Syndicate content

Are Institutional Births Institutionalizing Deaths?

Jishnu Das's picture

On November 12th in the Indian state of Chhattisgarh, twelve women who had received tubal ligations died. The tragic incident highlights the unfortunate reality that for many people around the world, hospitals and clinics may not satisfy the most basic assumption that visiting them will make you better. Equally worrying is the Indian government’s singular focus on increasing ‘institutional deliveries’ and family planning that led it to celebrate a surgeon who had performed 100,000 sterilizations, now spending no more than 4 minutes on each “case”.
 

 Around 9 am one of us (Das) arrives at the Community Health Center in a small town in Madhya Pradesh, India. There is a row of women lying on the floor outside the labor and delivery room, moaning or groaning in various stages of pain and clear discomfort. We pay them no heed; this is a sight we have seen before. Over two years, we have visited many health facilities in the state and they are either (i) deserted or (ii) packed to the brim with women giving birth, about to give birth, or just having given birth. Mass tubal ligations are performed on as many women as will consent—aided by the promise of money under India’s conditional cash transfer for institutional delivery—which, till recently would not pay women who were giving birth to a third or higher parity child unless they also consented to be sterilized. The obstetrician/gynecologist is happy to show us around. She is young and clearly exhausted. “I came here 5 months back. Since then, I have been alone with one nurse in this facility. Every month we do 1,000 deliveries and around 500-600 tubal ligations; almost 100 are C-sections. I am here 18 hours a day and even then at 2 every morning I stay up bleaching the operating room.” She shows me the bleach and the OR is truly spotless. She tells me that she is looking for the first opportunity to leave—either by pursuing a specialization or leaving public service. “This is no way to help. I thought I would work on improving people’s lives. But there is no help from the government and I can’t keep this up much longer”.

A short 30-minute drive away, we visit the nearest Primary Health Care center. A young man is waiting next to a motorcycle. He has been crying. “I brought my wife here to give birth last night. But when the child was born, the doctor said that he did not have sufficient oxygen. He told us to take the child to the district hospital. I rushed my child there on the motorcycle, but by the time a doctor saw the child it was too late. No one cared. This doctor is not bothered. If only he had worried a little. He just did not care.” He keeps repeating the same phrase again and again: “No one cared” and it remains with us for a while.

Spurred by an international consensus that the way to meet the Millennium Development Goals on reductions in maternal, child and infant mortality was to increase the number of institutional deliveries, countries have devoted themselves with a single-minded focus to doing just that. The Indian Government, encouraged by the “success” of the Chiranjeevi voucher scheme , expanded conditional cash transfers for institutional deliveries to the entire country. In Rwanda, facilities were paid for institutional deliveries. The results have been impressive. Between 2005 and 2011 (the last year for which public data are available in India), institutional deliveries increased from 20% to 49% in nine Indian states with relatively worse socioeconomic and health indicators. Similarly, between 2000 and 2008 in Rwanda, institutional deliveries increased from (approximately) 25% to 75%. What has the fast rise in institutional deliveries done to child mortality?

Figure 1, based on ongoing work with Shareen Joshi and Quy-Toan Do shows the pattern of U5M and infant mortality in India since 1980. Under-5 mortality has fallen sharply over this time, while infant mortality has been harder to budge. Consequently, the share of deaths due to infant mortality has increased dramatically, and by 2008, accounted for more than 80% of all U5 deaths. Second, infant mortality was declining somewhat till 2004. After that there is a sudden drop in 2005, followed by a flat-line. Between 2005 and 2008, infant mortality budges not an inch. We look at that sudden drop and show that it can be entirely accounted for by differences in survey methodology between the 2004 and the 2008 surveys. Using institutional variation in eligibility, we confirm findings from other research that the CCT has had no discernible impact on infant mortality. If anything, the rise of institutional deliveries is remarkably consistent with the halting of a slow decline in infant mortality from the 1970s onwards.
 


