What to scale first? A cross-sectional analysis of factors affecting cesarean delivery rates at first referral units in Bihar, India

Abstract

Background Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates. Objectives We aimed to determine caesarean delivery rates at Bihar’s first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates. Methods This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018–March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates. Results Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0–10), 39% had an anaesthetist (range 0–5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0–4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9–55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1–1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3–1.9, p < 0.001) were associated with facility-level CD rates. Conclusion Only 3.1% of the institutional childbirths in Bihar’s FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.

The blood deserts of Bihar and implications for postpartum hemorrhage care

“…This is in contrast to studies which do not assess the role of multiple transfusions to an individual patient, some of which might be ABO identical and some not, and therefore could not assess the overall clinical outcomes following ABO identical transfusions. 2 More problematic are studies that claim to find no benefit of ABO identical platelet transfusions, which include patients in the ABO identical group based solely upon a patient's first transfusion, and then ignoring subsequent, perhaps numerous ABO nonidentical transfusions. 3,4 This is concerning as it makes no scientific sense to include in the ABO identical group a patient who received a first ABO identical platelet transfusion and then received one or more ABO nonidentical transfusions.…”

“…Using open-source national datasets, the study included 149 government-owned secondary healthcare facilities known as first referral units (FRUs) in Bihar, from April 2018 to March 2019. 2 The study found that the state-wide FRU cesarean delivery (CD) rate was 3.1%, well below state, nationally, and internationally recommended CD rates. 2 A functioning operating room and availability of obstetriciangynecologists and other providers trained in emergency obstetric care were positively associated with facility-level CD rates.…”

“…2 The study found that the state-wide FRU cesarean delivery (CD) rate was 3.1%, well below state, nationally, and internationally recommended CD rates. 2 A functioning operating room and availability of obstetriciangynecologists and other providers trained in emergency obstetric care were positively associated with facility-level CD rates. Additionally, blood availability across Bihar's FRUs was found to be extremely low.…”