Situational Analysis of Caesarian-section services for deliveries in Based on Analysis of HMIS report 2015-16

Compiled By: State Health Resource Centre, Chhattisgarh Table of Contents

S.N. Content Page No. 1 Introduction & Objectives 3 2 Methodology 3 3 Findings 4 4 Annexure 12-16

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Introduction and Objectives:

Availability of Caesarian-section (c-section) services is a critical component of Emergency Obstetric Care the health facilities are expected to provide as First Referral Units (FRUs). Chhattisgarh has made some progress in making FRUs operational over the last decade. The Directorate of Health Services, Chhattisgarh as well as NHM have been analyzing the performance of FRUs regularly. It is also an aspect on which information is easily available as part of HMIS. Though the reports in HMIS are expected to be accurate, it was felt that it may be useful to seek feedback from community to verify overall functionality.

This report is an attempt to analyze the functionality of FRUs in Chhattisgarh based on the number of c-sections conducted. It also looks at role of private sector in providing c-section services (based on HMIS reports).

Methodology:

This study involved the following steps:

 From HMIS website of GoI, HMIS data on c-sections and deliveries of 2015-16 was downloaded – district-wise and facility-wise for government facilities as well as private facilities.  The data was sent to field to get community feedback on functionality of each Government FRU through Meetings with Mitanin Trainers and VHSNC members. FRUs with at least one c-section done in last year, were called ‘operational FRUs’. The geographical distribution of above classification was shown on map of Chhattisgarh.  An operational Government FRU was classified as ‘Functional’ if it conducted more than 24 c-sections in 2015-16 i.e. average of at least 2 c-sections per month. The rest of operational FRUs were categorized as ‘Poorly Functional FRUs’.  The estimated deliveries were calculated for each district based on projected population for 2015 and district-wise birth rates reported by AHS 2012-13.  Districts were classified into 4 categories of ‘Availability of c-section services in Government facilities’ based on percentage of expected deliveries conducted as c- sections in Government facilities.  Districts were classified into 4 categories of ‘Availability of c-section services in all facilities’ based on combined percentage of expected deliveries conducted as c-sections in Government and Private Facilities put together.  The geographical distribution of above classification was shown district-wise on map of Chhattisgarh.

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Findings: a) Number of operational and ‘functional’ FRUs:

In HMIS (April 2015 to March 2016), 54 Government health facilities have been reported as having conducted one or more c-section cases.

On verification from local community sources (Mitanins and VHSNCs), it was found that 11 of them have not conducted any c-sections in 2015-16. Presumably, these centres might have been reported as doing c-sections in HMIS due to data-entry mistakes. The list of the above 11 centres is provided in Annexure 1.

The remaining 43 facilities were found to be operational (i.e. conducted at least one c-section in 2015-16) as per HMIS as well as according to community. The functionality of these facilities was judged into two categories:

Functional If the FRU conducts average of 2 c-sections per month or more (>=24) Poorly If the FRU conducts less than average of 2 c-sections per month, i.e. Functional conducted less than 24 c-sections in 2015-16 (<24)

Based on the above criteria, 29 out of the 43 FRUs were found to be ‘functional’ i.e. conducted 24 or more c-sections in 2015-16. The following Table 1 summarizes the findings:

Table 1: Functionality of Government FRUs in Chhattisgarh

Type of Facility Functional FRU Poorly Functional FRU Medical College Hospital 5 0 District Hospital 13 6 CHC/Civil Hospital 11 8 Total 29 14

The list of above 43 facilities and their ‘functionality’ status is given in Annexure 2.

The above 43 facilities and their status of functionality are shown in the following maps. The first map (Map1) shows the location of facilities and their functionality status.

The second map (Map 2) shows the area that the 29 functional FRUs can serve well. It is assumed that each FRU can serve a radius of 40km (as the crow flies). This radius of 40km can mean actual distance to be travelled by road, is around 60-100 kilometers. The map shows that around half of geographical area of the state cannot be covered well by existing functional FRUs.

