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‘Two Sides of a Coin’: Quality of Childbirth Services in Indian Public Health Facilities, from the Perspectives of Women and their Care Providers
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.ORCID iD: 0000-0002-1285-7138
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Skilled birth attendance, usually available by promoting childbirth at health care institutions in low-resource settings, is known to prevent maternal and neonatal morbidity and mortality. While institutional childbirths in India have increased at an exponential rate, the infrastructure, material and manpower resources to support this practice are lagging, raising concerns about the quality of childbirth services.

Methodology: A mixed-method approach was used in this project: in-depth interviews with women (n= 13); and focus-group-discussions with the care providers (n=27) were conducted and analysed using Grounded Theory. A cross-sectional survey (n= 1004) assessed prevalence of Fear of Birth (FoB) and postnatal depressive symptoms (PND), along with satisfaction with childbirth services among women in the immediate postpartum period.

Results: The system of cashless childbirth provided at the public health facilities, in the women’s experiences, came at the hidden cost of them having to make themselves subordinate to the offered services. The prevalence of FoB and PND was 13.1% and 17.1%, respectively, and these were significantly associated (p < 0.001). Among women with vaginal births (VB), 41.2% had experienced a perineal wound and 59% of them underwent repair without local anaesthesia. While the majority of the women were satisfied (VB 68.7%; Caesarean births 79.2%) with the services; women having VBs at Community Health Centres (nearly 81%) were more commonly satisfied compared to those at the District Hospitals (nearly 60%) (p < 0.001). From the care providers’ perspective, maintaining quality of childbirth services was like a balancing act between the realities of low-resource settings with stakeholders’ expectations. While the providers remained proud and committed; the challenges often left them fatigued, disillusioned, irritable and sceptical.

Conclusion: There is a need to improve the sensitivity with which childbirth services are being delivered to women coming to public health facilities; as well as towards improving the care providers’ work conditions. Suboptimal birth experiences are associated with the women’s perinatal mental health and satisfaction, while perpetual work challenges may make the care providers frustrated and/or apathetic. Improving manpower resources could reduce work-stress in care providers and thereby improve childbirth processes.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , p. 82
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1384
Keywords [en]
Fear of Birth, Postnatal Depressive Symptoms, Hindi WDEQ, Hindi SMMS, Institutional Childbirth
National Category
Medical and Health Sciences
Research subject
Health Care Research
Identifiers
URN: urn:nbn:se:uu:diva-331673ISBN: 978-91-513-0110-5 (print)OAI: oai:DiVA.org:uu-331673DiVA, id: diva2:1149729
Public defence
2017-12-13, Auditorium Minus, Gustavianum, Akademigatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2017-11-22 Created: 2017-10-16 Last updated: 2018-03-07
List of papers
1. Cashless childbirth, but at a cost: A grounded theory study on quality of intrapartum care in public health facilities in India
Open this publication in new window or tab >>Cashless childbirth, but at a cost: A grounded theory study on quality of intrapartum care in public health facilities in India
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2016 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 39, p. 78-86Article in journal (Refereed) Published
Abstract [en]

Aim: this study aimed to explore and understand the perceptions and experiences of women regarding quality of care received during childbirth in public health facilities. Design: qualitative in-depth interviews were conducted and analysed using the Grounded Theory approach. Participants: thirteen women who had given vaginal birth to a healthy newborn infant. Setting: participants were interviewed in their homes in one district of Chhattisgarh, India. Data collection: the interview followed a pre-tested guide comprising one key question: How did the women experience and perceive the care provided during labour and childbirth? Findings: 'cashless childbirth but at a cost: subordination during childbirth' was identified as the core category. Women chose a public health facility due to their socio-economic limitations, and to have a cashless and safe childbirth. Participants expressed a sense of trust in public health facilities, and verbalised that free food and ambulance services provided by the government were appreciated. Care during normal birth was medicalised, and women lacked control over the process of their labour. Often, the women experienced verbal and physical abuse, which led to passive acceptance of all the services provided to avoid confrontation with the providers. Conclusions: increasingly higher numbers of women give birth in public health facilities in Chhattisgarh, India, and women who have no alternative place to have a safe and normal birth are the main beneficiaries. The labour rooms are functional, but there is a need for improvement of interpersonal processes, information-sharing, and sensitive treatment of women seeking childbirth services in public health facilities.