Avid followers of this topic will point to Lim and others study in the Lancet with the opposite results. Unfortunately, the Lim study is fatally flawed as shown by Mazumdar, Mills and Jackson and by Randive, Diwan and Costa. India observers will also point to summary reports from the subsequent annual health surveys in 9 states showing that infant mortality has declined since then. These data have not been publicly released for research and replication, and our work on the previous surveys shows that replication and consensus among multiple teams is critical to a shared understanding of the data.

But it gets worse. It turns out that even the “successful” program on which the entire CCT was premised had no impact whatsoever on anything at all. The COHESIVE group, which works on healthcare in India, went back to the state of Gujarat that started and implemented the Chiranjeevi scheme and conducted a large household survey to understand the impacts of the program. Their results show that the program was ineffectual. Of course, by the time their evaluation appeared, success had long since been claimed, both nationally and internationally. The Singapore Economic Development Board and The Wall Street Journal had already decided in 2006 that the program had “drastically reduced maternal and infant deaths” and therefore deserved an Asian Innovation Award.

”Wait,” experts will say, “Indian health care is really poor. It should be patently obvious that increasing institutional deliveries will decrease infant mortality in countries where healthcare works.” But there is no evidence for that either. A recent study from Rwanda shows that their pay-for-performance program led to a sharp increase in institutional deliveries, but there was no impact on neonatal mortality. In any case, recommendations to increase institutional deliveries never add the caveat “where facilities are working properly” or provide concrete advice on how to make them work before all these extra institutional deliveries are performed. We might all agree that “if things worked well then there should be more facility based births.” But if things do not work well, do we say there should be more such births anyway? And if things worked well, do we know that people would not already be using the institutions to deliver children in a safe environment?

Worse, the policy to increase institutional deliveries is likely to make it harder to “make them work properly”. In Chennai public hospitals, the Caesarean section rate is over 60%. The enormous traffic makes scheduling deliveries essential. Predictable Caesareans become more attractive to the facility leading to higher-risk deliveries and rates of infection. In other parts of the country, Caesarians being “more attractive” takes on darker meaning as ongoing research finds medical officers in public hospitals carrying on a lucrative trade performing such operations on women waiting for natural delivery. Combined with the customary tubal ligations that improve the doctor’s statistics, this is doubly profitable.

What has gone wrong?

Shoddy Evidence: The premise that institutional deliveries would lead to decreased child mortality is based on correlations of institutional deliveries and child mortality. Based on such correlations, the United Nations decided that, “countries should use the proportion of births assisted by skilled attendants as a benchmark indicator” to monitor progress and aim for 80% of births assisted by skilled birth attendants by 2010. This is wrong on at least two fronts. First, as always, correlations are not causality.
In rich countries, any drug has to go through at least 6 years of testing prior to clearance, but when it comes to the policies that affect the bodies of poor women, can we not do better than relying only on associations in the data? Second, the marginal revolution transformed economics more than 100 years ago, but it seems to have had no sway on global health policy. You cannot decide what is optimal without understanding the marginal costs and benefits. (Simple example: if the cost of increasing institutional deliveries to 70 is $10, to 75% $12 and for every percent above $10 million, and additional benefits were the same, is 80% the magic number? And do we know anything at all about the shape of that marginal cost curve? No.)

Lack of respect for the decisions of the poor: Furthermore, government encouragement of institutional deliveries is based on the idea that poor people choose to deliver at home either out of ignorance or an inability to make the right decisions or due to cultural norms and the exercise of (male) power. But an alternate starting point is that people were not using institutions to begin with precisely because quality was low, and that increasing quality would also bring more people in. In fact, this is the most obvious explanation for the correlation between increasing institutional deliveries and lower child mortality. To base policy on the belief that we can make better decisions over the lives of those who are about to be born than their parents is a stand that minimally requires the onus of proof to be on those who claim such knowledge.

