‘Two Sides of a Coin’ : Quality of Childbirth Services in Indian Public Health Facilities, from the Perspectives of Women and their Care Providers

Abstract: Background: Skilled birth attendance, usually available by promoting childbirth at health care institutions in low-resource settings, is known to prevent maternal and neonatal morbidity and mortality. While institutional childbirths in India have increased at an exponential rate, the infrastructure, material and manpower resources to support this practice are lagging, raising concerns about the quality of childbirth services.Methodology: A mixed-method approach was used in this project: in-depth interviews with women (n= 13); and focus-group-discussions with the care providers (n=27) were conducted and analysed using Grounded Theory. A cross-sectional survey (n= 1004) assessed prevalence of Fear of Birth (FoB) and postnatal depressive symptoms (PND), along with satisfaction with childbirth services among women in the immediate postpartum period.Results: The system of cashless childbirth provided at the public health facilities, in the women’s experiences, came at the hidden cost of them having to make themselves subordinate to the offered services. The prevalence of FoB and PND was 13.1% and 17.1%, respectively, and these were significantly associated (p < 0.001). Among women with vaginal births (VB), 41.2% had experienced a perineal wound and 59% of them underwent repair without local anaesthesia. While the majority of the women were satisfied (VB 68.7%; Caesarean births 79.2%) with the services; women having VBs at Community Health Centres (nearly 81%) were more commonly satisfied compared to those at the District Hospitals (nearly 60%) (p < 0.001). From the care providers’ perspective, maintaining quality of childbirth services was like a balancing act between the realities of low-resource settings with stakeholders’ expectations. While the providers remained proud and committed; the challenges often left them fatigued, disillusioned, irritable and sceptical.Conclusion: There is a need to improve the sensitivity with which childbirth services are being delivered to women coming to public health facilities; as well as towards improving the care providers’ work conditions. Suboptimal birth experiences are associated with the women’s perinatal mental health and satisfaction, while perpetual work challenges may make the care providers frustrated and/or apathetic. Improving manpower resources could reduce work-stress in care providers and thereby improve childbirth processes.