title: Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study.
abstract: BACKGROUND
  The maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India.
  
  
  METHODS
  We undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers' knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions.
  
  
  RESULTS
  84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets.
  
  
  CONCLUSIONS
  Addressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers' clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.
authors.affiliation: Karnataka Health Promotion Trust, IT Park, 5th floor, No 1-4, Rajajinagar Industrial Area, Behind KSSIDC Administrative Office, Rajajinagar, Bangalore 560044, India. krishnamurthy@khpt.org.
authors.forename: Krishnamurthy
authors.initials: K
authors.lastname: Jayanna
authors.forename: Prem
authors.initials: P
authors.lastname: Mony
authors.forename: Ramesh
authors.initials: R
authors.lastname: B M
authors.forename: Annamma
authors.initials: A
authors.lastname: Thomas
authors.forename: Ajay
authors.initials: A
authors.lastname: Gaikwad
authors.forename: Mohan
authors.initials: M
authors.lastname: H L
authors.forename: James F
authors.initials: JF
authors.lastname: Blanchard
authors.forename: Stephen
authors.initials: S
authors.lastname: Moses
authors.forename: Lisa
authors.initials: L
authors.lastname: Avery
mesh_terms: D000927:Anticonvulsants / Q000600:supply & distribution; D000959:Antihypertensive Agents / Q000600:supply & distribution; D002983:Clinical Competence; D003151:Community Health Centers / Q000458:organization & administration* / Q000592:standards; D003430:Cross-Sectional Studies; D004461:Eclampsia / Q000175:diagnosis / Q000188:drug therapy*; D005260:Female; D006269:Health Facilities, Proprietary / Q000458:organization & administration* / Q000592:standards; D006767:Hospitals, District / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007194:India; D008278:Magnesium Sulfate / Q000600:supply & distribution; D008485:Medical Audit; D009774:Obstetrics / Q000458:organization & administration*; D010120:Oxytocics / Q000600:supply & distribution; D006473:Postpartum Hemorrhage / Q000175:diagnosis / Q000628:therapy*; D011247:Pregnancy; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D017064:Process Assessment, Health Care
chemical_list: D000927:Anticonvulsants; D000959:Antihypertensive Agents; D010120:Oxytocics; D008278:Magnesium Sulfate