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\title{Obstetric Care Performance: A Situational Analysis of 24x7 Primary Health Centres from Gujarat, India}
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             \author[1]{Sandul  Yasobant}

             \author[2]{Kranti Suresh  Vora}

             \author[3]{Dileep  Mavalankar}

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\date{\small \em Received: 8 December 2013 Accepted: 2 January 2014 Published: 15 January 2014}

\maketitle


\begin{abstract}
        


Primary Health Centers are the cornerstone of rural healthcare in India. Updating these centers to provide round the clock services to reduce the unmet need for maternal healthcare; is an important objective of National Rural Health Mission since 2005. Yet, functionality of PHCs to provide 24x7 services remains poor due to several health system issues. The present cross-sectional facility based study evaluates the functioning of rural 24x7 primary health care facilities in 3 districts of Gujarat for obstetric care performance and its predictors. The study used pretested questionnaire for collecting data from all PHCs of study areas in 2012-13. Obstetric care performance was measured as number of deliveries conducted in last 3 months. Current study found that the obstetric care performance is independent of infrastructure or logistics situation but highly dependent availability on the skilled human resource. There is urgent need for a systematic study to evaluate performance of public health facilities along with use of routinely collected data to make the system efficient.

\end{abstract}


\keywords{obstetric care performance, primary health centres, 24x7 PHCs.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
ndia contributes one-fifth of the global burden of direct maternal deaths. National government has made efforts since independence in 1947 to improve health infrastructure and access to primary care including delivery care.\par
However India continues to face challenges in improving key maternal health indicators such as adequate antenatal care coverage, institutional deliveries \hyperref[b10]{[1]} . Low Utilization of health care services is an important issue in India with majority of mothers not receiving adequate antenatal care and an unacceptable proportion of home deliveries \hyperref[b1]{[2]} . Despite having tiered healthcare system to improve access for the basic healthcare needs including obstetric care at the community level, significant proportion of population in rural areas do not have round the clock access \hyperref[b2]{[3]} . Primary Health Centres (PHCs) comprise the second tier in rural healthcare structure envisaged to provide integrated curative and preventive healthcare. A medical officer, who is a basic medical graduate, is in charge of the PHC supported by fourteen paramedical and ancillary staff. It acts as a referral unit for six sub-centers that are based at the village level. It has four to six beds for inpatients. The activities of PHC involve curative, preventive, and family welfare services in accordance with the Indian Public Health Standards (IPHS) \hyperref[b3]{[4]} . Currently, India has 24,049 PHCs as per population based norms of one PHC per 30,000 populations \hyperref[b4]{[5]} . Under the National Rural Health Mission, launched in the year 2005, fundamental changes were made in the health care delivery system with a view to make it accountable, accessible and affordable system of quality maternal health care  {\ref [6]} .\par
Gujarat, a western state in India is one of the better performing states with more than 75\% institutional deliveries \hyperref[b5]{[7]} and maternal mortality ratio of 122 \hyperref[b6]{[8]} . Although it is not one of the NRHM high focus states but it does include many remote/geographically difficult and poorly served areas \hyperref[b6]{[8]} . The state has taken steps to strengthen its PHC services by upgrading about 100 PHCs to provide round-the-clock obstetric services (24X7), unfortunately only half of them remain functional in the year of 2013-14 \hyperref[b7]{[9]} . Even the functional PHCs have poor obstetric performance as the proportions of deliveries conducted in PHCs are very low at 3\% \hyperref[b8]{[10]} . Failure to deliver obstetric care at the grass root level despite significant improvements in infrastructure and numerous financial assistance programs deserve urgent attention.\par
To explore the issue, recently the Planning Commission of India carried out a study to evaluate the functionality of 24x7 health care facilities in high focus states and found that health system issues such as infrastructure and logistics that adversely affected the performance of these facilities  {\ref [11]} . In our knowledge, no such study has been conducted in better performing states such as Gujarat. The objective of current study is to make a comprehensive evaluation of the functioning of rural 24x7 health care facilities regarding obstetric care performance and to understand its predictors. 
