Excess Neonatal Mortality Among Private Facility Births in Rural North India

(English captions & Hindi subtitles available)

About the Seminar:
Almost one-fourth of neonatal deaths occur in India. Two-thirds of India’s neonatal deaths occur in Empowered Action Group (EAG) states. Research and policy efforts have focused on promoting institutional rather than at-home deliveries, with limited investigation of differences between public and private facilities. Prof. Coffey conducts a demographic analysis of NMR among rural births reported in the NFHS-2015, standardizing demographic rates by socioeconomic status. In the rural population of EAG states, NMR among private facility births is 52 per 1,000 (95 percent CI: 48-56), compared with 34 per 1,000 in public facilities (95 percent CI: 32-36) and 43 for home births (95 percent CI: 40-46). After standardizing by socioeconomic status, the NMR gap between private and public facility births increases from 18 to 29. Births in private facilities have higher NMR even stratifying on key predictors of neonatal mortality. She considers whether quality of care can help explain the differences she observes.

About the Speaker:
Diane Coffey is an Assistant Professor in the Department of Sociology & Population Research Center at the University of Texas, Austin. She is a social demographer who studies health in India. One area of her research focuses on the intergenerational transmission of poor population health resulting from India's exceptionally poor maternal nutrition. It traces links among gender, stratification, and poor birth, childhood, and adult health outcomes. Her work on maternal health in India has been published in the Proceedings of the National Academy of Sciences, Social Science and Medicine, and the Indian Journal of Human Development.

Another area of Prof. Coffey's research finds consequences of poor sanitation in developing countries for early life health, including for mortality, height, and anemia. She has also studied the causes of open defecation in rural India. Rural India's exceptionally high rate of open defecation has much less to do with poverty than with social forces: the renegotiation of caste and untouchability leads people to reject the inexpensive latrines that prevent disease in other developing countries. Her book on open defecation in India, with Dean Spears, is titled Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste, and won the Joseph W. Elder Prize in the Indian Social Sciences in 2017. 

Prof. Coffey is also a visiting researcher at the Indian Statistical Institute in New Delhi, India, and prior to joining UT, she co-founded a research non-profit called r.i.c.e. which aims to inform policies about child health in India. She received a B.A. in Sociology and Letters from Villanova University and an MPA in Development Studies and a Ph.D. in Public Affairs and Demography from Princeton University.

FULL TRANSCRIPT:

Naveen Bharathi:

Thanks, Diane for joining us. And also welcome everyone for the CASI all seminar series. I'm Naveen, a postdoctoral scholar at CASI. Me with my colleague [Nasiz Azin 00:00:13] will moderate this series. We have talks typically on Thursdays noon. So please sign up for them on our CASI website. Today we have Professor Diane Coffey who is an Assistant Professor in the Department of Sociology & Population Research Center UT, Austin. She's joining us right now from Lucknow where she's doing her field research. Diane is a social demographer who studies health in India. Her thesis focuses on intergenerational transmission of poor population health, malnutrition, sanitation in developing countries for early life health and many such related topics. Her work has been published in many peer review journals.

Professor Coffey is also visiting [inaudible 00:00:57] Indian statistical institute in New Delhi, and prior to joining UT, she co-founded a research non-profit called r.i.c.e. which aims to inform policies about child heath in India. She has a PhD in public affairs and demography from Princeton University. Today, she'll be talking about excess neonatal mortality among private facilities births in rural North India. Among one fourth of neonatal deaths occur in India. Research and policy efforts are focused on promoting institutional rather than at home deliveries with limited investigation of differences between public and private facilities. Diane conducts a demographic analysis of neo-mortality rates, NMR, among rural births reported in the NFHS, National Family Health Survey, 2015. The research finds that after standardizing by socioeconomic status, the NMR gap between private and public facility birth increases from 18 to 29. Births in private facilities have higher NMR, even stratifying on key predictors of neonatal mortality. She considers whether quality of care can help explain the differences she observes. As I explained, this seminar series, we have 30 minutes, the speaker will present, and the next 30 minutes will be Q and A.

So if you have any questions, please use the chat box to send them directly to me, Naveen Bharathi, and I'll call on you to pose your questions to Diane. Please keep your questions brief and to the point so that we can get to as many as possible. Also, please use the chat box only for questions. And finally, please be mindful about muting your mics for the duration of the event, and also, please remember that you cannot record this presentation without prior permission from the presenter.

Before handing over to Diane, I want to remind you that our next talk will be on October 21st by Suraj Jacob and Babu Jacob on governing locally institutions, policies, and implementation in Indian cities. Please visit our website to register for the talk and also register for many other talks too. Once again, thank you for your interest and for being here today. With that, I'm going to ask Diane to take us away. Thanks, Diane for joining us, even in spite of a lot of things happening in UP.