Of course, there are situations where women cannot leave home to give birth and where patriarchal power is played out over the birth of a child. But these are cases that have to be worked on piece by piece and not assumed to be the constraining factor in the general population. The likely reason why the community health center was packed and the primary health center was not was that our young obstetrician really cared and tried to do her best, relative to the doctor who just did not care.

Lack of contextual understanding: Especially, when it comes to disadvantaged populations who do not have a voice of their own, we must advocate on the behalf of evidence and an understanding of context. In India, the international drive to increase institutional deliveries was juxtaposed with a continuing obsession around family planning that has turned many public clinics into mass sterilization wards. This was a predictable outcome based on a cursory reading of the Indian government’s obsession with family planning.

Too often, we are seduced by the fallacy of immediacy (rigorous evidence will take too long) or the hubris of our own certainties (we know what we need to do). Let us also have the humility to accept the harm that has resulted and learn from these costly failures. Where the evidence is not clear or is not there, we should always take the time to set up the accompanying research—even when there is a global consensus that something needs to be tried due to extraordinary circumstance. And where we do not have the evidence, let’s be honest that we do not know.

Bertrand Russell once wrote: “There have been ages when everybody thought they knew everything, ages when nobody thought they knew anything, ages when clever people thought they knew much and stupid people thought they knew little, and ages when stupid people thought they knew much and clever people thought they knew little. The first sort of age is one of stability, the second of slow decay, the third of progress, the fourth of disaster.” (Russell: On Modern Uncertainty).

He believed that we are now in the fourth age; perhaps it is time to prove Russell wrong.

Comments

Submitted by Jorge on

I was at a public health center in an Indian village that shall remain unnamed this morning, where the doc told me he had never in his many years met his targets for sterilization and didn't care how much every year he was scolded or the fact that he would never be transferred back to a city, he would never perform a ligation against the will of the patient. I wanted to give him a hug.

Submitted by Jishnu on

Thanks, Jorge.

The system functions because of people like the person who you met. The sad part is that they are the ones who are penalized throughout their careers.

Submitted by Daniel Kress on

Thanks for this blog entry. Provocative, thoughtful, insightful: I would expect nothing less from you.

I would certainly agree (and many of my MNCH colleagues here have agreed) that forcing women into poor quality care for an institutional delivery is not the best course of action. I would also agree that this possibility, ie encouraging institutional delivery where quality of care is poor happens more than it should.

But I wonder if the boogeyman is institutional delivery or poor quality of care?? Knowing you I suspect it’s actually QOC, which I think is a legitimate concern.

I think the case for the impact of institutional delivery (in most conditions) is fairly good. For example, there is quite a bit of research that shows that the impact of institutional delivery overall and across many studies and countries is favorable on child health, ie
http://www.biomedcentral.com/1471-2393/13/18

To be fair, there is also this article which finds that alternatives to institutional birth (mainly in middle to high income countries) are not necessarily worse that in an institutional delivery setting. http://summaries.cochrane.org/CD000012/PREG_alternative-versus-conventional-institutional-settings-for-birth

We may find that JSY had little impact on mortality (due to QOC issues, etc) but I am not so sure that I would want to throw out the idea of institutional delivery altogether.

Submitted by Jishnu on

Dan

That's exactly right. People don't deliver in institutions because the quality of care is terrible. The clear policy implication is to improve the quality and people will then come. Instead, an alternative approach has been followed, predicated on the belief that households don't make good decisions, leading to adverse consequences for many poor people.

We do cite the report in the hyperlink in the shoddy evidence part, but note that the 19 studies there are all run of the mill correlations that just show that people deliver in institutions when the quality is high! Or at least, the evidence is completely consistent with that. To be fair, the systematic review clearly notes that all the evidence is based on correlations because RCTs are hard to conduct in this environment. Although RCTs may be hard, careful causal evidence can be obtained through a number of other means that build towards a consistent story, as the papers cited in the blog show.

