Exploratory Study on Maternal and Child Health Care Facilities in Two Districts of Karnataka State : A Health Systems Research

1Former Associate Professor, Department of Community Medicine, Kasturba Medical College, A Constituent of Manipal Academy of Higher Education, Mangaluru 575001, Karnataka, INDIA. 2Professor Emeritus, Department of Pediatrics, Kasturba Medical College, A Constituent of Manipal Academy of Higher Education, Mangaluru575001, Karnataka, INDIA. 3Professor, Department of Obstetrics and Gynecology, Kasturba Medical College, A Constituent of Manipal Academy of Higher Education, Mangaluru575001, Karnataka, INDIA. 4Professor, Department of Pediatrics, Kasturba Medical College, A Constituent of Manipal Academy of Higher Education, Mangaluru575001, Karnataka, INDIA. 5Associate Professor, Department of Pediatrics, Kasturba Medical College, A Constituent of Manipal Academy of Higher Education, Mangaluru575001, Karnataka, INDIA.


INTRODUCTION
Infant Mortality Rate [IMR] of India has decreased from 114 in the year 1980 to 40 in the year 2013.So has the Perinatal Mortality Rate [PMR] which was 55.7 in the year 1980 to 26 in the year 2013. 1 The contribution of Perinatal Mortality Rate [PMR] to Infant Mortality Rate [IMR] has varied from 50% to 60% during this period of time. 1 IMR of Karnataka State in India has also decreased from 71 in the year 1980 to 35 in the year 2011. 1 The PMR has also decreased from 40.2 in the year 1980 to 33.4 in the year 2011. 1 The contribution of PMR to IMR has varied from 60% to 70% during this period of time.Starting from the year 2011 the contribution of PMR to IMR of Karnataka State has increased to almost 95% to 99%.The IMR of Karnataka State for the years 2011, 2012 and 2013 are 35, 32, 31 respectively.The PMR of Karnataka State for the years 2011, 2012 and 2013 are 33.4,33.5 and 30.So we may see that starting from year 2011 the contribution of PMR to IMR of Karnataka State has increased to almost 99%. 1 From the available data the reasons for this are not clear.Facilities and Infrastructure for maternal care, delivery and neonatal care play an important role in child survival during the perinatal and immediate neonatal period.So, a field based study that explores the Maternal Child Health Care facilities would be helpful.Such a study would help the policy makers understand the situation better.The Maternal and Child Health Care facilities are not uniformly developed in the State of Karnataka.The northern parts of Karnataka State lag behind the southern parts of Karnataka State. 1 A field based study that includes Northern and Southern Parts would be helpful to the policy makers as the circumstances and reasons pertaining to Perinatal Death would be different.Koppal District is considered as one of the 5 backward districts of North Karnataka region. 2 The PMR of this district has been either equal to or higher than that of Karnataka State.The PMR during year 2012 -2013 was 30. 3 Dakshina Kannada District is considered as one of the developed district of South Karnataka Region.The PMR of this district was 12.64 during year 2012-2013 which is far below the PMR of Karnataka State. 4 Considering the PMRs and the operational feasibility it was decided to conduct the study in these two district of Karnataka State.
So, this study was conducted with the following objectives: 1].To know the infrastructure facilities that exist for the perinatal care in two districts of Karnataka.2].To know the deficiencies in Infrastructure and facilities if any in the 2 districts.

Study Setting
This field based study was conducted in 2 districts of Karnataka State.Dakshina Kannada District located in the Southern Part of Karnataka State and Koppal District from the northern part of Karnataka State were considered for the study.
Dakshina Kannada District located in the Southern Part of Karnataka State is divided in to 6 Talukas for administrative purpose.It has a total population of 20,80,640.It has 8 medical colleges, 5 dental colleges, colleges and hospitals that provide alternative medical facilities to the people.It is also the commercial and industrial hub of Karnataka as it is located on the sea coast with a well-developed port. 5ppal District located in the Northern Part of Karnataka State is divided in to 4 Talukas for administrative purpose.It has a total population of 13,80,920.It has only 1 medical college and people are referred to southern parts for any tertiary health care services.People are dependent on agriculture which does not work out as this is a relatively dry area with poor rainfall.This is one of the backward districts of Karnataka State. 2

Study Design
This is a descriptive study done to explore the perinatal care facilities provided in Maternal Child Health care facilities in both the districts of Karnataka State.

Study Units
The Maternal and Child Health Care Facilities of both the districts.It was decided to include any Health Care Facility which provided anyone of the following services: 1].Conducting Deliveries.2].Cesarean Section Facilities.3].Newborn Care Services, Those Health care facilities which did not meet the above criteria were excluded.

Categorization of Study Units
The Study Units which met the criteria were categorized in to 4 levels based on the criteria given in the Table 1.8][9][10] At each level if the study unit met the criteria as mentioned in Table 1, it was considered adequate otherwise it was considered deficient.
][8][9] The details of the Basic, Optimal and Advanced are as follows:

Basic
Which had the following facilities: Labour room with essential requirements, Adult resuscitation tray, Fully equipped delivery trolley, IV drip stand and Stethoscope/ Foetoscope/ Foetal Doppler, essential newborn care.Essential newborn care.

Advanced
Which had the following facilities: Basic + Optimal facilities, Doppler ultrasound scanning facilities, Continuous Intra-partum foetal monitoring facility -CTG, Facilities to provide, facilities to provide care for high risk newborn.

Study Tools
Checklists were developed for the purpose of evaluating the facilities present in the Health Care Units that were included in the study.