Diane Coffey:

Thank you so much for having me. I am really excited to be sort of back talking at CASI. I would have loved to have been there in person and see so many friends at Penn, but it's also a real delight to be back in India for the first time in a long time. So I'm going to go ahead and start sharing my screen. And I have to tell you guys, this is a short paper. So Naveen pretty much said it all already, but I'll give it to you in a bit more detail. So this is a short paper called excess neonatal mortality among private facility birth in North India. And it's going to be sort of a demography, public health type of paper, and then I also have a companion qualitative paper which was done with some of these co-authors here and also with [inaudible 00:04:13], and I'll be telling you a little bit more about that.

So before I jump in, I just want to recognize my coauthors on this paper. Nikhil is a colleague at r.i.c.e., a long-term collaborator. Aditi is an economic scholar who's applying for PhDs this year. Asmita is wrapping up her PhD at IIT Delhi. Alok is current principal secretary for medical education. And of course, my partner Dean, who is also a professor at UT Austin. And so this has been a really interesting collaboration and I think it's probably the first of more papers on this topic. And honestly to tell you the truth, I had a paper come out and demographic research on the topic of [inaudible 00:05:00] birth and neonatal mortality a couple of years before, and while there wasn't anything technically wrong in it, I realized that we overlooked a really big distinction between public and private facility birth and then brought in all these really fun people to help me think about it. So with all of that background, let me tell you a little bit about neonatal mortality in India broadly, and then in North India and in private facilities in particular.

So for those of you who are familiar with health in India, you'll know that neonatal mortality in India is really quite high. This is just a very simple graph of neonatal mortality which is deaths per 1,000 live births in the first month of life from various demographic and health surveys that were done around the same time as India's latest demographic and health survey, which was completed in 2015 and 2016. Now, you may say there was round five that was finished more recently, unfortunately, the unit level data are not out yet. So the paper is going to be using the 2015, '16 national family health survey which is India's name for the demographic and health surveys. And this is just a simple comparison to let you know that at 29, India's national neonatal mortality rate is quite a bit higher than countries that you might expect to have higher neonatal mortality because they're much poorer.

I won't get into sort of the overall details today, but we're going to look in particular at a group of states called the Empowered Action Group states where compared to India's 29, rural birth experience in neonatal mortality rate of 39 deaths per 1,000 live birth. So really very high. This group of Empowered Action Group states that we are going to be studying were given the name by the National Rural Health Mission in 2005. They have a very large population and they have a very large number of births. 9% of all births around the world take place in the rural parts of these states and 15% of neonatal deaths worldwide take place in the rural parts of these states. So it's a really important place to study for global health [inaudible 00:07:16]. And the states in case you can't read them are [inaudible 00:07:23].

So just a bit of background about maternal and neonatal health in India, it's just becoming much, much more common. So this is again, data for all India, and not the EAG state. It's becoming much, much more common for women to give birth in health facilities than it was now 15 years ago. In the NFHS-3 2005, '6, about 40% of births took place in facilities. Now it's about 80%. This is a huge difference. A large part of this difference is due to a government scheme called the Janani Suraksha Yojana program in which all rural EAG state residents who gave birth in public facilities were eligible for a 1400 rupee cash transfer. Now, I think that really did compel a lot of people, convince a lot of people. Of course, it was occurring alongside the OSHA program and scale up of the public facilities rather generally, but it was something that motivated people and we're going to return to this at the end to talk a little bit about how do we think about policy in the context of the public/private differences that we're going to talk about.

So just to give you a very small background on the literature here. There are a wealth of studies that think about the consequences of facility birth in India. But they tend to focus on public facilities. It's more common to have a public facility birth, and they're sort of more visible. We're going to talk in a minute about how the private facilities that we're talking about are really pretty invisible. There's a small number of studies on them. They're not regulated. The private providers don't want people like you and me to know that they're there.

Well, maybe it's better to say that they just don't care. But in any case, they're very often not legally operating. And yet they're important, they're an increasing part of facility births in India. So I just pulled out a paper in the Lancet that looked at the impact of the JSY program, that's sort of a common type of paper in the literature, and yet that would only be in the blue in these public facilities. So one reason we haven't seen a lot of studies looking at private facility births in India is because the DHS doesn't really let us distinguish among private facility births and what type of facilities they're in. So there's just an enormous range of private facilities in India. [inaudible 00:09:58] pulled out this picture on the left of Apollo Medics Hospital.

I took my son there to get Japanese encephalitis vaccine a few days ago. They have very well-trained doctors, hygienic facilities. Probably you're not going to experience a neonatal death giving birth in that facility. And yet most of the facilities that we're talking about today look more like this one which is in Eastern UP. There's nobody who's trained in this facility. It's not very clean. Your delivery is probably going to be done by somebody without a degree. This is not something that's operating legally, even if it is operating with sort of the blessing of local political leaders. So more on this later on, but when I'm talking about the rural private facilities, think much more about the thing on the right than the thing on the left. Even though the DHS doesn't allow us to distinguish among them, we think that if you're a rural resident of EAG states, you're probably not going to Apollo Medics.

