Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens

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Abstract

Background

Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens.

Design

Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the ‘three delays’ framework and were examined by using a human rights lens.

Results

All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility.

Conclusions

The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality.

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Naturalistic Inquiry

Yvonna S. Lincoln, Egon G. Guba (1985)

"Showing how science is limited by its dominant mode of investigation, Lincoln and Guba propose an alternative paradigm--a "naturalistic" rather than "rationalistic" method of inquiry--in which the investigator avoids manipulating research outcomes. A "paradigm shift" is under way in many fields, they contend, and go on to describe the different assumptions of the two approaches regarding the nature of reality, subject-object interaction, the possibility of generalization, the concept of causality, and the role of values. The authors also offer guidance for research in the field (where, they say, naturalistic inquiry always takes place). Useful tips are given, for example, on "designing" a study as it unfolds, establishing "trustworthiness," and writing a case report. This book helps researchers "both to understand and to do naturalistic inquiry." Of particular interest to educational researchers, it is valuable for all social scientists involved with questions of qualitative and quantitative methodology."--Publisher's description.

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Too far to walk: maternal mortality in context.

S Thaddeus, D Maine (1994)

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine 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. The literature clearly 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. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

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India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

Stephen Lim, Lalit Dandona, Joseph Hoisington … (2010)

In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes. We used data from the nationwide district-level household surveys done in 2002-04 and 2007-09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. Implementation of JSY in 2007-08 was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3.7 (95% CI 2.2-5.2) perinatal deaths per 1000 pregnancies and 2.3 (0.9-3.7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4.1 (2.5-5.7) perinatal deaths per 1000 pregnancies and 2.4 (0.7-4.1) neonatal deaths per 1000 livebirths. The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies. Bill & Melinda Gates Foundation. Copyright 2010 Elsevier Ltd. All rights reserved.

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Author and article information

Journal

Journal ID (nlm-ta): Glob Health Action

Journal ID (iso-abbrev): Glob Health Action

Journal ID (publisher-id): GHA

Title: Global Health Action

Publisher: Co-Action Publishing

ISSN (Print): 1654-9716

ISSN (Electronic): 1654-9880

Publication date (Electronic): 01 April 2015

Publication date Collection: 2015

Volume: 8

Electronic Location Identifier: 10.3402/gha.v8.24976

Affiliations

[1 ]United Nations Population Fund, Bhopal, India

[2 ]Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

[3 ]Swedish Research School for Global Health, Umeå University, Umeå, Sweden

[4 ]Umeå Centre for Gender Studies, Umeå University, Umeå, Sweden

Author notes

[* ]Correspondence to: Tej Ram Jat, United Nations Population Fund, UN Office, 41-42, Polytechnic Colony, Shyamla Hills, Bhopal, Madhya Pradesh, India, Email: tejram@ 123456unfpa.org ; jattejram@ 123456yahoo.co.in

Responsible Editor: Lucia D’Ambruoso, Umeå University, Umeå , Sweden.

Article

Publisher ID: 24976

DOI: 10.3402/gha.v8.24976

PMC ID: 4385127

PubMed ID: 25840595

SO-VID: 68d6787a-45d8-480a-8b4c-0ab6c06bb96d

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

History

Date received : 20 May 2014

Date revision received : 04 March 2015

Date accepted : 10 March 2015

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Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens

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Most cited references 91

Naturalistic Inquiry

Too far to walk: maternal mortality in context.

India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

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