Can India's primary care facilities deliver? A cross-sectional assessment of the Indian public health system's capacity for basic delivery and newborn services.
OBJECTIVES
To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states.


DESIGN
Cross-sectional study.


SETTING
Data from the nationally representative 2012-2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India.


PARTICIPANTS
8536 PHCs and 4810 CHCs.


OUTCOME MEASURES
We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location.


RESULTS
About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise.


CONCLUSIONS
Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.
['Sharma|Jigyasa|J|0000-0001-8860-0710', 'Leslie|Hannah H|HH|', 'Regan|Mathilda|M|', 'Nambiar|Devaki|D|', 'Kruk|Margaret E|ME|']
D019352:Censuses D003151:Community Health Centers D003430:Cross-Sectional Studies D004632:Emergency Medical Services D005260:Female D006297:Health Services Accessibility D006801:Humans D007194:India D007231:Infant, Newborn D008427:Maternal Health Services D011153:Population D011247:Pregnancy D011320:Primary Health Care D011634:Public Health
health systems newborn health health policy maternal health quality in healthcare