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Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 53-56  

Factors determining institutional delivery in rural India

Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Date of Submission26-Mar-2019
Date of Acceptance26-May-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Manas Pratim Roy
Department of Pediatrics, Safdarjung Hospital, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_92_19

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Introduction: For reducing maternal deaths, institutional delivery (ID) is a recognized strategy. India has introduced a combination of performance-based incentive and conditional transfer under Janani Suraksha Yojana to boost ID. The present study aims to find out factors deciding ID in rural India. Methods: Data were from nationally representative National Family Health Survey 4 (2015–2016). States were compared individually and in groups. Correlation was used for analysis. Results: Number of antenatal care visits (r = 0.807), early registration (r = 0.820), and consumption of 100 or more iron-folic acid tablets (r = 0.765) were significantly related to ID. Northeast states performed poorly, Nagaland being the worst performer (24% ID). Conclusion: Strategy for encouraging ID should focus around components of antenatal checkup, particularly in Northeast states.

Keywords: Antenatal visit, India, institutional delivery, National Family Health Survey

How to cite this article:
Roy MP. Factors determining institutional delivery in rural India. Med J DY Patil Vidyapeeth 2020;13:53-6

How to cite this URL:
Roy MP. Factors determining institutional delivery in rural India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2022 Jun 25];13:53-6. Available from: https://www.mjdrdypv.org/text.asp?2020/13/1/53/272894

  Introduction Top

The global tool of maternal death stands at staggering 303,000, India being the highest contributor with 45,000 deaths.[1] The cause of such a huge number of casualties is multifactorial, varying from biological aspects to socioeconomic characteristics. Out of all the potential causes, home delivery has been recognized as a vital factor in developing world for maternal deaths, mainly because deaths are mostly concentrated in the intrapartum period. In fact, it has been documented that skilled personnel could reduce maternal death by 16%–33%.[2]

Therefore, different mechanisms have been tried so far for encouraging institutional delivery (ID), performance-based incentive, and conditional cash transfer being two of them. In 2005, Janani Suraksha Yojana (JSY) was launched in India, as an effort to combine two successful models into one, and the effort paid off, as evident from the finding of the National Family Health Survey (NFHS) 4 (2015–2016), in comparison to its earlier version carried out in 2005–2006.[3]

Following documented success in promoting ID from 38.7% in 2005–2006 to 78.9% in 2015–2016, a need is felt to compare states/UTs so that further consolidation could be made in weaker parts of the country for closing the gap. It has been evident that disparities do exist between states and different social classes due to the interplay of several factors, including behavioral ones. Socioeconomic factors also play vital role in deciding the place of delivery, as suggested by the previous studies. Education, economic status, place of residence, and utilization of antenatal services have earlier linked with ID from different parts of the country.[4],[5] It may be assumed that identifying factors for low ID would be beneficial for pointing gaps in existing efforts to secure delivery outcome. Therefore, with an aim to find out the correlates of ID in rural parts of the country, the present paper explores data available from the NFHS 4.

  Methods Top

Data were taken from the NFHS 4 (2015–2016) and are available in the public domain. Only rural areas were considered. State/UT was the unit for analysis. Female literacy, age at marriage, teenage pregnancy, antenatal care (ANC) visits, time of ANC registration, and consumption of iron and folic acid (IFA) tablets during pregnancy were taken into account.

Interviewed women were aged between 15 and 49 years. Early marriage was assessed in women aged between 20 and 24 years (whether they got married before 18 years of age). Pregnant women aged 15–19 years were asked about teenage pregnancy. Early registration referred to starting ANC checkup in the first trimester.

Among states/UTs, Chandigarh does not have any rural area. For Delhi, data only on female literacy and ID were available. Data on early marriage and teen pregnancy were not available for Lakshadweep. Accordingly, analysis was carried out. Descriptive statistics was calculated for expressing results. The states were divided into three groups. Empowered action group (EAG) constitutes of Bihar, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttarakhand, Odisha, Jharkhand, and Madhya Pradesh. Northeast states were grouped together. Rest states/UTs were kept in another group. Using bar diagram, group averages were compared. Pearson correlation coefficient was calculated between ID and other variables. P < 0.05 was considered statistically significant. PASW for Windows software (version 19.0; SPSS Inc., Chicago, IL, USA) was used.

  Results Top

ID was recorded in 77.9% cases. Only one-third (36.9%) mothers consumed 100 or more IFA tablets during pregnancy. Early marriage was found in one-fourth cases (23.5%). Teenage pregnancy was documented in 8.3% cases. Average female literacy was 70.9%.

Highest female literacy was in Kerala (97.3%). Early marriage was commonly found in West Bengal (46.3%) and Jharkhand (44.3%), whereas teenage pregnancy was mostly found in Tripura (20.7%) and West Bengal (20.6%). Only 19.8% mothers got themselves registered in first trimester in Nagaland where 9.2% mothers went for four or more ANC visits and mere 3% consumed at least 100 IFA tablets. Puducherry recorded 100% ID, whereas 24% ID was found in Nagaland.