Okay. So that's a little bit of background. Here's our more precise research question. Is there excess mortality in the rural EAG states and private facilities, and if so, why? And by excess mortality, we're meaning over and above neonatal mortality rates experienced by rural residents who give birth in public facilities. So let's talk a little bit about the difference in neonatal mortality between public and private facility first, and then we'll talk about the socioeconomic status adjustments that we did. So here is a very simple sample means. I pulled out the numbers since it can be a little bit hard to read. But the neonatal mortality rate among private facility births among world EAG state residents is 52 in private, compared to 34 in public.

And one thing that's really perhaps surprising to people in the public health community would be that it's actually safer to give birth at home in the rural EAG states than it is in a private facility. You do a little bit better in a public facility, but you might rather stay home. Now, a lot of that is going to be about selection. It's higher birth order, women who are more likely to stay home. Higher birth order experiences lower neonatal mortality, so some of that is going to go away. But as we'll talk about in a little bit, there are actually reasons to think that these private facilities are doing harm and you might just be better having a birth that didn't have the intervention of these sorts of providers. Now, when we look in the rest of India outside of the EAG states among rural residents, we see a pattern that maybe was a little bit more expected.

Home birth are having the highest neonatal mortality rate, and there's not a statistically significant difference between birth in public and private facilities. You might've actually thought that births in private facilities would be less likely to die, but I think it's for another paper to try to understand whether the same forces that I'll be talking about in private facilities in North India apply in the other states as well. I have some guesses, but I don't want to go too far beyond the data here.

So as demographers and as social scientists who think about mortality, we know that the timing of death is an important indicator of the cause of death and the causes of death that can be controlled by people who supervise deliveries tend to happen on the first day of life, and so in addition to looking at neonatal mortality as a commonly understood indicator, we also look at the probability of death on the first day of life. And so that's a sanity check on thinking that this is about [inaudible 00:14:06] quality of healthcare in the private facilities. And yes, indeed we do see the same large difference in between the deaths in private facilities and in public facilities in the rural EAG states. So why not just sort of leave it there? Well, because we actually think that these simple differences that I've been showing you may mask an even larger difference in public and private facility births. And so the reason to do the statistical re-weighting that I'll show you is that babies born in public facilities are actually born to more disadvantaged households than babies born in private facilities.

So I've just pulled out a few summary statistics from my data in rural EAG states. You'll see that for all of these socioeconomic indicators, whether it's disadvantaged social background, [inaudible 00:14:58], wealth quintile, and the role of EAG state in the DHS or mother not being literate, the births that happen in public facilities are more disadvantaged. And the births that happen in private facilities, they're more likely to have literate moms or be part of the richest quintile. So that leads us to think that when we do the re-weighting, we're actually going to see a bigger gap between neonatal mortality in public and private facilities. So I won't get too much into the details of our statistical methods for this talk, but just know that what we're doing here is... Well, I'll ask you the question now, and then I'll reiterated on the next slide.

But what our method does is it's going to say what would neonatal mortality be among private facility births if the private facility births had the same socioeconomic characteristics of all of the birth that takes place in the rural EAG states? And similarly, what would the public facility neonatal mortality rate be if those births had the characteristics of all of the births? And so this is sort of a way for controlling for the differences in the socioeconomic backgrounds.

And in case you're interested, this is the method [inaudible 00:16:14] economics literature on wage discrimination. This old paper by DiNardo that will walk you through it. And so that was here in the blue. And the orange is the same question that I just posed, what would mortality rates be in each setting if those births counterfactually had the distribution of the observables that we reweight over in the region under study, regardless of the facility?

And so just to go back what those characteristics were where the asset wealth quintiles, the four religious groups, and social groups, and the mother's literacy, and that is when you combine those, you get 40 categories. And just to let you know, I'll be showing some standard errors on reweighted means. Those are computed by bootstrapping the whole analysis, so that means resampling with respect to the clustered and stratified survey design. Okay. So let me pull up my pointer. Well, I think I don't even need it. I think I have arrows. So the red squares are going to be just the simple mean of private facility neonatal mortality, and the blue circle is the simple mean of public facility neonatal mortality. So that's the gap that you saw on the earlier slide in the [inaudible 00:17:41]. Now let's look at the reweighted means. There you see that neonatal mortality for private facility births increases significantly.

So like I said, that was the broad gap that we saw in needs between public and private facility neonatal mortality earlier. And then [inaudible 00:18:02] the difference that we get once we've done the reweighting. So there because [inaudible 00:18:10] that happened in private facilities, were more advantaged, then we reweight using the whole population in the neonatal mortality and private facilities increases. The public one doesn't change very much because the fraction of the people in public facilities actually looked quite a bit like the whole population, so it just changes a little bit, not very much.

And so the gap difference increases from 18 per 1,000 to 29 per 1,000. And just so that you guys notice, when we look at outside the EAG states, other states in India, there's not really a difference in the adjusted gap between public and private, and there's not a difference in the adjusted gap between private and public, the [inaudible 00:18:54]. And of course, the gap in the EAG states is so vague and the population is so large and when you combine all of them, you [inaudible 00:19:02] of a gap between mortality and public [inaudible 00:19:07] facility. Okay. And just like I was saying before, we do our reweighting on the 1Q0 which is the way that demographers talk about the probability of death on the first day, and we see the same pattern. So this does point to quality of care and it's possibly important [inaudible 00:19:25] it's gap.

