and supervision

of health care workers and would also help families and communities to access and

use services easily.

Magoma M. et al (2010)144

showed in their research that increasing coverage of skilled

delivery care depends upon improved training and monitoring of health care providers

and greater family participation in antenatal care visits.

Christiana R.T. et al (2010)145

found in their study that strategies to increase the

accessibility and availability of health care services are important particularly for

communities in rural areas. Financial support that enables mothers from poor households

to use health services will be beneficial. Health promotion programs targeting mothers

with low education are vital to increase their awareness about the importance of antenatal

services.

Amanda Harris et al (2010)146

showed that utilization of maternal health care services is

associated with a range of social, economic, cultural and geographic factors as well as the

policies of the state and the delivery of services. Utilization is not necessarily increased

through easy access to a health facility and also identified the potential for improving

utilization through developing the role of village-based health care workers, expanding

mobile antenatal care clinics and changing the way township hospital services are

144 Magoma M, Requejo J, Campbell OM, Cousens S, Filippi V, High ANC coverage and low skilled attendance in a rural Tanzanian

district: a case for implementing a birth plan intervention, BMC Pregnancy and Child birth, 2010, 19: 10-13. 145 Christiana R Titaley, Michael J Dibley, Christine L Roberts, Factors associated with underutilization of antenatal care services in Indonesia: results of Indonasia demographic and Health survey 2002/2003 and 2007, BMC Public Health 2010; 10: 485. 146 Amanda Harris, Yun Zhou, Hua Liao, Lesley Barclay, Weiyue Zeng and Yu Gao, Challenges to maternal health care utilization

among ethnic minority women in a resource-poor region of Sichuan Province, China , Health Policy and Planning, 2010; 25(4): 311-

318.

http://heapol.oxfordjournals.org/search?author1=Weiyue+Zeng&sortspec=date&submit=Submit


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provided and funded.

Sheela Saravanan (2010)147

while assessing the contribution of Traditional Birth

Attendants (TBAs) in providing maternal and infant health care service at different stages

of pregnancy and after-delivery and birthing practices adopted in home births, found out

that apart from TBAs, there are various other people in the community also involved in

making decisions about the welfare and health of the birthing mother and new born baby.

However, TBAs have changing, localised but nonetheless significant roles in delivery,

postnatal and infant care in India. Certain traditional birthing practices such as bathing

babies immediately after birth, not weighing babies after birth and not feeding with

colostrum are adopted in home births as well as health institutions in India. There is

therefore a thin precarious balance between the application of biomedical and traditional

knowledge. Customary rituals and perceptions essentially affect practices in home and

institutional births and hence training of TBAs need to be implemented in conjunction

with community awareness programmes.

Ekabua J. et al (2011)148

found through their study that Awareness of birth preparedness /

complication readiness, by parturient, during antenatal care was very low. (21.5%). To

reduce maternal deaths through antenatal care, it is critical to link antenatal care with

detecting and treating causes of maternal mortality by a skilled attendant.

Gross K. et al (2011)149

found out in their study that efforts to improve antenatal care

should address shortages of trained staff through expanding training opportunities,

including health worker cadres with little pre-service training. Attention should be paid to

the identification of informal practices resulting from individual coping strategies and

"street-level bureaucracy" in order to tackle problems before they become part of the

organizational culture.

147 Sheela Saravanan, Gavin Turell, Helen Johnson, Jennifer Fraser, Birthing Practices of Traditional Birth Attendants in South Asia in

the Context of Training Programmes, Journal of Health Management, 2010 ; 12(2): 93-121. 148 Ekabua J, Ekabua K, Nioku C, Proposed framework for making focused antenatal care services accessible: a review of the

Nigerian setting, ISRN Obstetric and Gyneocology,2011; 253964 Epub 2011 Dec 29 149 Gross K, Armstrong Schellenberg J, Kessy F,Pfeiffer C, Obrist B, Antenatal care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. BMC Pregnancy and Childbirth, 2011; 11: 36.