In spite of having lower female literacy, low consumption of IFA tablets, and low proportion of women with four or more ANC visits, EAG states performed better than NE states, in terms of ID [Figure 1].
Figure 1: Comparison between state groups on institutional delivery and related factors

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ID was directly correlated with early ANC registration, ANC visits, and consumption of IFA tablets, and the relations were significant [Table 1].
Table 1: Correlation between institutional delivery and demographic variables from rural parts of Indian states

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  Discussion Top

The utilization of maternal health services depends much on availability, accessibility, and affordability of the beneficiaries. The present paper analyzed nationally representative data from a recent survey to find out correlates of ID. It is subjected to further introspection that more than one-third of the mothers still do not avail four or more ANC visits. JSY, by virtue of cash transfer, has reduced home delivery, but the success in promoting ANC visits was limited. The same is true for encouraging consumption of 100 IFA tablets. This probably leaves us with a huge scope for improvement. We need to devise some mechanism within our cultural practices for encouraging these two aspects of maternal care.

Few factors have been identified earlier for preferring home deliveries (HD) by Indian women. Believe in traditional birth-attendant, transport to nearby hospital, poor infrastructure/services, and out-of-pocket expenditure (OOPE) are some reasons cited in the literature. To a female due for delivery, the role Accredited Social Health Activist (ASHA) and Auxillary Nurse Midwives (ANM) play for convincing her for ID, arranging transport, and providing support at hospital were more important than the extent to which JSY was able to compensate OOPE. Another important factor is perception about the impending delivery as complicated. People generally wait till the last moment in any complicated case for seeking help from hospital, resulting in unnecessary delay/inability to reach hospital.[6],[7],[8]

Focusing on individual states, why all the components of ANC and ID are at the nadir in Nagaland is a matter of great concern. Hilly terrain could be a reason, but the same geography could be seen in other NE states or some northern states as well. Despite the focus of health-care delivery system on ID, as a measure to improve maternal health outcome, underutilization of health facilities may have reduced the effectiveness of the strategy.[9] Paucity of literature from this particular state makes it difficult to ascribe to some particular cause. However, as one article pointed out, lack of workforce, poor transport facilities, and nonavailability of services at emergency hours are some of the reasons for preferring HD in Nagaland.[10] The urban counterpart in this state recorded 56.3% ID, resulting in a state average of 32.8%. During 2005–2006, the state documented 11.6% ID.[11] From that point, the improvement after JSY was evident. Strengthening of public health facilities, with focus on weaker section of society could spell miracle in improving the overall performance of the state.[12] The introduction of conditional cash transfer could bring change in delivery practices, suggesting poverty as one of the underlying causes for HD. One study suggested a reduction in social inequity following the introduction of JSY.[13] Previous researches have highlighted the role of financial condition in determining the place of delivery.[13],[14] However, at times, it was felt that JSY was insufficient to cover complete cost of ID, particularly when we include wage loss.[6]

Early marriage and teenage pregnancy are two interlinked factors, the first one paving the way for the later. The present analysis found them to have negative effects on ID, supporting the notion that such social practices should be discouraged. Age of the mother has earlier associated with place for delivery.[15] With stronger social awareness, it is possible to have impact on deferring age of marriage. The fact that teenage is not the right time to conceive should be reflected during counseling by the first-line health workers. Most importantly, ID could not be enhanced in isolation.[12] There is a need to adopt an integral approach, keeping society at its center. Mass awareness would eventually give rise to higher acceptance of hospital services, making way for better proportion of ID.

There is no assurance that mere visiting health center would empower the pregnant clients with all required knowledge and provide motivation for ID.[16] Still, over the years, factors related to ANC visits seem to play important roles for determining the place for delivery. For example, four or more number of ANC visits is associated with ID.[13],[17] Probably more important is its interpretation as continuum of care. The health workers could convince the antenatal mothers about the benefits of ID and thus pave way for ensuring a better outcome of pregnancy. Repeated ANC visits not only help in securing maximum consumption of IFA tablets but also encouraging mothers for getting adequate diet and rest, two vital practices during pregnancy. Planning about delivery gets easier with inputs from ASHA and ANM. In our rural setup, these two cadres of frontline health workers play a pivotal role in providing maternal care and bridging between community and health-care delivery system. After introduction of performance-based incentive, the role of health workers in ensuring complete ANC care became crucial. Conditional cash transfer has reduced OOPE for the clients. These two strategies together have built the base of success JSY enjoys today.[18] Early registration indicates timely initiation of professional health care during gestational period. Higher consumption of IFA tablets may indicate possible ID. In one way, it reflects maternal adherence to medical advices. Previous researchers also found similar tendency.[19] All these factors probably decide maternal behavior even during subsequent pregnancies.

