Examining equity in access to institutional childbirth in India using the social determinants of health framework

Abstract

Background: Promoting institutional childbirth through demand-side financing has been the key strategy adopted to achieve global goals on maternal and child health in India, and considerable investments have been made in this area in the last two decades. India has improved the coverage of institutional childbirth dramatically in a short period of time– from 39 per cent in 2005-2006 to 89 per cent in 2021. Despite these intensive efforts, there remain large inequities in maternal, neonatal and infant mortality outcomes, and in access to institutional childbirth.Aim: The overall aim of the study is to examine the nature, extent, and determinants of inequity in access to institutional childbirth in India using the social determinants of health framework, in order to identify areas for improving equity in access to institutional childbirth.Methods: Adopting a pragmatic philosophical paradigm, the study used a triangulated multilevel mixed methods research design involving: (a) a mixed methods systematic review of the effectiveness of interventions that address access to institutional childbirth and equity in access to institutional childbirth in the South Asia region; (b) quantitative analysis of nationally representative secondary data on the determinants of access to and equity in institutional childbirth in India; and, (c) a qualitative primary study by conducting in-depth interviews with experts on maternal and child health to generate evidence in the policy, governance and programmatic spectrum.Results: Systematic review yielded 42 studies (13 cluster RCTs; 18 quasi experimental studies; and 11 non-experimental studies), vast majority of which came from India and Bangladesh. Meta-analysis of nineteen studies (including twelve RCTs,) suggests that overall, there is significant effect of interventions on access to institutional childbirth (OR 1.72; 95% CI:1.33–2.23). Pooled OR of twelve RCTs (1.47; 95% CI: 1.08, 1.99) and other studies (2.29; 95% CI: 1.63, 2.22) also indicated a significant positive effect of interventions. Further subgroup analyses suggests that while women's group interventions (6 studies) and interventions involving traditional birth attendants (four studies) did not indicate a significant effect, other community-based interventions (6 studies) and maternal voucher schemes (3 studies) indicated a significant effect on access to institutional childbirth.Quantitative analysis of secondary data suggests that inequity in access to institutional childbirth in India has been substantially reduced. Decomposition of concentration indices show that the wealth-based socioeconomic inequality in institutional childbirth declined from 0.31 to 0.09, indicating that the economic inequalities in access declined almost two thirds during the period. Further, decomposition of change in the concentration index between 2005–2006 and 2015–2016 show that the biggest contributor to the change in inequalities in access to institutional delivery was the change in poverty (29 per cent) followed by four or more antenatal care visits (22 per cent), and urban residence (13.8 per cent).Many well-meaning policies, programmes are available to address equity in institutional childbirth in the country, but effective implementation is still lagging. The qualitative study found that although the level of investment is increasing, the health system in relation to pregnancy and delivery care in many parts of the country is marked by inadequate infrastructure, poor labour room facilities, insufficiently trained and skilled human resources, undignified care, and inadequate coverage of prenatal and postpartum care. Poor and the marginalised women still face challenges in accessing dignified care during pregnancy, delivery and postpartum. Further, poorly regulated private health sector, alarmingly high proportion of caesarean section (C-section) deliveries both in public and in the private sector health facilities, and increase in economic burden to the poor for delivery care are some of the major concerns.Conclusion: While the quantitative analysis reaffirms the importance of several determinants of inequity in access such as birth order, age of mother at birth, social status (caste), economic status (wealth), health service coverage (ANC), the systematic review of interventions highlights the need to devote increased attention to analysis of the effectiveness of interventions in reducing inequity, and calls for more qualitative research. There remain several gaps and challenges at the policy- and governance-level that inhibits equity in access to institutional childbirth. Qualitative study underscored the need for increased policy attention to regulate private sector health facilities; control alarming increase in C-section deliveries; reduce the out-of-pocket expenditure for prenatal, delivery and postpartum care; and, improve ineffective referral and emergency transport system.

Date of Award	Jul 2023
Original language	English
Awarding Institution	University of Bedfordshire
Supervisor	Shuby Puthussery (Supervisor) & Gurch Randhawa (Second supervisor)