Submitted by Gabriel on

Interesting post. I have a paper looking at changes in infant mortality in Kenya using DHS data, focusing on the massive increase in bednet usage. One of the hardest minor results to explain to reviewers was with or without controls for other factors neonatal mortality is consistently higher for those born in a clinic in Kenya. Here’s what we wrote:
"Surprisingly, neonatal mortality rates are higher if the child was born in a health facility, and this difference is significant at the 1 percent level. This could reflect a causal effect, perhaps because of higher risk of infection due to exposure of the infant to patients in the facility. It is possible, however, that this represents at least in part a selection effect: women with higher risk pregnancies for which the newborn will face greater mortality risk may be more likely to seek birth in a health facility, and it is also possible that neonatal deaths are more likely to be reported if they take place within a facility. With available data it is not possible to distinguish between these two hypotheses."

This isn't the kind of study amenable to an RCT, but one could imagine looking at with other identification strategies, e.g. an encouragement design. Just a study looking at the correlation with and without controls between institutional births and mortality at the individual birth level, using DHS microdata from many countries, would be informative.

Submitted by katyayni on

Hi Jishnu,

Thanks for writing the blog. My two cents are that the deaths in Chhattisgarh should not be attributed to one cause. The government’s (and development partner’s) push for institutional deliveries are as responsible for the deaths as India’s policies on human resources for health, lack of health regulation and accountability, insufficient resources for health communication and awareness on patient rights, etc. Lack of quantitative data on the impact of these factors does not mean they aren’t causal. Aiming the gun only at institutional deliveries is harmful because it distracts us from delving into the underlying systemic failures that enable such disasters.

Secondly, I agree that the appropriateness of institutional deliveries in different parts of India needs to be studied. I would suggest incorporating historical evidence into this research. The push for institutional deliveries in India started around the late nineteenth century and has gained strength for multiple reasons, only one of which is the claim that it reduces maternal and child mortality.

Submitted by Jeff Hammer on

Hi Katyayni,
Complete agreement. The causes of the deaths are many, varied and dependent on context. We should do more to understand a complicated reality. The consequences of the recent re-emphasis on institutional deliveries are many, varied and dependent on context as well. It’s deeply concerning that only a small bit of the problem is even considered when such policies are promoted.
Jeff

Submitted by Anrudh Jain on

Hi Jishnu and Jeffery,
Thank you for bringing to our attention this poor quality of services and its potential adverse effect on maternal mortality. It is true that maternal mortality ratio (MMR) declines with an increase in the proportion of births that take place in health facilities or are attended by trained birth attendants. However, the assumptions underlying this negative relationship may not remain valid with the financial incentives or CCT of the type offered through the JSY scheme in India to promote institutional deliveries. First, it may disproportionately attract pregnant women without any complications to health facilities. The probability of maternal death among women with these normal deliveries (about 80 to 85 percent of all deliveries) is close to zero. Second, pregnant women with complications either may not reach these facilities in time or may not get the care they need because of overcrowding. The overall impact of increased institutional deliveries under the JSY scheme may not translate in to a reduction in MMR. The effect of JSY on MMR cannot be measured from household surveys. We need to set up client-level monitoring systems at health facilities offering comprehensive emergency obstetric care (cEmOC) services to monitor quality of care received by them. Specifically, we need to monitor two indicators: (1) proportion of pregnant women reaching these facilities who experience complications related to childbirth, and (2) case-fatality ratio among women with complications around childbirth who deliver at these facilities. An increase in the first indicator and a decrease in the second indicator together will imply a reduction in MMR. I have pointed this out in a Commentary on “Janani Suraksha Yojna and Maternal Mortality Ratio” published in Economic and Political Weekly, March 13, 2010 vol xlv no 11, 15-16.

