Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Pregnancy and Childbirth
Published in: BMC Pregnancy and Childbirth 1/2016

Open Access 01-12-2016 | Research article

Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites

Authors: Sushmita Das, Glyn Alcock, Kishwar Azad, Abdul Kuddus, Dharma S. Manandhar, Bhim Prasad Shrestha, Nirmala Nair, Shibanand Rath, Neena Shah More, Naomi Saville, Tanja A. J. Houweling, David Osrin

Published in: BMC Pregnancy and Childbirth | Issue 1/2016

Login to get access

Abstract

Background

Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share.

Methods

We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates.

Results

The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal.

Conclusions

The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia.
Appendix
Available only for authorised users
Literature
1.
WHO, UNICEF. Countdown to 2015: maternal, newborn & child survival. Building a future for women and children: the 2012 report. Geneva: World Health Organization and United Nations Children’s Fund; 2012.
2.
UN. The Millennium Development Goals Report 2015. New York: United Nations; 2015.
3.
Mitra SN, Nawab Ali M, Islam S, Cross AR, Saha T. Bangladesh Demographic and Health Survey 1993–1994. Calverton: National Institute of Population Research and Training (NIPORT), Mitra and Associates, Macro International Inc; 1994.
4.
National Institute of Population Research and Training (NIPORT), Mitra and Associates, ICF International. Bangladesh Demographic and Health Survey 2011. Dhaka and Calverton: NIPORT, Mitra and Associates, ICF International; 2013.
5.
International Institute for Population Sciences. Macro International: National Family Health Survey (NFHS 1), 1992–93. Mumbai: IIPS; 1995.
6.
Ministry of Health and Family Welfare. Family welfare statistics in India. New Delhi: Government of India, Statistics Division; 2011.
7.
Pradhan A, Aryal R, Regmi G, Ban B, Govindasamy P. Nepal Family Health Survey 1996. Calverton, Maryland and Kathmandu: His Majesty’s Government, Nepal, Ministry of Health; New ERA; Macro International Inc; 1997.
8.
Ministry of Health and Population, New ERA, ICF International. Nepal Demographic and Health Survey 2011. Calverton: Ministry of Health and Population, New ERA, ICF International; 2012.
9.
Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries. DHS Comparative Reports No. 26. Calverton: ICF Macro; 2011.
10.
Ministry of Health and Family Welfare. Health Bulletin 2013. Dhaka: Government of the People’s Republic of Bangladesh, Management Information System, Directorate of Health Services; 2014.
11.
Schmidt J-O, Ensor T, Hossain A, Khan S. Vouchers as demand side financing instruments for health care: A review of the Bangladesh maternal voucher scheme. Health Policy. 2010;96:98–107.CrossRefPubMed
12.
Ahmed S, Khan MM. A maternal health voucher scheme: what have we learned from the demand-side financing scheme in Bangladesh? Health Policy Plan. 2011;6:25–32.CrossRef
13.
Witter S, Khadka S, Nath H, Tiwari S. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy Plan. 2011;26 Suppl 2:ii84–91.PubMed
14.
Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet. 2010;375:2009–23.CrossRefPubMed
15.
Ministry of Health and Family Welfare. Guidelines for Janani-Shishu Suraksha Karyakram (JSSK). New Delhi: Government of India; 2011.
16.
17.
Newbrander W, Moser P. The future of health sector reform in Asia. In: Newbrander W, Moser P, editors. Private Health Sector Growth in Asia Issues and implications. New York: Wiley; 1997. p. 221–34.
18.
De Costa A, Vora KS, Ryan K, Sankara Raman P, Santacatterina M, Mavalankar D. The state-led large scale public private partnership ‘Chiranjeevi Program’ to increase access to institutional delivery among poor women in Gujarat, India: How has it done? What can we learn? PLoS One. 2014;9:e95704.CrossRefPubMedPubMedCentral
19.
Mohanan M, Bauhoff S, La Forgia G, Babiarz KS, Singh K, Miller G. Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat, India: a difference-in-differences analysis. Bull WHO. 2014;92:187–94.PubMed
20.
