Emergency Obstetric Care (EmOC) at CHC of Wardha

District of Maharashtra State

A Project Proposal Submitted to

CHSJ, New Delhi

Population Leadership program University of Washington,
Seattle, USA
UNFPA India

Submitted by

Datta Meghe Institute of Medical Sciences Universiy

Sawangi (Meghe), Wardha
Maharashtra, India
 INDEX

Sr No Content Page no

1 Introduction 1
2 Evaluation Question / Sub question / Objectives 2
 Emergency Obstetric Care (EmOC) at CHC of Wardha District of
Maharashtra State

Background:

Health care delivery in India has been envisaged at three levels namely primary,
secondary and tertiary. The Community Health Centres (CHCs) which constitute
the secondary level of health care were designed to provide referral as well as
specialist health care to the rural population.

CHCs are established and maintained by the State Governments. Manned by

four specialists i.e. Surgeon, Physician, Gynecologist and pediatrician and
supported by 21 paramedical and other staff, a CHC has 30 indoor beds with
one OT, X ray facility, a labour room and laboratory facility. It serves as a referral
centre for 4 PHCs. CHC thus catering to approximately 80,000 population in
tribal / hilly areas and 1, 20,000 population in plain areas. Currently there are
3222 Community Health Centres in the country and 8 in Wardha District of
Maharashtra state.

Service delivery in CHCs: Every CHC has to provide the following services
which can be known as the Assured Services:
1. Care of routine and emergency cases in surgery:
This includes Incision and drainage, and surgery for Hernia, hydrocele,
Appendicitis, haemorrhoids, fistula, etc. Handling of emergencies like
intestinal obstruction, haemorrhage, etc.
2. Care of routine and emergency cases in medicine:
Specific mention is being made of handling of all emergencies in relation to
the National Health Programmes as per guidelines like Dengue
Haemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are already
available under each programme, which should be compiled in a single
manual.
3. 24-hour delivery services including normal and assisted deliveries
4. Essential and Emergency Obstetric Care including surgical interventions like 5.
Caesarean Sections and other medical interventions
6. Full range of family planning services including Laproscopic Services
7. Safe Abortion Services
8. New-born Care
9. Routine and Emergency Care of sick children
10. Other management like nasal packing, tracheostomy, foreign body removal etc
11. All national health programs
12. Facility for blood storage
These centres are however fulfilling the tasks entrusted to them only to a limited
extent. The launch of the National Rural Health Mission (NRHM) gives us the
opportunity to have a fresh look at their functioning. We undertook this rapid
assessment to find out of the CHC in Wardha District of Maharashtra state meet
the standards of NRHM.
Evaluation Question:

Did the CHC / SDH for Wardha District of Maharashtra State meet the
expectation of NRHM with regards to EmOC?

Objectives (sub questions):

1. Does the CHC/SDH of the meet the Indian Public Health Standard
given of NRHM for providing EmOC?
2. What is the current utilization pattern of OB services with special
reference to EmOC at CHC/SDH?
3. What are the constraints or facilitators in providing the EmOC at and
CHC/SDH level? (providers perspective)
4. What are the barriers or facilitators for accessing the EmOC at
different levels? (clients perspective)

Operational definitions:

All the Definition will be as per the NRHM guidelines / Concept note

EmOC - are defined as Basic EmOC and Comprehensive EmOC

1. Basic EmOC: It is defined as obstetric care facilities available round the

clock through out the year at the center with regards to
a. Parenteral administration of Antbiotic
b. Parenteral administration of Anticonvulsants
c. Parenteral administration of Oxytocics
d. Assisted Vaginal delivery
e. Manual removal of Placenta.
f. Removal of retained products of conception

2. Comprehensive EmOC: It is defined as obstetric care facilities available

round the clock through out the year at the center with regards to
a. Parenteral administration of Antbiotic
b. Parenteral administration of Anticonvulsants
c. Parenteral administration of Oxytocics
d. Assisted Vaginal delivery
e. Manual removal of Placenta.
f. Removal of retained products of conception
g. Availability of blood and blood transfusion facility.
h. Facility for Caesarian section for delivery of foetus in emergency
cases

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 CHC:

CHCs are established and maintained by the State Governments. Manned by

four specialists i.e. Surgeon, Physician, Gynecologist and pediatrician and
supported by 21 paramedical and other staff, a CHC has 30 indoor beds with
one OT, X ray facility, a labour room and laboratory facility. It serves as a
referral centre for 4 PHCs.

Geographical Boundaries:

The proposed work rapid assessment will be conducted in 2 BLOCKS

(Taluka) of Wardha District of Maharashtra State, India.

Study design:

This will be a cross-sectional study.