Pretesting
The study instruments were Pre-Tested in neighbouring district of Udupi to know the feasibility and appropriateness of use.Some modifications were made in the study instruments to suit our study.

Data Collection
Permissions were obtained from Karnataka Government to conduct the study.The district Commissioners were directed by the government about the study.Trained Field workers collected the data by visiting the health care facilities.They filled the checklists by observing the equipments in the health care facilities.The doctors in these facilities were approached for any clarifications about the equipments and facilities.The filled checklists were scrutinized by the investigators.In case of doubts the health care facilities were approached more than once to collect the data.

Data Analysis
The collected data was entered in MS Excel worksheet.It was analysed using SPSS version 12.The results are expressed as proportions in appropriate tables and figures.Comparisons were made between the two districts.The deficiencies in facilities are qualitative data.So, the implications have been explained in sentences.

RESULTS
Totally

DISCUSSION
This unique type of study conducted in the state of Karnataka has the following implications:  13 Koppal District being a dry and famine stricken area, has more number of people depending upon the public health care facility where the services are free.So, we get to see predominance of private sector in Dakshina Kannada District as compared with Koppal District.This implies that to reduce the PMR in Koppal district, the facilities in government sector needs to be upgraded.

Level of Care
There is predominance of Level I and II care facilities in Koppal District.There are no Level IV care facilities in Koppal District.Level III and IV care facilities are required for handling High Risk Pregnant women and High Risk Newborns.So, the chances of neonatal and perinatal deaths increase as reflected by the high PMR of Koppal district.Absence of facilities implies that such high risk cases have to be referred to other well developed districts where Level III and IV facilities exist.In Dakshina there are 13 Level IV Facilities.The presence implies that high risk pregnant women and high risk newborns could be cared for in Dakshina Kannada.This is reflected by the low PMR of Dakshina Kannada District.

Figure 1 :
Figure 1: Geographical Distribution of Maternal and Child Health Care Facilities in Koppal District.

Figure 2 :
Figure 2: Geographical Distribution of Maternal and Child Health Care Facilities in Dakshina Kannada District.

*
At the time of conducting the study, Mangalore Taluka was one Taluka.As of now it is divided in to 2 Talukas ie, Mangalore Taluka & Moodabidri Taluka

Table 1 : Categorization of Maternal and Neonatal services.
*In general the type of deliveries conducted in the facility is based on the available infrastucture in the facility.Level I can provide care for normal term cases to Level IV can provide care for all high risk cases International Journal of Medicine and Public Health, Vol 8, Issue 4, Oct-Dec, 2018 Optimal Which had the following facilities: Basic facilities, Obstetric forceps/ vacuum, ultrasound scanning, Facility to conduct Caesarean Section Facilities for neonatal resuscitation.
They were Checklists for evaluating 1].Labour Theatres.2].Facilities for conducting a Caesarean section.3].Facilities for providing Essential newborn care.4].Facilities to care for "High Risk new born".
63 and 65 Health care facilities met the criteria in Dakshina Kannada and Koppal Districts respectively.Dakshina Kannada District showed a predominance of Private Health Care Facilities [52 out of 63].Koppal District showed a predominance of Public Health Care Facilities [40 out of 65].The geographic distribution of these facilities in both the districts are presented in Figure 1 and 2. The distribution of these according to level of care is provided in Table 2.It shows a predominance of Level 1 and 2 Public Health Care facilities in Koppal District which are deficient.Most of the level 4 Private health care facilities in Dakshina Kannada district are deficient.The Maternal and Child Health Care facilities available in these hospitals are presented in Table3.The number of SNCU, NICU and Warmer Beds in Dakshina Kannada district makes it better placed to handle sick and High Risk Newborns as compared to Koppal District.To fulfil the objective of our study the deficiencies in the health care facilities in both the districts are presented in Table4.These show that the facilities are deficient in both the districts though Dakshina Kannada District fares better than Koppal District.

Table 2 : Distribution of facilities according to Levels of Maternity and Neonatal Care in Private and Public Health Care Facility in both the districts.
At each level if the study unit met the criteria as mentioned in Table no 1, it was considered adequate otherwise it was considered deficient.**Those paediatric hospitals where maternal care is not given has been placed as NICU/SNCU separately

Table 1
[11][12]at Private Sector is the predominant service provider in Dakshina Kannada but not in Koppal District where Government Sector is the predominant service provider.Available data from National Family Health Survey 4 shows that in the district of Dakshina Kannada, only 38.6% of total births occur in Public Health Facility.[11][12]Privatesector thrives on the paying capacity of the people.Dakshina Kannada District being a economic and industrial hub with higher per capita incomes implies that more people would pay for better services in the private sector as compared with public sector.Data from NFHS 4 indicate that in Koppal District 72.6% of births occur in Public Health Care facilities.

Table 4
shows that available facilities do have deficiencies in equipments and facilities.The facilities are better in Dakshina Kannada as compared with Koppal District.High Risk Pregnant women and Newborns could be managed in Dakshina Kannada District.Because of absence of such facilities in Koppal District, service delivery gets affected.This increases the chances of Neonatal and Perinatal Deaths.So, we get to see the higher PMR in Koppal District as compared with the Dakshina Kannada District.This study is limited by the fact that due to feasibility reasons we could not study the Functioning of 1].Health Care facilities.2].Health Care personnel involved in providing Maternal and Child health care services in both the districts.Our effort was limited to studying the distribution and availability of infrastructure and facilities.