Hotchkiss DR, Godha D, Do M. Expansion in the private sector provision of institutional delivery services and horizontal equity: evidence from Nepal and Bangladesh. Health Policy Plan. 2014;29 Suppl 1:i12–9.CrossRefPubMedPubMedCentral
21.
Harding A. Partnerships with the private sector in health: what the international community can do to strengthen health systems in developing countries. Washington DC: Center for Global Development; 2009.
22.
23.
24.
Ministry of Health and Population. Annual report: Department of Health Services. 2068/69 (2011/2012). Kathmandu: Government of Nepal; 2012.
25.
26.
Anwar I, Sami M, Akhtar N, Chowdhury M, Salma U, Rahman M, Koblinsky M. Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh. Bull WHO. 2008;86:252–9.PubMedPubMedCentral
27.
Dhakal S, van Teijlingen E, Raja EA, Dhakal KB. Skilled care at birth among rural women in Nepal: practice and challenges. J Health Popul Nutr. 2011;29:371–8.CrossRefPubMedPubMedCentral
28.
Jat TR, Ng N, San Sebastion M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10:59.CrossRefPubMedPubMedCentral
29.
Abeje G, Azage M, Setegn T. Factors associated with Institutional delivery service utilization among mothers in Bahir Dar City administration, Amhara region: a community based cross sectional study. Reprod Health. 2014;11:22.CrossRefPubMedPubMedCentral
30.
Feyissa TR, Genemo GA. Determinants of institutional delivery among childbearing age women in Western Ethiopia, 2013: unmatched case control study. PLoS One. 2014;9:e97194.CrossRefPubMedPubMedCentral
31.
Kawakatsu Y, Sugishita T, Oruenjo K, Wakhule S, Kibosia K, Were E, Honda S. Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study. BMC Pregnancy Childbirth. 2014;14:265.CrossRefPubMedPubMedCentral
32.
Azad K, Barnett S, Banerjee B, Shaha S, Khan KS, Rego AR, Barua S, Flatman D, Pagel C, Prost A, et al. Effect of scaling up women’s groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. Lancet. 2010;375:1193–202.CrossRefPubMed
33.
Shrestha BP, Bhandari B, Manandhar DS, Osrin D, Costello A, Saville N. Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial. Trials. 2011;12:136.CrossRefPubMedPubMedCentral
34.
Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S, Rath S, Gope R, Mahto D, Sinha R, et al. Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet. 2010;375:1182–92.CrossRefPubMed
35.
Shah More N, Bapat U, Das S, Alcock G, Patil S, Porel M, Vaidya L, Fernandez A, Joshi W, Osrin D. Community mobilization in Mumbai slums to improve perinatal care and outcomes: a cluster randomized controlled trial. PLoS Med. 2012;9:e1001257.CrossRef
36.
Ministry of Health and Family Welfare. Janani Suraksha Yojana: guidelines for implementation. New Delhi: Government of India; 2006.
37.
Shah More N, Alcock G, Bapat U, Das S, Joshi W, Osrin D. Tracing pathways from antenatal to delivery care for women in Mumbai, India: cross-sectional study of maternity in low-income areas. International Health. 2009;1:71–7.CrossRef
38.
Filmer D, Pritchett L. Estimating wealth effects without expenditure data - or tears: an application to educational enrollments in states of India. Demography. 2001;38:115–32.PubMed
39.
Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21:459–68.CrossRefPubMed
40.
Fottrell E, Azad K, Kuddus A, Younes L, Shaha S, Nahar T, Aumon BH, Hossen M, Beard J, Hossain T, et al. The effect of increased coverage of participatory women’s groups on neonatal mortality in Bangladesh: A cluster randomized trial. JAMA Pediatr. 2013;167(9):816–25.CrossRefPubMed
41.
Sarbani Roy S, Mahapatra R, Rath S, Bajpai A, Singh V, Rath S, Nair N, Tripathy P, Gope RK, Sinha R, et al. Improved neonatal survival after participatory learning and action with women’s groups: a prospective study in rural eastern India. Bull WHO. 2013;91:426–33.
42.
National Institute of Population Research and Training (NIPORT), Mitra and Associates, ICF International. Dhaka and Calverton. Maryland: NIPORT, Mitra and Associates, ICF International; 2007. p. 2009.
43.
International Institute for Population Sciences. District Level Household and Facility Survey 2007–08. Mumbai: Government of India Ministry of Health and Family Welfare; 2010.