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Map 1 : Functionality of FRUs in Chhattisgarh

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Map 2 : Catchment area (40km) of FRUs in Chhattisgarh

6 b) How many c-sections are taking place in Chhattisgarh?

As a thumb rule of rational practice in obstetric-care, around 10% of all deliveries should be through c-sections. In Chhattisgarh, according to HMIS reports, 8.1% of total deliveries took place through c-sections. However, the proportion of c-sections in government-sector remained very low as the following Table 2 shows.

Table 2: C-sections out of total expected deliveries: Relative contribution of Government and Private sector

% out of total estimated HMIS reported no. Parameter 6.49 lakh deliveries in of c-sections state in 2015-16 Total C-section in Government 13795 2.1% Facilities Total C-section in Private Facility 38805 6.0% Total C-section conducted 52600 8.1%

The following table further shows the contrast. While Government sector carried out c-section in 4% of the institutional deliveries conducted by it, the figure for private sector was as high as 46%.

Table 3: What proportions of deliveries are through c-section - Comparison of Government and Private sector

C-sections Total institutional Parameter done deliveries % conducted By Government facilities 13795 317763 4.3% By Private facilities 38805 83386 46.5% Total 401149 13.1%

c) District-wise availability of c-section services in Government facilities:

As stated above, as a thumb rule around 10% of all deliveries should be through c-sections. In order to judge the relative district-wise availability of c-section services in Government facilities, a much lower rate was taken as criteria.

The analysis is summarized in Table 4 below:

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Table 4: District-wise Availability of functional c-section services in Government facilities

Criterion - % of c- section done in Government facilities No.of Category Names of districts out of total expected Districts deliveries in the district District with No c- section services in Balrampur, Jashpur, Nil 4 Government Sukma Bijapur facilities District with poorly Kawardha, Dantewada, functional c- Gariyaband, Kondagaon, section services in 0.01% to 0.3% 8 Balodabazar, Bemetara, Government Balod, Mungeli facilities District with moderately Koriya, Narayanpur, functional c- Korba, Janjgir, Kanker, 0.3% to 2% 8 section services in Dhamtari, Mahasamund, Government Surajpur facilities District with fully functional c- , Raigarh, Bastar, section services in >2% 7 Bilaspur, Rajnandgaon, Government Sarguja, facilities

The District-wise information is given in Annexure-3.

The map of above analysis shows the following picture (Map 3):

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Map3: Availability of c-section services in Government facilities:-

9 d) Availability of c-section facilities (Government and Private sector Combined): Government of Chhattisgarh has extended health insurance with entire population being eligible for coverage under RSBY or MSBY. Though actual coverage is in progress, it can be useful to look at availability of c-section services in different districts, irrespective of whether provided by private or government sector. The district wise number of c-sections conducted and its percentage out of total expected deliveries in given in Annexure 4. Table 5 below lists the districts according to combined availability.

Table 5: District-wise availability of c-section facilities (Government and Private sector Combined)

No.of Category Name of District District District with Bastar, Rajnandgaon, Korba, Raigarh, functional C-section 9 Koria, Bilaspur, Dhamtari, Raipur, facility with Mungeli, Balod, Balodabazar, moderately 9 Sarguja, Mahasamund, Dantewada, functional C-section Janjgir, Kanker, Jashpur facility District with poorly Bemetara, Surajpur, Kondagaon, functional C-section 6 Narayanpur, Gariyaband, Kawardha facility

District with No C- 3 Balrampur, Bijapur, Sukma section facility

Map-4 shows the districts with varying level of overall availability of c-section services.