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Nyamterna A.S. et al (2011)150

study presents a list of evidenced-based packages of

interventions for maternal health, their impacts and factors for change in resource limited

countries. It indicates that no single magic bullet intervention exists for reduction

of maternal mortality and that all interventional programs should be integrated in order to

bring significant changes. State leaders and key actors in the health sectors in these

countries and the international community are proposed to translate the lessons learnt into

actions and intensify efforts in order to achieve the goals set for maternal health.

Programs integrating multiple interventions were more likely to have significant positive

impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement

of care providers, and refurbishment of existing health facility infrastructure and

improved supply of drugs, consumables and equipment for obstetric care were the most

frequent interventions integrated in reviewed programs. Statistically significant reduction

of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the

programs respectively. Births in Emergency Obstetric Care facilities and caesarean

section rates increased significantly in 71%-75% of programs using these indicators.

Insufficient implementation of evidence-based interventions in resources limited

countries was closely linked to a lack of national resources, leadership skills and end-

users factors.

Nyametema A.S. et al (2011)151

study‟s findings indicate that audit can be implemented

in rural resource limited settings and suggest that the vast majority of maternal mortalities

and severe morbidities can be averted even where resources are limited if strategic

interventions are implemented. Improving responsiveness to obstetric emergencies,

capacity building of the workforce for health care, referral system improvement and

upgrading of health centers located in hard to reach areas to provide comprehensive

emergency obstetric care (CEmOC) were proposed and implemented as a result of audit.

150 Nyamtema AS, Urassa DP, Van Roosmalen J, Maternal health interventions in resource limited countries: a systematic review of

packages, impacts and factors for change.BMC Pregnancy and Child birth, 2011; 11: 30. 151 Nyamtema AS, De Jong AB, Urassa DP, Van Roosmalen J, Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania, BMC Pregnancy and Child birth, 2011; 11: 94.


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Gabrysch S. et al (2011)152

concluded from their review that there is ample evidence that

higher maternal age, education and household wealth and lower parity increase use, as

does urban residence. Facility use in the previous delivery and antenatal care use are also

highly predictive of health facility use for the index delivery, though this may be due to

confounding by service availability and other factors. Obstetric complications also

increase use but are rarely studied. Quality of care is judged to be essential in qualitative

studies but is not easily measured in surveys, or without linking facility records with

women. Distance to health facilities decreases use, but is also difficult to determine.

Further they conclude that studies of the determinants of skilled attendance concentrate

on socio cultural and economic accessibility variables and neglect variables of perceived

benefit/need and physical accessibility.

Chakrabarti et al (2012)153

enlisted major findings of their study as follows. First, a

woman with greater educational qualification and autonomy in terms of her power to take

decisions on her own, control over household resources and complete freedom to move

beyond the confines of her household exerts a significant influence on the probability of

seeking care. In addition to this, formal care is more likely to be sought for children

whose mothers are more exposed to the media. Programmes devised to enhance

utilization of formal health care for children should be targeted to catering for the needs

of the vulnerable group i.e. female child, predominantly, residing in households

belonging to Scheduled Tribe. In addition to this, children belonging to Muslim

households are at higher risk of contracting the diseases but there is no significant

difference in their health seeking behavior as compared to other religious groups.

152 Gabrysch S, Campbell OM, Still too far to walk: literature review of the determinants of delivery service use, BMC Pregnancy and Childbirth, 2009; 9: 34. 153 Chakrabarti, Anindita, Determinants of child morbidity and factors governing utilization of child health care: evidence from rural

India. Applied Economics, 2012; 44(1): 27-37.


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3.3 Health education and Health promotion

Health education is widely promoted in primary care, but there have been few rigorous

evaluations of its impact, especially in developing countries The efficacy of health

education interventions that rely solely on giving people information to bring about a

change in health behaviour is unproved; interventions should be evaluated before being

implemented on a large scale Alternative strategies for health promotion in developing

countries such as interactions within families, peer groups, or communities may be more

effective but are costly and difficult to implement on a large scale.

According to Alma Ata declaration of 1978, the rational approach to health promotion,

information given by health workers during clinic based or community based contacts

will bring about a change in health behaviour, is an integral part of primary healthcare

strategies. In practice, opportunities for one to one health education are given low priority

by busy health workers. Health education and information is critical for ensuring people‟s

participation in rural health service.