Stakeholders and means for reaching them:

1. Civil Surgeon – through appointment

2. Medical Superintendent or In-charge of CHC/SDH or doctors at
CHC/SDH– after approval from CS and through appointments
3. Nurses: approval through MS/Officiating In-charge
4. Mothers (who availed EmOC in last one year) – List will procured through
CHC and they will be reached through Anganwadi worker at their homes
(villages)
5. Community leader: in community through Pahchayat Samiti (Block
Development Officer) or Panchayati Raj Institutions of the respective
village.
6. Doctors from Private sector- directly approaching them prior
appointment will be taken.

Population and Phenomenon:

Population: Beneficiaries (mothers/couple who received EmOC services)

Providers of EmOC at CHC/SDH

Phenomenon: EmOC Services at CHC/SDH

Ethical issue / Consent:

Study protocol will be get approved by the IRB before commencing the study.

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Data Elements (Variables)

(Note: Detail schedule is in annexure ____)

Mothers (Beneficiaries):
Predictors /independent variables
1. Age of the respondents
2. Education (of respondent and husband)
3. Residence (distance from the nearest CHC/SDH)
4. Income: (monthly per capita income)
5. Family type:
6. Age at marriage:
7. Children ever born
8. Number of living children Boy(s): Girl(s)
9. Registered for ANC for recent pregnancy: (if Yes, where, which
trimester. Services received, whether identified as high risk, knew
before hand where to go for delivery)
Main outcome variables:
10. Delivery place:
11. Pattern of referral (visit to various Health Care Providers) for OB
care and expenses incurred from detection of pregnancy till
delivery.
12. EmOC received at CHC/SHD: (if yes, what services received)
13. Delivery outcome
14. Are you satisfied with the services received: (Likert Scale)

Provider (CS/MS/MO/In-charge):
Predictors /independent variables
1. Age
2. Highest level of qualification
3. Designation
4. Place of work (name of CHC)
5. Experience (total and at current CHC/SDH)
6. What are the EmOC services proposed by the NRHM at CHC level
7. Is your staff trained in EmOC? If yes, where? what type of training
(curriculum/duration etc)? who trained them?
Main outcome variables:
8. Do you receive patients for EmOC at your CHC/SDH? If yes,
usually from which area / region?
9. Roughly what proportion of the ANC received EmOC at your
CHC/SDH in last 6 months or one year?
10. What are the constraints for providing EmOC at your center? Is it
possible to provide EmOC at your CHC level?
11. Are you satisfied with the EmOC provided through your CHC/SDH?
12. What more would you need to provide EmOC better?

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Observational checklist: Annexure ___
(ref NRHM, IPHS standard for CHC level)

Secondary Data:
Proportion (total) patients who received EmOC services at CHC/SDH?
Characteristics of patients receiving these services
Geographical area from where the CHC is receiving the patients for
EmOC

Data Collection Methods:

Key Informant Interview - CS/MS/Doc/Local leader

FGD
In-depth Interview /tracking the events– Mother (User)
Observation checklist – facilities
Record revives (of CHC/SDH) – for secondary data

Data Collection Instrument: (annexure -)

Guides for Interview
Checklist for observation
Checklist for extracting secondary data

Matrix for information needed to address the issues (answer research

question), its source and respondents
Issues Interview Observation FGD Secondary data
(29) / Checklist (2) review
(2) (1 Dist.+2 Block)
EmOC facilities at CHC (2) Review of district
CHC as per the data
NRHM Standards
current utilization Review of District
pattern of EmOC MIS and 2 CHC
at CHC records
(2 blocks)
Facilitators & CS (1)
barriers for MO I/C of CHC (4)
providing EmOC PP (4)
Facilitators & Mothers (16) Mother
barriers for Local leader (4) (2)
Accessing EmOC
Figures in parenthesis are quantity of activities

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 Network Dynamics for field work:
Objective: To have a fastest mode of communication between various level and
solving problems
Network structure: Level Manpower per team No of teams
1 – Field Level One SI 1
Three RA
2 – DMIMSU Principal investigator -
Support Staff
3 - CHSJ New Delhi -

Networking in field:
Day 1 – SI & 3 RA - Meetings &
Preparations
1. Field Level Day 2 – 3 RA – Observation of facility
SI - Interview of 1 M/S
Receive Day 3 – SI – Secondary data collection &
the call Update RCO Daily Record review
daily and evening at 6.00 pm 1st RA - 2 Community Leaders
sort out by telephone about 2nd & 3rd RA – Interview of 8 user mother
problem the status of work. Day 4 to Day 7 – All RA - 2 FGD
if any Communicate SI - Interview of PP - 1
problem if any SI will check the all schedule for completeness and sign
Feedback Dispatch schedule Transfer the schedule to RCO & log sheet after
to field on eight day to completion of block
team RCO

Will receive the schedule on Saturday of each week and

check the schedule for the completeness
2 RCO
Tran scripter will check the transcript and triangulate the
written one with the recorded one
Feed- Update CCO on email
back weekly about the status

Communicate problem if
any

Send log sheet on first

Monday of each month

3. CCO

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HUMAN RESOURCE:

Sr N Position Post % effort in project

1 Principal Investigator 1 10

2 Co Investigator (one for each field team 2 50

& total two field team)

3 Research Associates (Three for each 3 100

field team & total two field team)

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 Logic Model

Research Resources Activities Activity Feature Output Short term Medium term Long term
Question Element Outcome outcome Impact
Did the CHC Time Development of the Data 2 days workshop / meeting for Data Collection tools # of facilities Recommendati EmOC could be
/ SDH for Collection tools and pilot tools development and developed & pilot tested where EmOC on for made available
Wardha Funds testing. finalization of field activity is not available improvement of at the CHC /
District of Blueprint of the field work as per the the EmOC at SDH
Maharashtra Technical Finalization / plan of the field Pilot testing at least one site prepared NRHM standard CHC/SDH
State meet expertise work will be identified Reduction in
the (Inst.) Taking needed approvals (IRB Proposal will be submitted to Received approvals from Evaluation maternal and
expectation and District health officials) IRB & the IRB and District Health Barriers for report will be child mortality
of NRHM Manpower District health Officials Authority accessing disseminated and morbidity
with regards and necessary approvals EmOC will be government due to
to EmOC? Logistics for sought identified health officials availability of
training Selection and training the Selection of RA # of RA selected and (Users EmOC
research associates (RA) recruited Perspective)
Logistic for 2 days hands on training of RA In the process
field work to have a common One training held Constraints for the district
(schedule understanding of tools and providing the health officials
printing, travel, study objectives (to ensure # of RA trained services will be will be findings
stationary etc) data quality) identified (user so that they can
Key Informant Interview - Identifying the respondents and # of Interview conducted perspective) take decision at
Travel (vehicle CS/MS/Doc/Local leader conducting interviews with CS/MS/local leaders. district level
hire / own
vehicle) In-depth Interview /tracking Listing the informants # of mothers interviewed Faciliators
the events– Mother (User) Selecting the respondents and events tracked
Home visit for interview
Observation checklist – Observation of the selected # of facility observed
facilities facilities
Record review (of CHC/SDH) Extracting the required Record review of #
– for secondary data information (utilization of facilities completed and
EmOC) from the records of required information
selected facilities extracted
Data Compilation and analysis Data Collected at the # schedules received daily
peripheral level transferred to # scheduled that are

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 central coordinating office complete and consistent
(CCO) daily # schedule complied and
Schedules will be check for analysis done
completeness
Data will be collated at CCO
Data will be analyzed at CCO
Report writing Preparing the draft report Final report ready for the
Get if vetted from the main dissemination
coordinating center
Prepared a final report &
dissemination

Time line

Activities Months
1 2 3 4 5 6
Linkages and coordination with Main coordinating office (CHSJ)
Development of the Data Collection tools and pilot testing.
Finalization / plan of the field work
Taking needed approvals (IRB and District health officials)
Selection and training the research associates (RA)
Key Informant Interview – CS/MS/Doc/Local leader
In-depth Interview /tracking the events– Mother (User)
Observation checklist – facilities
Record review (of CHC/SDH) – for secondary data
Data Compilation and analysis
Report writing

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CONCEPTUAL FRAMEWORK Yes
Availed * Place of CHC
EmOC EmOC
Private
provider
Delivery
Occur
District
Hospital
Do Not Need**
avail EmOC ?
EmOC
Place of
delivery
Do Not
Need
EmOC
? - Reason / Barriers for non utilization of the

* User of the services Yes - Reason for utilization of the services

** Non User of the services

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Threats for evaluation: (measure to overcome)

1. Instrument error – instrument will be pilot tested. Final instrument will

be translated in local language and then retranslated into English.
2. Interviewer Bias – Will be overcome by training the interviewer for
common understanding of the study objectives and hands on
experience for data collection.
3. Recall bias for mother – however since the event is from last one year
and very much related life of the women we assume the recall bias
could be minimum.

Storage of data

Optimum care will be taken for storage safety of data and will be taken from the
start of the study from carrying to the field of the proforma’s/ interview forms/ tape
recorder to coming back from the field in the appropriate files in the bag.

Analysis plan:

The data entry, processing and analyzing data will be done using SPSS
package.

1. Data Coding: Before entering data, the raw information will be

transformed for tabulation and analysis. Non-numerical data that are to be
analyzed quantitatively will be converted into numerical codes. Qualitative
data will be analyzed appropriately.
2. Data Entry and Editing
Coded data need to be entered into the computer with a minimum of
typing errors and then edited to correct any errors in the data.

To ensure data quality: Researcher will verify the data and check for the
following types of errors:
1. Omissions
2. Illegal Codes
3. Logical Inconsistencies
4. Improbabilities

Field editing will always be done by the supervisors whenever there is a chance
that the error can be converted by talking with the data gatherer or perhaps re-
interviewing the respondent for clarification.

Variable transformation
1. Recodes
2. Counts
3. Conditional Transformation
4. Other Mathematical Transformation

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