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Map 4: District-wise availability of c-section facilities (Government and Private sector Combined)

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Annexure 1: List of Facilities incorrectly reported in HMIS as conducting c-sections in 2015-16

No. of C-section Number of c-sections Health S.N. District reported in 2015-16 as per community Facility/FRU as per HMIS reports 1 Sukma District Hospital 44 0 2 Sukma Chhindgarh CHC 29 0 3 Surajpur Bhaiyathan CHC 55 0 4 Bilaspur Takhatpur CHC 9 0 5 Durg Nikum CHC 31 0 0 6 Janjgir-Champa Navagarh CHC 13

7 Baloda Bazar Bhatapara CHC 2 0 8 BIJAPUR District Hospital 1 0 9 Hospital 2 0 10 Kawardha Kawardha CHC 1 0 11 Rajnandgaon CHC 1 0 Total 188 0

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Annexure 2: Operational FRUs and Functionality Status:

No. of C-section S.N. District FRU conducted at public Functionality facilities in 2015-16 1 Raipur Medical College Hospital 3,503 Functional 2 Bastar Medical College Hospital 771 Functional 3 Bilaspur Medical College Hospital 1,430 Functional 4 RAIGARH Medical College Hospital 1,573 Functional 5 Rajnandgaon Medical College Hospital 1,499 Functional 6 Durg District Hospital 1,164 Functional 7 Bilaspur District Hospital 759 Functional 8 Sarguja District Hospital 757 Functional 9 Hospital 703 Functional 10 Hospital 213 Functional 11 Janjgir-Champa District Hospital 210 Functional 12 Koria District Hospital 184 Functional 13 Hospital 146 Functional 14 RAIGARH LAILUNGA CHC 103 Functional 15 RAIGARH KHARSIYA-Civil Hospital 86 Functional 16 Hospital 52 Functional 17 Janjgir-Champa JAIJAIPUR CHC 50 Functional 18 Hospital 47 Functional 19 Kanker Bhanupratappur CHC 46 Functional 20 Kanker Charama CHC 45 Functional 21 Durg Dhamdha CHC 41 Functional 22 Kawardha District Hospital 40 Functional 23 Dhamtari Kurud CHC 38 Functional 24 Hospital 31 Functional 25 Raipur Abhanpur CHC 29 Functional 26 Dhamtari Nagri CHC 28 Functional 27 Korba Pali CHC 28 Functional 28 Koria Manendragarh CHC 28 Functional 29 Hospital 25 Functional 30 Korba Katghora CHC 21 Poorly Functional 31 RAIGARH GHARGHODA CHC 21 Poorly Functional 32 Baloda Bazar District Hospital 20 Poorly Functional 33 Gariyaband District Hospital 16 Poorly Functional 34 Janjgir-Champa AKALTARA CHC 14 Poorly Functional 35 Raipur Tilda CHC 14 Poorly Functional 36 Sarguja Sitapur CHC 14 Poorly Functional 37 Kondagaon District Hospital 10 Poorly Functional 38 Bemetara District Hospital 9 Poorly Functional 39 Bilaspur BILHA CHC 9 Poorly Functional 40 Hospital 9 Poorly Functional 41 Balod Gunderdehi CHC 4 Poorly Functional 42 Balod District Hospital 3 Poorly Functional 43 Mungeli Lormi CHC 2 Poorly Functional Total 13,795

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Annexure 3: District wise status of C-Section services

Whether No.of District hospital No.of C- CHC Estimated No.of C- /Medical Section in No.of C- S.N. District have C- Deliveries Section College hospital Medical Section in DH Section in 2015-16 in CHC has c-section College facility service 1 Balrampur 0 No 20681 0 0 2 Bastar 0 Yes 18874 771 -- 3 Dantewada 0 Yes 7040 9 0 4 Gariyaband 0 Yes 17243 16 0 5 Sukma 0 No 23792 0 0 6 Jashpur 0 No 20392 0 0 7 Surajpur 0 Yes 6212 31 0 8 Balodabazar 0 Yes 37661 20 0 9 Balod 1 Yes 18075 3 4 10 Mungeli 1 No 20457 0 2 11 Bijapur 0 No 6338 0 0 12 Bemetara 0 Yes 17410 9 0 13 Kawardha 0 Yes 28324 40 0 14 Kondagaon 0 Yes 13094 10 0 15 Dhamtari 2 Yes 17949 52 66 16 Korba 2 Yes 29291 213 49 17 Kanker 2 Yes 16534 25 91 18 Mahasamund 0 Yes 25595 146 0 19 Janjgir 2 Yes 36694 210 64 20 Narayanpur 0 Yes 3163 47 0 21 Raipur 2 Yes 62345 3503 703 43 22 Bilaspur 1 Yes 57195 1430 759 9 23 Koria 1 Yes 14256 184 28 24 Sarguja 1 Yes 22348 757 14 25 Durg 1 Yes 37673 1164 41 26 Rajnandgaon 0 Yes 39884 1499 -- 0 27 Raigarh 3 Yes 34492 1573 -- 210 Total 19 22 districts 649285 5704 7470 621