44.
Government of India Ministry of Health and Family Welfare. National Family Health Survey, India (NFHS-3 2005–06). Mumbai: International Institute for Population Sciences; 2007.
45.
Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull WHO. 2007;85:812–9.PubMedPubMedCentral
46.
Teferra AS, Alemu FM, Woldeyohannes SM. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, north west of Ethiopia: a community-based cross sectional study. BMC Pregnancy Childbirth. 2012;12:74.CrossRefPubMedPubMedCentral
47.
Afful-Mensah G, Nketiah-Amponsah E, Boakye-Yiadom L. Rural–urban differences in the utilization of maternal healthcare in Ghana: the case of antenatal and delivery services. Afr Soc Sci Rev. 2014;6:42–63.
48.
49.
Tsawe M, Moto A, Netshivhera T, Ralesego L, Nyathi C, Susuman AS. Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland. Int J Equity Health. 2015;14(1):32.CrossRefPubMedPubMedCentral
50.
Anwar I, Nababan HY, Mostari S, Rahman A, Khan JAM. Trends and inequities in use of maternal health care services in Bangladesh, 1991–2011. PLoS One. 2015;10, e0120309.CrossRefPubMedPubMedCentral
51.
Tey NP, Lai SL. Correlates of and barriers to the utilization of health services for delivery in South Asia and Sub-Saharan Africa. Scientific World Journal. 2013;2013:423403.CrossRefPubMedPubMedCentral
52.
Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190.CrossRefPubMedPubMedCentral
53.
Chakraborty N, Islam MA, Chowdhury RI, Bari W, Akhter HH. Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int. 2003;18(4):327–37.CrossRefPubMed
54.
Wagle RR, Sabroe S, Nielsen BB. Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal. BMC Pregnancy Childbirth. 2004;4(1):8.CrossRefPubMedPubMedCentral
55.
56.
Prinja S, Bahuguna P, Gupta R, Sharma A, Rana SK, Kumar R. Coverage and financial risk protection for institutional delivery: how universal is provision of maternal health care in India? PLoS One. 2015;10:e0137315.CrossRefPubMedPubMedCentral
57.
Mackintosh M, Channon A, Karan A, Selvaraj S, Cavagnero E, Zhao H. What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries. Lancet. 2016;388:596–605.CrossRefPubMed
58.
Kamal N, Curtis S, Hasan MS, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. Int J Equity Health. 2016;15:27.CrossRefPubMedPubMedCentral
59.
McPake B, Hanson K. Managing the public-private mix to achieve universal health coverage. Lancet. 2016;388:622–30.CrossRefPubMed
60.
Ahmed SM, Evans TG, Standing H, Mahmud S. Harnessing pluralism for better health in Bangladesh. Bangladesh: innovation for universal health coverage 2. Lancet. 2013;382:1746–55.CrossRefPubMed
61.
Bhatia J, Cleland J. Health care of female outpatients in south-central India: comparing public and private sector provision. Health Policy Plan. 2004;19(6):402–9.CrossRefPubMed
62.
Ergler CR, Sakdapolrak P, Bohle HG, Kearns RA. Entitlements to health care: why is there a preference for private facilities among poorer residents of Chennai, India? Soc Sci Med. 2010;72:327–37.CrossRefPubMed
63.
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS Med. 2012;9:e1001244.CrossRefPubMedPubMedCentral
64.
Morgan R, Ensor T, Waters H. Performance of private sector health care: implications for universal health coverage. Lancet. 2016;388:606–12.CrossRefPubMed
65.
Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull WHO. 2002;80:325–30.PubMedPubMedCentral
66.
Tung E, Bennett S. Private sector, for-profit health providers in low and middle income countries: can they reach the poor at scale? Globalization Health. 2014;10:52.CrossRefPubMedPubMedCentral
67.
Alcock G, Das S, Shah More N, Hate K, More S, Pantvaidya S, Osrin D, Houweling TA. Examining inequalities in uptake of maternal health care and choice of provider in underserved urban areas of Mumbai, India: a mixed methods study. BMC Pregnancy Childbirth. 2015;15:231.CrossRefPubMedPubMedCentral
68.
Alam B, Mridha MK, Biswas TK, Roy L, Rahman M, Chowdhury ME. Coverage of emergency obstetric care and availability of services in public and private health facilities in Bangladesh. Int J Gynecol Obstet. 2015;131:63–9.CrossRef
