title: Quality of obstetric referral services in India's JSY cash transfer programme for institutional births: a study from Madhya Pradesh province.
abstract: BACKGROUND
  India launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30%in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter- facility referrals and study quality of referral services in JSY.
  
  
  RESULTS
  Women accessing intra natal care (n = 1182) at facilities (reporting >10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR- 2.6, 95% CI: 1.0-6.6 p = 0.04). Maternal death record review (April 10-March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from <2 hours. Median time between arrival and death was 6.75 hours.
  
  
  CONCLUSIONS
  High odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.
authors.affiliation: Department of Public Health and Environment, R D Gardi Medical College, Ujjain, India; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Sarika
authors.initials: S
authors.lastname: Chaturvedi
authors.affiliation: Department of Public Health and Environment, R D Gardi Medical College, Ujjain, India; Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.
authors.forename: Bharat
authors.initials: B
authors.lastname: Randive
authors.affiliation: Department of Public Health and Environment, R D Gardi Medical College, Ujjain, India; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; International Centre for Health Research, R D Gardi Medical College, Ujjain, India.
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D003625:Data Collection; D005260:Female; D006268:Health Facilities / Q000191:economics* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007194:India; D063130:Maternal Death / Q000517:prevention & control; D009774:Obstetrics / Q000191:economics* / Q000706:statistics & numerical data; D036801:Parturition; D011787:Quality of Health Care / Q000191:economics / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000191:economics* / Q000706:statistics & numerical data; D055815:Young Adult