Keywords
Birth experience, Institutional delivery, Abuse, Communication, Care providers, Grounded theory
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-299546 (URN)10.1016/j.midw.2016.04.012 (DOI)000377935800011 ()27321724 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2016-07-25 Created: 2016-07-22 Last updated: 2017-11-28Bibliographically approved
2. Fear of Childbirth and Depressive Symptoms among Postnatal Women: A Cross-sectional Survey from Chhattisgarh, India
Open this publication in new window or tab >>Fear of Childbirth and Depressive Symptoms among Postnatal Women: A Cross-sectional Survey from Chhattisgarh, India
2018 (English)In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 31, no 2, p. 122-133Article in journal (Refereed) Published
Abstract [en]

Background: Prevalence rates of Fear of Birth and postnatal depressive symptoms have not been explored in Chhattisgarh, India.

Objective: To validate Hindi Wijma Delivery Experience Questionnaire and to study the prevalence of Fear of Birth and depressive symptoms among postnatal women.

Methods: A cross-sectional survey at seventeen public health facilities in two districts of Chhattisgarh, India among postnatal women who gave birth vaginally or through C-section to a live neonate. Participants were recruited through consecutive sampling based on health facility records of daily births. Data were collected through one-to-one interviews using the Wijma Delivery Experience Questionnaire Version B and the Edinburgh Postnatal Depression Scale. Non-parametric associations and linear regression data analyses were performed.

Results: The Hindi Wijma Delivery Experience Questionnaire Version B had reliable psychometric properties. The prevalence of Fear of Birth and depressive symptoms among postnatal women were 13.1% and 17.1%, respectively, and their presence had a strong association (p < 0.001). Regression analyses revealed that, among women having vaginal births: coming for institutional births due to health professionals' advice, giving birth in a district hospital and having postnatal depressive symptoms were associated with presence of FoB; while depressive symptoms were associated with having FoB, perineal suturing without pain relief, and giving birth to a low birth-weight neonate in a district hospital.

Conclusion: The prevalence of Fear of Birth and depressive symptoms is influenced by pain management during childbirth and care processes between women and providers. These care practices should be improved for better mental health outcomes among postnatal women.

Keywords
Depression/depressiveve symptoms; EPDS; Fear of Birth (phobic disorders); Institutional births; WDEQ Version B
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-331599 (URN)10.1016/j.wombi.2017.07.003 (DOI)000427813500008 ()28756932 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2017-10-16 Created: 2017-10-16 Last updated: 2018-05-30Bibliographically approved
3. Satisfaction with childbirth services provided in public health facilities: results from a cross-sectional survey among postnatal women in Chhattisgarh, India
Open this publication in new window or tab >>Satisfaction with childbirth services provided in public health facilities: results from a cross-sectional survey among postnatal women in Chhattisgarh, India
2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1386932Article in journal (Refereed) Published
Place, publisher, year, edition, pages
Taylor & Francis Group, 2017
Keywords
Hindi-translated Scale for 30 Measuring Maternal Satisfaction; intrapartum care; institutional births; Caesarean section; quality of care
National Category
Medical and Health Sciences
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-331601 (URN)10.1080/16549716.2017.1386932 (DOI)000417193300001 ()
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2017-10-16 Created: 2017-10-16 Last updated: 2018-03-07Bibliographically approved
4. “The balancing act”: Maintaining the quality of childbirth services in low-resource settings- a Grounded Theory study exploring nurse-midwives’ perceptions and experiences of providing services in public health facilities of Chhattisgarh, India
Open this publication in new window or tab >>“The balancing act”: Maintaining the quality of childbirth services in low-resource settings- a Grounded Theory study exploring nurse-midwives’ perceptions and experiences of providing services in public health facilities of Chhattisgarh, India
Show others...
2017 (English)Article in journal (Refereed) Submitted
National Category
Medical and Health Sciences
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-331602 (URN)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2017-10-16 Created: 2017-10-16 Last updated: 2017-10-26Bibliographically approved

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