Cleland J.G. et al (1988)154

concluded through their study that during the past two

decades a considerable amount of information has become available from developing

countries showing that maternal education has a strong impact on infant

and child mortality. On average each one-year increment in mother's education

corresponds with a 7-9% decline in under-5s' mortality. Education exercises a stronger

influence in early and later childhood than in infancy.

Paivi Rautava et al (1990)155

found in their study on women‟s opinion on antenatal

training courses that according to puerperal women the training courses increased their

knowledge, helped them to cope up with pregnancy and delivery and helped in reducing

anxiety but few felt that the information they received was out-of-date, inadequate and

154 Cleland JG, Van Ginneken JK, Maternal education and child survival in developing countries: the search for pathways of

influence, 1988; 27(12): 1357-68. 155 Päivi Rautava, Risto Erkkola, Matti Sillanpää, The Finnish Family Competence Study: new directions are necessary in antenatal education, Health Education Research,1990; 5(3): 353-359.

http://her.oxfordjournals.org/search?author1=P%C3%A4ivi+Rautava&sortspec=date&submit=Submit

http://her.oxfordjournals.org/search?author1=Risto+Erkkola&sortspec=date&submit=Submit

http://her.oxfordjournals.org/search?author1=Matti+Sillanp%C3%A4%C3%A4&sortspec=date&submit=Submit


3-41

poorly presented. women wanted more detailed information about both normal and

abnormal delivery, as well as life at home after delivery.

Rajna P.N. et al (1998)156

shows through their study on the effect of maternal education

on child mortality that education has direct as well as indirect effects through antenatal

care and family formation patterns on neonatal mortality. Maternal education also has a

substantial effect on later childhood mortality. While improving maternal education is a

means of reducing childhood mortality, an immediate reduction in childhood mortality is

feasible even under existing social conditions by enhancing accessibility to maternal and

child health services and safe drinking water.

Anne McDonald Culp et al (2007)157

found out in their study that mothers who received

early education home visits from child development specialists experienced positive

health and safety outcomes. Further, authors have highly recommended that a program

such as this be implemented as part of health delivery program with new mothers and

infants.

Britta et al (2007)158

provide evidence through their study that educating pregnant women

and their male partners yields a greater net impact on maternal health behaviors

compared with educating women alone.

Jennings K. et al (2010)159

demonstrated in their study that the messages provided to

pregnant women significantly improved in birth preparedness, danger sign recognition

and new born care and authors concluded that a job aids-focused intervention can be

integrated into routine antenatal care with positive outcomes on provider communication

and maternal knowledge. Efforts are needed to address time constraints and other

communication barriers, including introduction of on-going quality assessment for long-

term sustainability.

156 Rajna PN, Mishra AK, Krishnamoorthy S, Impact of maternal education and health services on child mortality in Uttar Pradesh,

India, Asia-Pacific Population Journal/ United Nations, 1998; 13(2): 27-38. 157 Anne McDonald Culp, R. E. Culp, J. W. Anderson and S. Carter, Health and safety intervention with first-time mothers, Health

Education Research, 2007; 22(2): 285–294. 158 Britta C. Mullany, S. Becker and M. J. Hindin, The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial, Health Education Research, 2007; 22(2): 166–

176. 159 Jennings L, Yebadokpo AS, Affo J, Agbodbe M, Antenatal counseling in maternal and newborn care: Use of ob aids to improve health worker performance and maternal understanding in Benin, BMC Pregnancy and Child birth, 2010; 10: 75.


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Akhund S.A. et al (2011)160

found from their pretesting study that a majority of pregnant

women have an understanding of the culturally relevant ANC handbook, as a part of

health education during antenatal care. The handbook was found to be practical by

healthcare paraprofessionals and community workers for use in different tiers of

the health care system. The ANC handbook can be applied in the health service sector

and can be adopted with relevant cultural modifications by countries with a similar

context.

Titaley C.R. et al (2010)161

found in their study that a comprehensive strategy to increase

the availability, accessibility, and affordability of delivery care services should be

considered and also, health education strategies are required to increase community

awareness about the importance of health services along with the existing financing

mechanisms for the poor communities. Public health strategies involving traditional birth

attendants will be beneficial particularly in remote areas where their services are highly

utilized.