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Annexure 4: District wise combined (in Government and Private sector) number of C-Section

Estimated Total C- No.of C- Grand S.N. District Deliveries in Section in Section in Total 2015-16 Govt facility Private facility

1 Balrampur 20681 0 0 0 2 Bijapur 6338 0 0 0 3 Sukma 23792 0 0 0 4 Bemetara 17410 9 0 9 5 Surajpur 6212 31 0 31 6 Kondagaon 13094 10 165 175 7 Narayanpur 3163 47 0 47 8 Gariyaband 17243 16 287 303 9 Kawardha 28324 40 676 716 10 Mungeli 20457 2 792 794 11 Balod 18075 7 695 702 12 Balodabazar 37661 20 1521 1541 13 Sarguja 22348 771 235 1006 14 Mahasamund 25595 146 1181 1327 15 Dantewada 7040 9 383 392 16 Janjgir 36694 274 1831 2105 17 Kanker 16534 116 854 970 18 Jashpur 20392 0 1197 1197 19 Bastar 18874 771 562 1333 20 Rajnandgaon 39884 1499 1387 2886 21 Korba 29291 262 2007 2269 22 Raigarh 34492 1783 1859 3642 23 Koria 14256 212 1339 1551 24 Bilaspur 57195 2198 5236 7434 25 Dhamtari 17949 118 2723 2841 26 Raipur 62345 4249 6530 10779 27 Durg 37673 1205 7345 8550 Total 649285 13795 38805 52600

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Annexure 5: C-section District wise in Government and Private sector and combined as % of Total Deliveries

C Section in C Section in Combined (in Government facility Private facility Government and S.N. District as % of total as % of total Private sector) % Deliveries Deliveries of C section

1 Balrampur 0.00% 0.00% 0.00% 2 Bijapur 0.00% 0.00% 0.00% 3 Sukma 0.00% 0.00% 0.00% 4 Bemetara 0.05% 0.00% 0.05% 5 Surajpur 0.50% 0.00% 0.50% 6 Kondagaon 0.08% 1.26% 1.34% 7 Narayanpur 1.49% 0.00% 1.49% 8 Gariyaband 0.09% 1.66% 1.76% 9 Kawardha 0.14% 2.39% 2.53% 10 Mungeli 0.01% 3.87% 3.88% 11 Balod 0.04% 3.85% 3.88% 12 Balodabazar 0.05% 4.04% 4.09% 13 Sarguja 3.45% 1.05% 4.50% 14 Mahasamund 0.57% 4.61% 5.18% 15 Dantewada 0.13% 5.44% 5.57% 16 Janjgir 0.75% 4.99% 5.74% 17 Kanker 0.70% 5.17% 5.87% 18 Jashpur 0.00% 5.87% 5.87% 19 Bastar 4.08% 2.98% 7.06% 20 Rajnandgaon 3.76% 3.48% 7.24% 21 Korba 0.89% 6.85% 7.75% 22 Raigarh 5.17% 5.39% 10.56% 23 Koria 1.49% 9.39% 10.88% 24 Bilaspur 3.84% 9.15% 13.00% 25 Dhamtari 0.66% 15.17% 15.83% 26 Raipur 6.82% 10.47% 17.29% 27 Durg 3.20% 19.50% 22.70% Total 2.12% 5.98% 8.10%

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