And to give you a sense of how large this is, here's a very mechanical quantification we could perhaps level with the details, but I do want to give you a sense of the scale. So there are 1.5 million rural births that take place in private facilities in 2015. And if you multiply that by the difference between the standardized neonatal mortality for births in private and the standardized neonatal mortality for births in public, you get that there are over 43,000 excess neonatal deaths annually coming from those different [inaudible 00:20:07] private facilities. And to give you a sense of how large that is, it is about... not quite three times the number of neonatal deaths that take place from all causes in United States in 2015. So it took a really large number of deaths globally. So what's going on here? What can explain the gap between public and private facilities? So we have a couple of candidate explanations and I'm here I'm going to be combining some of our qualitative research with just a little bit more data analysis from the [inaudible 00:20:40].

So we did do a qualitative study that's being reviewed by [inaudible 00:20:45] right now about private facility births [inaudible 00:20:49] particular, and we're excited to at some point pick up that qualitative work in other states, but the stuff that you'll see today it's from [inaudible 00:20:58]. So there is certainly from that qualitative work some evidence for adverse selection, the idea being that riskier births are taking place in private facilities. And so I'll talk a little bit about why that is. But one big reason that contributes to it is public provider behavior and public providers pushing high risk cases out of the public system. Over and over again, we would hear stories of CHC staff referring patients, taking patients out on public facilities in order to avoid risky cases that could lead to them getting in trouble or legal cases.

There's also financial gain to be had from public providers sending people to private facilities. So if a public provider sends somebody to a private facility, he or she is probably going to get some sort of financial kickback later on. And then there's also patients with riskier births choosing to go to [inaudible 00:22:04] themselves, one big reason is that the private sector does do a better job of just interacting with the patients, not abusing the patients, talking with them about what's going on, even if they're often [inaudible 00:22:17]. And so one way that we see these, now this is back to the DHS and the quantitative data, so one way that we see this operating is that the private facilities, even in rural areas are much more likely to give C-section surgeries than public facilities, although I don't want you to walk away thinking that, that's what's going on in our difference between neonatal mortality.

It's true that it tells us something about the financial incentives that private providers, but when we look at vaginal or normal deliveries which are the vast majority of firsts in both places, we find that there's still a very big difference in neonatal mortality rates. And so this leads us to think, "Okay, it's not just those [inaudible 00:23:04] CS first, but those that are supposed to be done by C-section that are causing this. We're going to have to look at what's going on with normal deliveries as well. And so [inaudible 00:23:14] again, the difference between public and private facilities natal mortality, but now just [inaudible 00:23:21] vaginal deliveries and these are less common types [inaudible 00:23:25]. We do from the qualitative work think that there is selection of higher risk [inaudible 00:23:36] facilities in the rural EAG states.

But that's really not the only story in the qualitative work, and in the quantitative work, we're going to find some evidence for it also being about quality of care and that the private facilities have significantly worse quality of care. So one way that we try to look at this and the quantitative data is by focusing on different sub-samples of births to try to see whether in different sub samples, is there still a difference between public and private? And so I've highlighted the riskier categories involved, and we see that among moms who had a prior neonatal death, so [inaudible 00:24:14] neonatal mortality is higher and better than public among moms who are adolescents at the time of birth. Neonatal mortality is higher in private than public among moms who are underweight similarly.

And so here is some more evidence that selection can't be the whole story. We use the DHS data to look at the least [inaudible 00:24:39] and try to see if there are still differences between public and private. We look at best risky births or vaginal births to moms who are not adolescents who have had one prior living child, no prior neonatal deaths, neonatal mortality is 38 in private and 24 in public. If we further restrict that to mothers who reported [inaudible 00:25:03] or transfers, so basically, a suitable head down presentation, again the neonatal mortality is higher in private than in public. So there's got to be something going on with quality of care, with training, with what actually happens during the birth. There is not a lot of information about the quality of care at birth in the DHS unfortunately.

There's really just one indicator that we could find. It's about really initiation of breastfeeding [inaudible 00:25:31] there, we see that women in public facilities are more likely to initiate breastfeeding both in the first hour and the first 24 hours, and in this context, early initiation of breastfeeding is an important contributor to child survival. We can talk a little bit more at the end about why that might be the case, but it's one small indication of quality of care. The qualitative research gave us a lot more information about [inaudible 00:26:02] care in private facilities, and I have to say it was just really disturbing and a bit small. We found that the vast majority of credit providers in [inaudible 00:26:13] where we were doing the work don't have any formal training, and they're often really misinformed about the risks involved in medical interventions. And so they're doing a lot of labor induction and they're doing a lot of speeding along labors that have already started in dangerous ways.

