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Background: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat.Methods: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth.Results: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme.Conclusion: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality, which primarily burdens developing countries, reflects the greatest health divide between rich and poor. This is especially pronounced for access to safe abortion services which alone avert 1 of every 10 maternal deaths in India. Primarily due to confidentiality concerns, poor women in India prefer private services which are often offered by untrained providers and may be expensive. In 2006 the state government of Madhya Pradesh (population 73 million) began a concerted effort to ensure access to safe abortion services at public health facilities to both rural and urban poor women. This study aims to understand the socio-economic profile of women seeking abortion services in public health facilities across this state and out of pocket cost accessing abortion services. In particular, we examine the level of access that poor women have to safe abortion services in Madhya Pradesh.Methods: This study consisted of a cross-sectional client follow-up design. A total of 19 facilities were selected using two-stage random sampling and 1036 women presenting to chosen facilities with abortion and post-abortion complications were interviewed between May and December 2014. A structured data collection tool was developed. A composite wealth index computed using principal component analysis derived weights from consumer durables and asset holding and classified women into three categories, poor, moderate, and rich.Results: Findings highlight that overall 57% of women who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for postabortion complications (67%) than induced abortion. Women reported spending no money to access abortion services as abortion services are free of cost at public facilities. However, poor women spend INR 64 (1 USD) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food.Conclusions: Improved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion. [ABSTRACT FROM AUTHOR]

Background: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program.Methods: This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program.Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities.Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section. [ABSTRACT FROM AUTHOR]

Background: India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).Methods: A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.Results: EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.Conclusions: The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector. [ABSTRACT FROM AUTHOR]

Background: Social accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived.Methods: We conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants.Results: There are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women's groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants - governance, policy, health beliefs, women's status, and intermediary determinants - social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women's groups' demands.Conclusion: Social accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures. [ABSTRACT FROM AUTHOR]