69.
Singh PK, Kumar C, Rai RK, Singh L. Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts. Health Policy Plan. 2013;29:542–59.CrossRefPubMed
70.
71.
Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy Childbirth. 2010;10:30.CrossRefPubMedPubMedCentral
72.
Shah More N, Bapat U, Das S, Barnett S, Costello A, Fernandez A, Osrin D. Inequalities in maternity care and newborn outcomes: one-year surveillance of births in vulnerable slum communities in Mumbai. Int J Equity Health. 2009;8(1):21.CrossRef
73.
Maiti S, Unisa S, Agrawal PK. Health care and health among tribal women in Jharkhand: a situational analysis. Stud Tribes Tribals. 2005;3:37–56.
74.
Saroha E, Altarac M, Sibley L. Caste and maternal health care service use among rural Hindu women in Maitha, Uttar Pradesh, India. J Midwifery Women’s Health. 2008;53:e41–7.CrossRef
75.
Nayar KR. Social exclusion, caste & health: a review based on the social determinants framework. Indian J Med Res. 2007;126:355–63.PubMed
76.
Sinha RK, Chatterjee K, Nair N, Tripathy PK. Out-of-pocket and catastrophic health expenditure: a cross-sectional assessment of a rural district of the state of Jharkhand in India. J Disease Global Health. 2015;4:130–40.
77.
Powell-Jackson T, Masumder S, Mills A. Financial incentives in health: new evidence from India’s Janani Suraksha Yojana. J Health Econ. 2015;43:154–69.CrossRefPubMed
78.
Govil D, Purohit N, Gupta SD, Mohanty SK. Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India. J Health Popul Nutr. 2016;35:15.CrossRefPubMed
79.
Powell-Jackson T, Neupane B. Evaluation of the Safe Delivery Incentive Programme: final report of the evaluation. Kathmandu: Support to the Safe Motherhood Programme; 2008.
80.
Dutta S, Lahiri K. Is provision of healthcare sufficient to ensure better access? An exploration of the scope for public-private partnership in India. Int J Health Policy Management. 2015;4:467–74.CrossRef
81.
Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, Warren CE. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Preg Childbirth. 2015;15:224.CrossRef
82.
Njuki R, Abuya T, Kimani J, Kanya L, Korongo A, Mukanya C, Bracke P, Bellows B, Warren CE. Does a voucher program improve reproductive health service delivery and access in Kenya? BMC Health Serv Res. 2015;15:206.CrossRefPubMedPubMedCentral
83.
Bellows BW, Conlon CM, Higgs ES, Townsend JW, Nahed MG, Cavanaugh K, Grainger CG, Okal J, Gorter AC. A taxonomy and results from a comprehensive review of 28 maternal health voucher programmes. J Health Popul Nutr. 2013;31(4 Suppl 2):106–28.PubMed
84.
Montagu D, Goodman C. Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector? Lancet. 2016;388:613–21.CrossRefPubMed
Metadata
Title
Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites
Authors
Sushmita Das
Glyn Alcock
Kishwar Azad
Abdul Kuddus
Dharma S. Manandhar
Bhim Prasad Shrestha
Nirmala Nair
Shibanand Rath
Neena Shah More
Naomi Saville
Tanja A. J. Houweling
David Osrin
Publication date
01-12-2016
Publisher
BioMed Central
Published in
BMC Pregnancy and Childbirth / Issue 1/2016
Electronic ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-016-1069-7

Other articles of this Issue 1/2016

BMC Pregnancy and Childbirth 1/2016 Go to the issue

Research article

Ureaplasma parvum genotype, combined vaginal colonisation with Candida albicans, and spontaneous preterm birth in an Australian cohort of pregnant women

Research article

Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania

Research article

Does mobile phone ownership predict better utilization of maternal and newborn health services? a cross-sectional study in Timor-Leste

Research article

Why do some women choose to freebirth in the UK? An interpretative phenomenological study

Research article

A retrospective review of birth outcomes at the Mother and Child Health Hospital in Lao People’s Democratic Republic, 2004–2013

Research article

Determinants of use of supervised delivery care under Ghana’s fee exemption policy for maternal healthcare: the case of the Central Region