So this is for those of you who are familiar with induction of labor. This is an untrained provider talking about how he uses labor inducing drugs. He says, "If the mother is not having labor pains, we administer oxytocin. Oxytocin is given both intermuscular and intravenous. And misoprostol is given orally and intravaginally. Give another misoprostol oral and intravaginal at the same time. If the pain does not start, we can repeat the dose of misoprostol. For oxytocin, we usually give one IM in one IV at the same time. If pain contractions do not start, we repeat the dose within half an hour." Medical providers who would look at this would just like hold their head in their hands.

This sort of behavior would lead to premature birth, birth trauma and higher rates of [inaudible 00:27:25]. While there may be more need for labor induction than the public facilities are currently providing, the private providers are overusing it and are not trained to do so. So that's something we can talk more about at the end. It's something that I would be concerned about. So here's some open policy questions. One thing that this has led our authorship team to think about is whether we should advocate for regulation of the private sector. Perhaps we should, but this may or may not be possible. So there's not a ton of research about private facilities. This is one paper that we read that talked about some about relationships between public providers and the private sector. Again, they're very interconnected. There's a lot of local political support of private providers. There's a lot of bribe paying and kickbacks to local political leaders to allow the private facilities to keep functioning. It may not even be possible to regulate the private providers.

If we did, I'm concerned that sometimes private providers have a foot in the market because public providers aren't functioning well in those areas. And so will taking them away have a worse effect? I don't think so, but I think we do need to think about unintended consequences. So I think a direction that I'm more comfortable advocating is increasing public facility births and the quality of public facility births, but as we'll see in a minute that's going to be easier said than done. So this is the paper that I did back in 2014 about JSY in Uttar Pradesh and what it basically showed was that the quality of care in one particular public hospital is really very poor. So that was sort of an ethnographic way of showing that.

And then this is a very [inaudible 00:29:35] interesting study that came out in New England Journal of Medicine. It's sort of an internationally renowned program of training nurses who work in delivery rooms to have safer childbirth. And although this intervention has shown promising results in other parts of the world across UP, there was no difference in mortality between people who were coached in proper birth practices and those who weren't. And as you can see that from this table that I pulled out, the rates of stillbirth and early neonatal death are really very high. So one thing that is sort of unfortunate about the DHS data is that we only have neonatal mortality and neonatal death in the first day of life. We don't even know what's going on with stillbirths, but as you can see, those are very high in this data which [inaudible 00:30:28] and that would be another indicator of the quality of care and also just gives you a sense of how bad the facility [inaudible 00:30:39], and then first we think about what happens in public facilities after babies are born, this is just sort of a shout out to some of the work that I'm currently doing about postnatal care, and I'll just let you know that postnatal care in public facilities is also not very good.

And so if we bring more and more versed into the public sector, hopefully it would be with the strengthening of those systems and [inaudible 00:31:07] those systems.But I think that's pretty hard to do. I'm really happy to hear your questions, and hopefully we'll have a productive conversation about this topic. I'll go ahead and stop sharing.

Naveen Bharathi:

Thanks, Diane for a very interesting presentation. So we have few questions. Let me start with Tariq. Tariq, do you want to unmute yourself and ask your question?

Tariq Thachil:

Oh, sure. Thanks so much, Diane, for that very thought-provoking talk. And forgive me, my two questions probably belie my lack of knowledge in this area, but the first question I had was on the calculation of excess mortality. I'm not sure if I understood that correctly, but is the counterfactual that all births would be in public facilities, and when we're saying what excess mortality is, is the assumption that what it would be if everybody was going to a public facility, and if so, if not, then that's different, but if so, I was wondering about doesn't that rest on an assumption that rates in public facilities would stay the same, even with an increased case load? And I think even beyond that narrow question, the broader implication of increasing people going to public health facilities, just even assuming that, that would not decrease their performance.

I know that the DHS doesn't give you access to this, but in your qualitative work, did you find that absenteeism at public facilities drives going to private facilities, even when approaching the hospitals, so like during labor, and so does that drive complications of care and adverse selection? I mean clearly you're finding lots of other things that are going wrong, but I was wondering if there's some of that, that's contributing as well.

Diane Coffey:

Yes, yes, and yes. So the assumption is that the mortality rates would stay the same with an extension of private facilities, and obviously, we don't think that that's accurate because these facilities are already overcrowded. It's already the case that one nurse could be watching five or six deliveries at any given time. So it was more sort of like a, "Hey global health people, this is an important type of quantification as opposed to what would actually happen if we could move all the births to public facilities." And then absenteeism is a huge problem. We did see at some rare cases in the field where the facilities were completely closed, but I would say a bigger problem is that the facilities may be staffed with nurses, but there's lots of stuff that nurses aren't allowed to do and that they're supposed to do under the supervision of a doctor, but the doctors aren't present and the nurses don't want to take the risk. So if it doesn't say need a labor induction, they're going to say, "Go somewhere else." None of the CHCs provides C-sections [inaudible 00:34:11] you need a C-section [inaudible 00:34:12] that sort of thing.