\section[{II.}]{II.} 
\section[{Methodology}]{Methodology}\par
Current study included all functional 24x7 PHCs (32 facilities) located in the rural areas of 3 study districts (Surendranagar, Sabarkantha, Dahod) of Gujarat. The facility-based cross-sectional study conducted between May 2012 and April 2013. A semistructured and pre-tested study questionnaire translated in vernacular language (Gujarati) was used by trained nurses. Some data from records of the facilities was captured by the data collectors with help of pretested tool. Obstetric performance is defined as number of deliveries conducted in last 3 months which is collected by data collector and verified with facility records.\par
Data were summarized using the descriptive statistics and linear regression was done for obstetric care performance as a dependent variable for predictors such as facility infrastructure, equipment and skilled human resources for delivery care. Pearson's Correlation test was performed to know the level of prediction for significant predictors. The data analysis carried out using R version 3.0.1 software. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
The study results show more than half PHCs are located within village boundary. Basic amenities such as chamber is available in only 22\% of the facilities surveyed while sterile gloves for delivery are available in 69\% of the PHCs. On an average 4 plus beds are available for about 41 deliveries performed over 3 months. These results show adequate infrastructure for delivery care in majority of the PHCs surveyed irrespective of obstetric performance.\par
Results of the current study show the number of healthcare providers and years of experience are higher among PHCs with better obstetric performance. Difference in number of medical officers and years of experience of staff nurse are significant predictors of obstetric performance. Pearson's correlation coefficient indicates that about 48\% of variance in the obstetric performance of study facilities is explained by differences in experience of staff nurses (r=0.48). These findings highlight the importance of having adequate numbers of well experienced human resources to improve the obstetric performance of a health facility.   
\section[{Discussion}]{Discussion}\par
Under the NRHM, the federal/national government is providing major financial support to states to strengthen their health systems with emphasis on new constructions and up gradation of PHCs \hyperref[b11]{[12]} . Historically, national/state governments of India as well as developmental agencies such as World Bank have concentrated on infrastructure development to improve healthcare service delivery while generally disregarding the development of skilled human resources for health [13, 14]   . Previous research and government data suggests that infrastructure in public health facilities has significantly improved in last decade \hyperref[b14]{[15,}\hyperref[b15]{16]} . Current study found that almost all of the surveyed PHCs have basic amenities required for providing obstetric care, which may be the reason that infrastructure did not have major bearings on obstetric performance of facilities.\par
In current study, a significant proportion of variance in the obstetric performance of surveyed PHCs was seen in the years of experience of staff nurses. Also, the regression analysis showed that the number of medical officers and years of experience of staff nurses are significant predictors of obstetric performance at the PHC level. Lack of qualified human resources for health care (HRH) is a major limiting factor in implementing health policies and health reforms in the developing world \hyperref[b16]{[17]} . One of the major HRH challenges is the availability of qualified/skilled staff. Current study findings highlight the importance of ensuring availability of skilled and experienced healthcare providers to make facilities functional for obstetric care.\par
In India, public health is a state subject hence states decide strategies to improve health of the local population even if funding is from national government. In 2012, about 33\% of PHCs in Gujarat did not have any medical officers, the situation is worse than 2008 when only 5\% of PHCs were without a doctor \hyperref[b17]{[18]} . It should also be noted that majority of PHCs in Gujarat have only one medical officer and proportion of female medical officers is even lower. It is difficult to provide round the clock obstetric care with only one healthcare provider. Development of human resource for health in the state is limited to establishing new medical colleges and training of medical graduates to provide emergency obstetric care while ignoring training of skilled birth attendants such as staff nurses and midwives \hyperref[b18]{[19]} .  