3.4 Social marketing of health programmes for public health

Social marketing, the use of marketing to design and implement programs to promote

socially beneficial behavior change, has grown in popularity and usage within the

public health community.162

Social marketing is the use of marketing principles to design

and implement programs that promote socially beneficial behavior change. Contrary to

the marketing of consumption goods, social marketing does not deal with material

products, but with “behavior”, Ex: Immunization for infant or child. This 'product' has a

basic benefit (i. e. reduction of health risks in the long run), which is, however, difficult

to convey. Therefore, the intended change in behavior has to be related to a further

reward which consists of symbolic goods, e. g. social appreciation or a better body

feeling.163

Social marketing uses commercial marketing strategies to change individual

160 Akhund S, Avan BI, Development and pretesting of an Information,, Education and Communication (IEC) focused antenatal care handbook in Pakistan, BMC research Notes, 2011; 4: 91. 161 Titaley CR, Hunter CL, Dibley MJ, Heywood P, why do some women still prefer traditional bith attendants and home delivery?: a

qualitative study on delivery care services in west Java Province, Indonesia, BMC Child Pregnancy and Child birth, 2010; 10: 43. 162 Grier S, Bryant CA, Social Marketing in Public health, Annual review of Public Health, 2005; 26: 319 – 39.

163 Loss Nagel E., Social marketing-seduction with the aim of healthy behaviour?, Genusdheitnswesen (Germany), 2010; 72(1): 54-

62.


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and organizational behavior and policies. It has been effective on a population level

across a wide range of public health and health care domains.164

Blair J. E. (1995)165

concluded in their study concluded that Social marketing provides a

theoretical basis to increase awareness of preventable health conditions and to increase

participation in health wellness programs. Social marketing is distinguished by its

emphasis on "non-tangible" products such as ideas, attitudes, and lifestyle changes.

"Marketing mix" is a social marketing strategy that intertwines elements of product,

price, place, and promotion to satisfy needs and wants of consumers. Further, the

philosophy of social marketing underscores the necessity to be aware of and responsive

to the consumer's perception of needs.

Linq J.C. et al (1992)166

concluded in their study that the strengths of social

marketing include knowledge of the audience, systematic use of qualitative methods, use

of incentives, closer monitoring, strategic use of the mass media, realistic expectations,

aspiring to high standards, and recognition of price. Weaknesses of social

marketing include its time, money, and human requirements. Also they pointed out that

few the marketing elements are missing like public health lacks the flexibility to adjust

products and services to clients‟ interests and preferences.

Loss J. et al (2006)167

concluded in their study that the increasing call for quality

management and evaluation of health promotion interventions, the social marketing

concept may contribute useful insight at an operational level and thus add to discussion

on effective approaches for programme planning.

Steven J. Szydlowski (2007) 168

showed in their study on the justification for utilization

of the concepts and tools of social marketing to bring about proactive behavior

164 W Douglas Evans, Lauren McCormack, Applying Social Marketing in Health Care: Communicating Evidence to change Consumer Behaviour, Medical Decision Making: An International Journal of the Society for Medical Decision Making, 2008; ISSN: 0272-989X. 165 Blair J E, Social marketing: consumer focused health promotion, American Association of Occupational Health Nurses, 1995; 43

(10): 527 -31. 166 Linq JC, Franlin BA, Lindsteadt JF, Gearon SA, Social marketing: its place in public health, Annual review of Public Health,

1992; 13: 341-62. 167 J Loss, K Lang, S Ultsch, C Eichhorn, E Nagel, the concept of social marketing potential and limitations for health promotion and prevention in Germany, Gesundheitswesen (Germany), 2006; 68(7): 395 – 402. 168 Steven J Szudlowsi, Satya P. Chattopadhyay, Robert Babela, Social marketing as a tool to improve behavioural health services for

underserved populations in transition countries, The health care Manager, 2007; 24(1): 12-20.


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modification that in recent times, pioneers and community groups have used social

marketing as an instrument to change public perceptions and behaviors within societies.

These efforts have transformed nations in the acceptance and understanding of

community health and rehabilitation, education, service, and human rights.


3-45

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