And so one thing that I had to talk to people about here, and it doesn't go very far is can we increase the responsibilities of the nurses so that... Obviously, they're not going to be giving C-sections, but in a context in which those private providers are so dangerous, it may make sense to allow nurses to do labor induction in some cases.

Naveen Bharathi:

Thanks, Diane. We have a question from Sneha. Sneha how do you want to unmute yourself and ask the question?

Sneha:

Thanks Diane for the talk. I just had to birth related question, in a way following up to Tariq's question. Given the poor quality of public facilities, like you mentioned. Are private facilities worse in terms of quality than public facilities? And is the terms of quality in terms of personnel or equipment, how would we define quality in this situation?

Naveen Bharathi:

So just add to that question, what about the distance of private hospitals versus public hospitals, distance from the place of living and place of delivery? What is the penetration of private hospitals versus public hospitals? How does that play out because private hospitals maybe far [inaudible 00:35:44], do take them into consideration?

Diane Coffey:

Sure. Let me actually answer your question first, and I think it'll sort of set the stage better for the second question. So we are really facing data limitations in the DHS, and it was part of why it was really essential to do the qualitative work. We know almost nothing about the private facility where [inaudible 00:36:08] give birth. So we know that the person is a rural resident and we knew that they gave birth in a private facility. We kick out all urban residents and we'd have a model in our mind where urban residents are going to urban facilities. We've checked a lot of urban facilities, some of them are registered and regulated in this context, and some of them aren't. With the rural residents, it's true that some of them are going to be seeking care in urban facilities that are registered, but what we found in the field though was that by and large, and somewhat to our surprise and dismay, the private facilities that we're talking about are actually very close to people's homes. They may be in villages or just in a block town, in a market town.

And they really range from a small [inaudible 00:37:03] doctor who mostly specializes in fertility medicine, but he hires the local [inaudible 00:37:07] to come and supervise somebody for a normal delivery to a place that I showed him the picture which is some young man who went to the city, learned in a private facility there about doing a C-section and is now performing C-sections in villages. We were really shocked at the extent of that. So we have a lot of data limitations when [inaudible 00:37:34] we could do is map the distance of the GPS coordinate of the person to a city and further refine our results by kicking out anybody who was anywhere near a city. So that could be something interesting to do to make sure that we're kicking out people who are getting private facility first, hence it means we haven't done it yet.

And then to turn to the question quality from the first person, so here, when I'm talking about quality, I'm more talking about the quality of medical care during the birth. One thing that is a bit sad about this whole situation is that when we talk about the quality of interaction with the patients, the private providers are going to outperform on that. They're going to be nicer to the patients, they are less likely to verbally and physically abuse them, although there would be some of that in private facilities. And they're going to be doing more talking to the patients about the care, because at the end of the day, they want them to pay for it. And the public facilities are doing less harm, but they're lower quality in terms of patient interaction.

Naveen Bharathi:

Thanks, Diane. So we have a question from Jere. Can you unmute yourself and ask the question?

Jere:

Thanks and very, very interesting. I have two questions. One is early on, you said that there were subsidies given for women who went to public facilities to give birth. And these subsidies were not them for women who go to the private facilities. And my question is, is there a good reason for discriminating when you give subsidies on the basis of the ownership of the facilities. And then secondly, how do you understand the choice people to go to the private facilities if they seem worse in terms of outcomes? If there's not some kind of selection [inaudible 00:40:09] when they are worse in terms of outcomes, why is it the people... It's like they are willing to pay more to go get worse outcomes. Is it just lack of information or you have other explanations. Thank you.

Diane Coffey:

So, yeah, thanks for those two great question. On the question of subsidies, so somebody can correct me if I'm wrong, but I believe that across the EAG states it's not the case that the private facilities [inaudible 00:40:54] they do subsidized for some private facilities as well. [inaudible 00:40:59] is a state where they're championing private sector more than other places. And I think that there are some registered facilities [inaudible 00:41:07] that also provide the JSY's payment. In terms of why most of the states didn't start with it, this is going to be a gas and somebody else perhaps rather than might even know better, but I think it was just really about infrastructure that like there were a lot of private facilities, most of them not registered. It was just sort of easier to give it out through the government system and private facilities were not very common back in 2005. We've gained popularity since then.

And I think even now, if the government were to move to subsidizing private deliveries in the EAG states, they wouldn't recognize these informal providers that are the bulk of private facility care. They would go with ones that are registered with the government and then you're looking at a much richer population. And so the government may not cover that. So how do we understand rural residents choices to deliver in [inaudible 00:42:05] facilities when it's a lot more expensive and they're getting more risky outcomes. So that's been something at least special [inaudible 00:42:13] to the qualitative work shed some light on something that does seem quite true to me, which is, although this is a big difference for a demographer, it's not the sort of thing that people are going to be able to see in the small sample size of their lives.