Literacy might play an important role in gathering information about maternal health care being provided in the vicinity.[13],[14] In the present study, there was no significant correlation. However, it is worth mentioning that husband's literacy might be equally important. The present study did not take male literacy into account, but at the individual level, the factor may prove vital. In general, lack of education may pose obstacles in perceiving the need of accessing health care.[20]

Many aspects of medical care and services were kept outside in the present study, transport and OOPE being few of them. Quality of the care was beyond the scope of the analysis. Availability of IFA tablets at health facility or with health workers were not considered while accounting for client compliance. Ecological nature of the study probably underestimates individual characteristics. Still, analysis of nationally representative data makes it appealing for the policy-makers. The concept of coordination with the social sectors evolves, giving rise to the need of identification of potential partners for developing a comprehensive approach for ensuring maternal health in the future. In addition, the study also indicates the areas for future research, which could potentially act as the stepping stone for achieving sustainable development goals. For exploring available data and utilization of the same for taking informed decision, upcoming researches on this topic should be encouraged.

  Conclusion Top

For betterment of ID, emphasis should be on antenatal checkup. For exploring available data and utilization of the same for taking informed decision, upcoming researches on this topic should be encouraged, particularly in Northeast states.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/194254/9789241565141_eng.pdf; jsessionid=9397F50648F4DB453C37264361B6085C?sequence=1. [Last accessed on 2019 Feb 14].  Back to cited text no. 1
Graham W, Bell JS, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries? Stud Health Serv Organ Policy 2001;17:97-130.  Back to cited text no. 2
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS; 2017. Available from: http://rchiips.org/NFHS/NFHS-4Reports/India.pdf. [Last accessed on 2019 Feb 14].  Back to cited text no. 3
Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: A multilevel analysis. Int J Equity Health 2011;10:59.  Back to cited text no. 4
Pallikadavath S, Foss M, Stones RW. Antenatal care in rural Madhya Pradesh: provision and inequality. In: Chaurasia AR, Stones RW, editor. Obstetric Care in Central India. Southampton: University of Southampton; 2004. p. 111-28.  Back to cited text no. 5
Vellakkal S, Reddy H, Gupta A, Chandran A, Fledderjohann J, Stuckler D. A qualitative study of factors impacting accessing of institutional delivery care in the context of India's cash incentive program. Soc Sci Med 2017;178:55-65.  Back to cited text no. 6
Sidney K, Diwan V, El-Khatib Z, de Costa A. India's JSY cash transfer program for maternal health: Who participates and who doesn't – A report from Ujjain district. Reprod Health 2012;9:2.  Back to cited text no. 7
Rai SK, Dasgupta R, Das MK, Singh S, Devi R, Arora NK. Determinants of utilization of services under MMJSSA scheme in Jharkhand 'client perspective': A qualitative study in a low performing state of India. Indian J Public Health 2011;55:252-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
Tolera H, Gebre-Egziabher T, Kloos H. Utilization of decentralized health facilities and factors influencing women's choice of a delivery site in Gida Ayana Woreda, Western Ethiopia. PLoS One 2019;14:e0216714.  Back to cited text no. 9
Nienu T, Longkumer K. Maternal health care in Nagaland – Some contemporary issues. EPRA Int J Econ Bus Rev 2015;3:52-60.  Back to cited text no. 10
International Institute for Population Sciences and Macro International. National Family Health Survey (NFHS-3), 2005-06: India. Mumbai: IIPS; 2007.  Back to cited text no. 11
Vellakkal S, Gupta A, Khan Z, Stuckler D, Reeves A, Ebrahim S, et al. Has India's national rural health mission reduced inequities in maternal health services? A pre-post repeated cross-sectional study. Health Policy Plan 2017;32:79-90.  Back to cited text no. 12
Shahabuddin A, De Brouwere V, Adhikari R, Delamou A, Bardají A, Delvaux T, et al. Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 2011. BMJ Open 2017;7:e012446.  Back to cited text no. 13
Yaya S, Bishwajit G, Ekholuenetale M. Factors associated with the utilization of institutional delivery services in Bangladesh. PLoS One 2017;12:e0171573.  Back to cited text no. 14
Bhattacharyya S, Srivastava A, Roy R, Avan BI. Factors influencing women's preference for health facility deliveries in Jharkhand state, India: A cross-sectional analysis. BMC Pregnancy Childbirth 2016;16:50.  Back to cited text no. 15
Dixit P, Khan J, Dwivedi LK, Gupta A. Dimensions of antenatal care service and the alacrity of mothers towards institutional delivery in South and South East Asia. PLoS One 2017;12:e0181793.  Back to cited text no. 16
Feyissa TR, Genemo GA. Determinants of institutional delivery among childbearing age women in Western Ethiopia, 2013: Unmatched case control study. PLoS One 2014;9:e97194.  Back to cited text no. 17
Roy MP. Unaddressed issues in Janani Suraksha Yojana in India. Nepal J Epidemiol 2014;4:341-3.  Back to cited text no. 18
Panja TK, Mukhopadhyay DK, Sinha N, Saren AB, Sinhababu A, Biswas AB. Are institutional deliveries promoted by Janani Suraksha Yojana in a district of West Bengal, India? Indian J Public Health 2012;56:69-72.  Back to cited text no. 19
  [Full text]  
Sen A. Health: Perception versus observation: Self reported morbidity has severe limitations and can be extremely misleading. BMJ 2002;324:860-1.  Back to cited text no. 20


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