Submitted by Lester Coutinho on

Jishnu and Jeffery

The observations you make in this blog are insightful - shoddy evidence has driven national health programs. More recently the GOI decided to launch adolescent peer education programs despite global evidence indicating poor to no health impact of such programs. And one can go on list other such examples. However, what I missed in your discussion is an attempt to understand why we end up with bad policy decisions. Part of the answer lies in global development efforts which focus on outputs as a proxy for outcomes. The reluctance to measure is tied to the unwillingness to be held accountable. Unless the incentive structure for policy makers is changed eminence will trump evidence.
On an aside - pegging your story on the Chattisgarh deaths due to complications post sterilization make for sensational opening lines but poor judgement as the issue was not followed through the blog. Unlike institutional deliveries there is a high demand for sterilization - it is not the cash incentive that attracts women - but the desperation of not wanting another pregnancy and not having information and choice of other methods. The high number of first trimester abortions suggests that desired fertility is declining but the means to enable women to achieve this have remained unchanged for over 50 years. And ironically the Indian state refuses to introduce other modern methods because they are concerned about quality. And again eminence trumps evidence.

Submitted by Jeff Hammer on

Lester,
I couldn't agree more that we should be measuring outcomes far more often than we do and I agree that the failure to do so often reflects willful ignorance - simply not knowing whether something worked is easier to deal with than explaining why something didn't work. I think that we (donors) are at least partially to blame. We have priorities backwards with far more money trying to overdesign projects beforehand and little to nothing on supervision that would regularly measure those outcomes later.
I'd like to understand the political economy of policy choices much better, too. In India it is always striking that governments want to provide private goods (excludable, rival) instead of public goods. Is it easier to take credit for private goods? Water tankers with the politician's name on it instead of clean water in pipes? Dunno. Wish we knew more.
Another thing I'd like to know is "how many of the sterilizations are really voluntary and how much are done without informing (or bullying) the woman?" There are stories on either side and, while obviously hard to measure, sure could use some clarification.
Jeff

Submitted by Lester Coutinho on

Hi Jeffery - thanks for the response.
The question on whether sterilization is voluntary or not has not been part of any large survey like DHS but there are smaller studies including a couple of 'sterilization regret'. PMA2020 - an effort led by Scott Radloff and Amy Tsui at JHU is measuring some aspects of decision making and autonomy wrt to contraception.We know more from some private sector social franchinsing programs that women are willing to pay for sterilization, and more importantly when govt contracts out to franchised / accredited clinics women prefer these services over public sector even though they have to forego the incentive. Of course such clinics. We have reasonable data that women of even lower quintiles seek services in such clinics because they have some notions of quality.

Would be happy to connect and talk about the hope of evidence based policy making and govt responsiveness to learning from what's not working. We have found that enabling govt to own the evidence gathering process ensures ownership of the findings and willingness to act.

Lester

Submitted by Bashi Kumar-Hazard on

Dear Mr Das,

Congratulations on an excellent piece of research on this very important issue!

I am a board director of Human Rights in Childbirth based in Sydney, Australia. My colleagues in India and I are working together to develop a conference to discuss the concept of womens' and families' human rights - regardless of economic status - in the context of pregnancy and childbirth. The conference, to be held in January 2016 at the National Law School in Bangalore, is not just about access to health care, but the kind of care that will suit women from different backgrounds, and whether we are listening to the people who are affected by that care in the process of developing these various healthcare policies. A core component of our conference program is (a) exploring the extent to which behaviourally accepted abuse and disrespect is taking place in birth in all sectors public and private and (b) whether economic power can address such breaches, or whether the "abuse" takes a different form in private sectors (such as overcharging, overservicing through unnecessary interventions, dismissing a mother's choices, systems discouraging breastfeeding). We think your research and insights will have a powerful impact on the people who will be attending our conference, both as speakers and attendees.

We would be very grateful for the opportunity to talk about whether and what sort of involvement you can offer to our conference. Please contact me directly when you have a moment to discuss this further.

With kind regards, Bashi Kumar-Hazard

Submitted by Nora Kropp on

Excellent article. Please check this website for details about the Human Rights in Childbirth Conference being held in Bangalore, India 28-31 January 2015. http://www.humanrightsinchildbirth.org/event/india-2016/

Add new comment