title: The effect of health-facility admission and skilled birth attendant coverage on maternal survival in India: a case-control analysis.
abstract: BACKGROUND
  Research in areas of low skilled attendant coverage found that maternal mortality is paradoxically higher in women who seek obstetric care. We estimated the effect of health-facility admission on maternal survival, and how this effect varies with skilled attendant coverage across India.
  
  
  RESULTS
  Using unmatched population-based case-control analysis of national datasets, we compared the effect of health-facility admission at any time (antenatal, intrapartum, postpartum) on maternal deaths (cases) to women reporting pregnancies (controls). Probability of maternal death decreased with increasing skilled attendant coverage, among both women who were and were not admitted to a health-facility, however, the risk of death among women who were admitted was higher (at 50% coverage, OR = 2.32, 95% confidence interval 1.85-2.92) than among those women who were not; while at higher levels of coverage, the effect of health-facility admission was attenuated. In a secondary analysis, the probability of maternal death decreased with increasing coverage among both women admitted for delivery or delivered at home but there was no effect of admission for delivery on mortality risk (50% coverage, OR = 1.0, 0.80-1.25), suggesting that poor quality of obstetric care may have attenuated the benefits of facility-based care. Subpopulation analysis of obstetric hemorrhage cases and report of 'excessive bleeding' in controls showed that the probability of maternal death decreased with increasing skilled attendant coverage; but the effect of health-facility admission was attenuated (at 50% coverage, OR = 1.47, 0.95-1.79), suggesting that some of the effect in the main model can be explained by women arriving at facility with complications underway. Finally, highest risk associated with health-facility admission was clustered in women with education ≤ 8 years.
  
  
  CONCLUSIONS
  The effect of health-facility admission did vary by skilled attendant coverage, and this effect appears to be driven partially by reverse causality; however, inequitable access to and possibly poor quality of healthcare for primary and emergency services appears to play a role in maternal survival as well.
authors.affiliation: Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Canada.
authors.forename: Ann L
authors.initials: AL
authors.lastname: Montgomery
authors.affiliation: Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Canada.
authors.forename: Shaza
authors.initials: S
authors.lastname: Fadel
authors.affiliation: School of Public Health, Post Graduate Institute of Medical Education, Chandigarh, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Kumar
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Canada.
authors.forename: Sue
authors.initials: S
authors.lastname: Bondy
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Canada; The Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Rahim
authors.initials: R
authors.lastname: Moineddin
authors.affiliation: Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Canada.
authors.forename: Prabhat
authors.initials: P
authors.lastname: Jha
mesh_terms: D000293:Adolescent; D000328:Adult; D002983:Clinical Competence / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007194:India / Q000453:epidemiology; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008875:Middle Aged; D008880:Midwifery / Q000706:statistics & numerical data*; D008962:Models, Theoretical; D016017:Odds Ratio; D010343:Patient Admission / Q000706:statistics & numerical data*; D011247:Pregnancy; D011336:Probability; D055815:Young Adult