Most babies in both public and private facilities don't die. We do see individual families changing their decisions based on locations of prior neonatal deaths, and so we see people moving from private to public when their baby's dying, and we see people moving from public to private when their babies dying. On the one hand not, the difference is not being quantitatively large enough in very small samples that are part of people's lives, and then also people really lack information about what is a good delivery. In fact, many people think that if they're getting medical interventions such as labor inducing drugs during delivery, that's a better standard of care than letting the birth proceed naturally on its own. And so the fact that they see something happening combined with being treated more nicely, combined with just the assumption that if you're paying it must be better, I think leads to that sort of misunderstanding of the safety of private facility wards.

Naveen Bharathi:

[Akshar 00:43:42] do you want to unmute yourself and the question.

Akshar:

Sure. Thank you, Diane, for that really nice talk. I have two questions. One is just with the NFHS data, can you also talk about any differences that may have been there in prenatal care use and interactions with the health system in those three different categories that you looked at? And then secondly, you spoke about neonatal mortality differences, and I'm also curious if you see something comparable or do we know if there's something comparable in maternal mortality, maternal birth outcomes as well? Do you think that might be correlated in terms of the mother's health and neonatal health?

Diane Coffey:

[inaudible 00:44:38] looking at neonatal care a little bit, and we basically gave up because the DHS does a good job of collecting set of big information about prenatal care, and it turns out the [inaudible 00:44:54] of the EAG states seek prenatal care everywhere. They go to private facilities, they go to public facilities. They see people who have degrees, they see people who have no training. They often don't know who does and doesn't have a degree. And so we just weren't really able to separate out what was coming from public and private sectors there. I think maybe we would have to, again, do more qualitative work to try to understand that or set up different DHS questions. This isn't exactly what you asked, but one thing that I have really wanted to do is do a study where we try to propose a question to the DHS that would help us understand the nature of the private providers that people went to. And we've tried piloting this sort of stuff, what we realize is that people just do not know if their providers have degrees or not, and they don't know the quality of their providers.

And so we haven't yet been able to think of a way of trying to rate based on people's reports of their providers. And to talk about maternal mortality, my personal suspicion is that we're going to see very similar patterns in maternal mortality that if anything, the selection is going to be really high... Pretty much nobody wants a maternal up in their facility. So maybe not, but I do think that the public facilities are going to be kicking people out and private facilities want to keep people paying until the very end.

But the maternal mortality data from the DHS, and here I'll make a [inaudible 00:46:37] for a paper that I'm really excited to be working on right now, it's great that it was collected and we're analyzing it, comparing it to the SRS and finding much higher maternal mortality rates in the AHS [inaudible 00:46:52] than in the comparable SRS time periods. But it's a very simple question and it doesn't ask about place of delivery. And unfortunately, the AHS which is the only place where you might think you could do that, it talks about the place of death, but not about the place of delivery. [inaudible 00:47:13].

Akshar:

Thank you, Diane.

Naveen Bharathi:

Radhika you want to ask next?

Radhika:

Hi. Thanks, Diane. That was super, super interesting. I think that we need to do so much more in looking at hospital quality and measuring it across facilities, so this is great. I work on hospital care in Rajasthan to some extent, and so I have done, not systematic, qualitative visits, but have visited a lot of public and private facilities looking at each in the same city or town or both in [inaudible 00:48:01]. And so my first thought when I was watching your results was it goes completely against what I had seen. I was comparing public and private facility hospitals in the same place. I personally would way rather deliver in the private facility, and then it occurred to me, I realized you guys are looking at the deliveries in the full distribution of private facilities. Whereas, because I'm studying things in the context of health insurance, government health insurance, that specifically targets poor people. So I was just visiting the hospitals that were covered by insurance, by this program. Sorry, this is kinda a long run-

Diane Coffey:

[inaudible 00:48:46] government registered facilities.

Radhika:

Not necessarily, but much more likely and definitely much more established. Three story buildings. I haven't done something systematic, but not necessarily all registered, but certainly much more formal than some of the places that you're talking about. Long story short, what I'm getting at is that I think it's certainly true that there's huge variation in what private hospital is and what its quality is likely to be. We don't have data on this, but just from watching these. And so where people go, which type of private facility they go to might matter a lot for their outcomes. And so I was curious with your qualitative work whether you saw this kind of variation in the kinds of private facilities that are available especially... Not setting aside the cities, but relatively rural areas.

This is not quite a question, but does something like this government health insurance, could it by subsidizing less than the worst mom and pop private guys, could that improve outcomes by directing people to the somewhat better private facilities? Sorry, that was kind of rumbling.

Diane Coffey:

So this is forcing me to own up to something about which I'm a little bit embarrassed. So we wrote this paper about the EAG states because we wanted to submit it to high profile public health journals where we didn't think our reviewers would have the patients for us to say, "We looked in UP and Bihar, and a couple of other states that we looked at and thought about carefully. We thought we needed to pick a grouping that was going to be internationally recognized. But this difference between public and private or rural resident is largely not present in Rajasthan. Part of the qualitative field work that didn't get included in the paper, but that hopefully will get written someday soon, we went to two districts in Rajasthan on the UP border and found that people were driving a lot further for private facility birth and that by and large, they were registered, and even if they did suffer from some of the same incentives around induction and C-sections, it wasn't horribly mismanaged as it was in UP and Bihar.

