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EmOC Indian context EmOC provision a policy priority JSY to promote institutional births, thus provide access to EmOC Three tiered health system with referral services Free referral transport in some states-Janani Express in MP

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Figure 1. Model of referral chain, adapted from Jahn A and De Brouwer V 2001. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

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Objectives To study quality of referral services in JSY by examining 1. association between maternal referral and adverse birth outcomes 2. spatial access to Emergency obstetric care (EmOC) among mothers referred to and died at referral facility

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Objective 1: Methods Nested matched case control design Three heterogenous districts of Madhya Pradesh Cross sectional facility based study at facilities reporting >10 deliveries/month (n=96), 5 days at each facility Interviews with mothers delivered at the facility (n= 1182)

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Table 2. Study facilities by level and distribution of mothers who accessed intra-partum care at these levels. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

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Figure 2. Mothers who reached study facilities for intra-partum care by referral status. Chaturvedi S, Randive B, Diwan V, De Costa A (2014) Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province. PLoS ONE 9(5): e96773. doi:10.1371/journal.pone.0096773 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0096773

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Design Cases: mothers with adverse birth outcome at term delivery (n=34) Controls : mothers with live neonates at 48 hours postpartum (n=68) Controls matched individually to cases for type of complication and place of delivery Adverse birth outcome: Intra partum foetal death /early in facility neonatal death

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Sample characteristics Cases (n==34)Controls (n=68) Age in years, median (range)22 (18-35)23 (18-40) Below poverty line *65%41% Illiterate32% Referred*50%25% Primiparous50%44% Caesarean section delivery15%28% ANC visits < 238%25% Delivery care by doctor21%30% * Significant at p