\section[{Recommendations}]{Recommendations}\par
Gujarat needs to improve human resources management to increase the proportion of deliveries taking place in PHCs and provide basic maternal health care at the community level. There is a need for evidence based human resource policy and its implementation at the grass root level to improve current situation. Gujarat needs to employ innovative strategies to ensure posting of adequate numbers of skilled and experienced health care providers who could be a medical graduate or trained midwives to all the PHCs to ensure round the clock obstetric services. Tamil Nadu has posted 3 staff nurses to provide 24X7 delivery care in PHCs and the intervention has improved provision of obstetric services at the community level \hyperref[b19]{[20]} . Such innovations can be replicated to implement low cost evidence based strategies and increase obstetric performance of PHCs. 
\section[{VI.}]{VI.} 
\section[{Conclusions}]{Conclusions}\par
Current study emphasizes the issue of human resources for health and its impact on the functionality of health facilities to provide round the clock obstetric care. As a result of past and present national and state level programs, infrastructure of majority of primary health centers has improved significantly and is adequate to provide basic delivery care. Yet, proportion of deliveries taking place in these grass root level facilities is dismally low. Gujarat needs to improve its human resources management for obstetric care and ensure posting of adequate numbers of skilled providers for effective tiering of delivery care.\par
VII.\begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.14228529839883552\textwidth}P{0.5542940320232896\textwidth}P{0.1534206695778748\textwidth}}
Year 2014\tabcellsep \tabcellsep \\
22\tabcellsep \tabcellsep \\
Volume XIV Issue V Version I\tabcellsep Basic Amenities Separate Delivery Room\tabcellsep Available (\%) 100\\
( D D D D )\tabcellsep Power Backup for delivery room Water Supply to delivery room\tabcellsep 63 59\\
Medical Research\tabcellsep Drinking Water Provision Adequate Lighting of Delivery Room Toilet Privacy Available for Women in Labor Equipment Sterile Gloves for Delivery Episiotomy Scissors Baby Care Unit\tabcellsep 84 69 84 Available (\%) 69 72 50\\
Global Journal of\tabcellsep Performance Statistics Total delivery performed in last 3 months Total No. of Beds No. of Doctors No. of Nurses Experience of Doctors (in yrs.) Experience of Nurses (in yrs.)\tabcellsep Median (Min-Max) 41 (1-252) 4 (1-7) 1 (0-2) 3 (1-7) 9 (1-33) 7 (1-30)\\
© 2014 Global Journals Inc. (US)\tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: E]} 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.5365731462925851\textwidth}P{0.10390781563126252\textwidth}P{0.0970941883767535\textwidth}P{0.11242484969939878\textwidth}}
Variables\tabcellsep Estimate\tabcellsep Std. Error\tabcellsep p-value\\
Power Backup for delivery room\tabcellsep 16.35\tabcellsep 23.31\tabcellsep 0.488\\
Water Supply to delivery room\tabcellsep -65.70\tabcellsep 19.81\tabcellsep 0.002**\\
Adequate Lighting of Delivery Room\tabcellsep -89.86\tabcellsep 18.25\tabcellsep 0.000***\\
Toilet Privacy Available for Women in Labor\tabcellsep -12.26\tabcellsep 38.96\tabcellsep 0.755\\
Baby Care Unit\tabcellsep -47.44\tabcellsep 21.04\tabcellsep 0.031*\\
Sterilizer/ Boiler\tabcellsep -43.67\tabcellsep 21.50\tabcellsep 0.091\\
No. of Medical officers\tabcellsep 50.91\tabcellsep 18.69\tabcellsep 0.011*\\
No. of Nurses\tabcellsep 10.76\tabcellsep 8.43\tabcellsep 0.211\\
Experience of Medical Officers\tabcellsep 0.03\tabcellsep 1.33\tabcellsep 0.978\\
Experience of Nurses\tabcellsep 4.05\tabcellsep 1.42\tabcellsep 0.007**\\
? p < 0.1, * p < 0.05, ** p < 0.01, *** p < 0.001\tabcellsep \tabcellsep \tabcellsep \\
IV.\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 		 		\backmatter   			 
\subsection[{Acknowledgement}]{Acknowledgement}\par
We are thankful to facilities who participated in the study who gave us unconditional support and team at MATIND for working hard for the timely completion of Phase-II. 
\subsection[{VIII.}]{VIII.} 
\subsection[{Conflicts of Interest}]{Conflicts of Interest}\par
The authors declare that they have no competing interests.\par
The research leading to these results has received funding from the European Community's Seventh Framework Programme under grant agreement n° [261304]. 			  			  				\begin{bibitemlist}{1}
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