And so that really sort of helped us understand, okay, we don't see a big difference between public and private facility whereas the public facilities are pretty awful and they ignore people a lot. The private facilities do some clinical mismanagement, but these sort of things sort cancel each other out in Rajasthan and [inaudible 00:51:44]. I would've just kicked out [inaudible 00:51:50] where this wasn't true, but we felt like we couldn't just cherry pick in a public health audience that maybe isn't as happy with demographic and scripted statistics, and they like a pre-designed research plan involving experiments and that sort of stuff. I'm hoping that I'm not saying too much about [inaudible 00:52:10].

Radhika:

Just a follow up thought on that actually. So that obviously then begs the question why is it different in Rajasthan and Bihar and UP? I want whether the quality of the public hospitals is a factor here. Like where the public facilities are better, it kind of disciplines... To compete with them, the private facilities have to be at least at... Well that doesn't quite go with your paper, but anyway, that's something to think about.

Naveen Bharathi:

Thanks, Radhika. We have Radhika presenting at our seminar series soon. Please register, [inaudible 00:52:48], and register for her seminar. We have our last question from Manya. Can you unmute and ask the question?

Manya:

Yes. Thank you. My first question is about, I know you said you weren't certain, but why do you guess the gap between the EAG and non-EAG states is so wide, and just generally what factors might affect that? And secondly, you mentioned patient abuse and lack of communication in public facilities, do you think those factors ever increase or affect mortality in those facilities as well or do they just affect patient perceptions of care? Thank you.

Diane Coffey:

So why the gap in neonatal mortality between EAG states and the rest of India? I mean, just every reason that affects neonatal mortality. People are richer in the rest of India, the facility staff are better trained, are more educated than the rest of India. Underlying health of moms is better in the rest of India. Just mortality rates are almost as if they were a different country outside of the [inaudible 00:54:00]. So that's why the big gaps there. And I absolutely think that abuse of patients and lack of communication with patients is killing babies.

I'm trying to come up with like of examples. So one example that our team personally witnessed was about a public facility doctor telling somebody that she needed a caesarian section, but not really communicating it and the person believing that the person was just out to get money from her. And if that person doesn't trust and goes home and tries to deliver, say a transverse baby in another setting, the baby can very well end up dead. So people need to understand why their providers are recommending the things they do. That's a pretty rare one. [inaudible 00:54:58] I could probably come up with a bunch more... And just like [inaudible 00:55:06] that I was in very recently, moms, they're really hesitant to bring their expressed breast milk for their admitted babies because when they bring it, then the nurses shout at them. And so that on top of the fact that the nurses hardly ever remind them or feed it if they drop it off means that the babies just aren't being fed in inpatient public settings. So yeah, this abuse is really [inaudible 00:55:32].

Naveen Bharathi:

Before we end, there's one question which missed from Alex Gardner from Penn Medicine. Alex, do you want to unmute yourself and ask the question Alex?

Alex Gardener:

Hello. Can you hear me now?

Naveen Bharathi:

Yes.

Alex Gardener:

Oh, well, thank you so much. Thanks for your presentation. I don't mean to make this US centric here, but I was wondering, obviously, there is neonatal mortality in morbidity here in the United States and different issues. I see some similarities and differences, obviously with the public and private health facilities. Things are a little different in the states, but I'm wondering if you think there are any interventions to encourage people to use the best facilities available to them or make sure people get the best care, whether they're in the United States or in India, or are there any interventions that you see or [inaudible 00:56:44] from one country that the other country could learn from? Thank you very much.

Diane Coffey:

I'm sorry, but I'm going to leave aside the part of the question about the US because I just don't know anything about it. But I will mention what interventions could cause people to use better quality care in this context. And so one thing that even sort of holding my head and just [inaudible 00:57:20] talking to people in [inaudible 00:57:25] about revising the JSY incentive to keep up with inflation and give it the same teeth that it had in 2005 to try to basically buy people into putting up with the abuse of the public sector in order to prevent their babies from dying of asphyxia due to poor quality care that we see in public facilities. It's not a policy recommendation that comes without hesitation, but I think that on that even if it were to lead to more overcrowding of the public facility, just keeping people away from dangerous deliveries would probably be good on average.

Naveen Bharathi:

Thanks Diane for such a fascinating [inaudible 00:58:15]. We had a very nice interaction and I'm grateful that you could join even in spite of all the troubles which... So thanks everyone for attending the talk. So our next talk is on October 21st by Suraj Jacob and Babu Jacob on urban governance in cities, so please go to our website and register for the talk. And without much, I think it's late for you in India, without I don't want to hold you for long. Thanks a lot for everyone attending and see you on October 21st. Thank you.

Tariq Thachil:

Thanks so much, Diane.

Diane Coffey:

Take care. It was a pleasure.