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    Chapter I

    Introduction & Review of Literature

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    Chapter I

    Introduction 1.1 Introduction:

    Health Status of the women acts as great divide between the developing and developed countries.

    For the women in order to benefit the primary healthcare requirement is to access and utilize the

    interventions and services initiated and made by the government regarding improvement of

    maternal health care and services. The challenge faced here is how to deliver such packages to

    the people and specifically those for which they are meant. Every year, over half a million

    women die of pregnancy related causes worldwide and more than 99% of these occur in the

    developing world (Graham W). Among the major objectives of National Rural Health Mission

    (NRHM, 200512) are to reduce Infant and maternal mortality and also to improve it which is

    expected to be achieved with increased utilization of the maternal healthcare services and

    promoting Institutional Delivery in order to protect both mother and child. Maternal health as a

    concept is about Family planning, Preconception, Prenatal and Postnatal care. Various studies

    have shown that women who started prenatal care early in their pregnancies have better birth

    outcomes than women who do not receive any care or very little care.

    National Rural Health Mission as a flagship programme of the central government of India focus

    to provide better health facilities in the rural villages of India. The larger emphasis is upon on the

    eighteen states with weak public health infrastructure. Essentially it aims at improving the

    availability, accessibility, affordability, and quality of health care services to rural population

    particularly among poor and underserved women and children. In India, the maternal mortality

    ratio (MMR) dropped from 600 deaths per 100,000 live births in 1990 to 390 in 2000 and

    approximately 212 in 2007-09 (RGI SRS Report). Under NRHM several initiatives are under

    implementation in order to achieve reduction in maternal mortality and improving the maternal

    health. Essential obstetric care which includes ante natal care regarding prevention and treatment

    of anemia, institutional & safe deliveries and post natal care. Quality ANC includes minimum of

    at least 4 ANCs including early registration and 1st ANC in first trimester along with physical

    and abdominal examinations, hb estimation and urine investigation, two doses of TT vaccine and

    consumption of IFA tablet s for 100 days. Ensuring post natal care within first 24 hours of

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    delivery and subsequent home visits on 3rd

    , 7th

    and 42nd

    day is the important components for

    identification and management of emergencies occurring during post natal period.

    The ANMs LHVs and staff Nurses are being oriented and trained for tackling emergencies

    identified during these visits (Annual Health survey, 2010-11). Government of India is having a

    commitment to provide skilled attendance at both community and institutional level, in order to

    improve maternal health. With these also India still lags at the back in order to meet the goals of

    MDGs. Using data from National rural health Mission conducted during 2008-09 focus is on

    analyzing the utilization of the maternal health services such TT injection, place of delivery and

    Women receiving the Postnatal Care in the seven EAG states of India. In addition, the paper has

    also tried to focus upon the role of ASHA in promoting these services and relationship between

    the women taking advices from ASHA and her utilization pattern in all seven EAG states.

    Table 1: Utilization Pattern of Maternal Healthcare Services in all EAG states

    Utilization Pattern of Maternal Healthcare Services in all EAG states

    Tetanus Toxoid




    Birth Assistance

    at Home

    Rajasthan 87.1 49.2 69.2

    Uttar Pradesh 81.9 34.6 57.6

    Bihar 86.7 37.8 65.4

    Jharkhand 83.2 17.8 81.2

    Orissa 96.6 60.4 35.7

    Chhattisgarh 92.7 21.1 72.8

    Madhya Pradesh 88.7 54.7 55.7

    India 98.3 48.3 89.1

    Table 1 gives us a clear view regarding the disparity and situation of the maternal health services

    in the EAG States of India. All the EAG states are having a very high percentage of the women

    receiving TT injection, where approximately all states except Uttar Pradesh, are having

    percentage of more than 85% of utilization. At the national level the women who have received

    the vaccine is 98.3, with regard to that among EAG Orissa stands at top and Uttar Pradesh at the

    bottom with 81.9%. Institutional delivery at the national level is around 48.3 and among the

    EAG states we can see a lot of variation among the states such as in Jharkhand its lowest with

    17.8 and in Orissa the percentage is maximum with 60.4%. Orissa is followed by Madhya

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    Pradesh (54.7%) and Rajasthan (49.2%). It has to be mentioned that the institutional deliveries

    have been increased in all the EAG states. According to the DLHS 3 the rural percentage of the

    institutional delivery of Jharkhand was only 13.4 which have risen to 17.8.

    Similar increase has also been found in all the EAG states. Providing the incentives for women

    if she delivers at the institutions is a milestone in the field of Maternal Health. It has led women

    to increase the utilization pattern of theirs along with also securing the health and life of their

    child. It is a well known fact that nothing can stop a Home based deliveries due to several

    reasons such as Social, economic, and cultural. Home based deliveries will happen and will

    continue for some more time. Among the EAG states Jharkhand is having the highest practice of

    the Birth assistance at home based deliveries. With regard to bottom, Orissa comes with the

    lowest percentage. It has to be mentioned that Madhya Pradesh is the only state where the

    institutional deliveries and birth assistance for home based deliveries are very close to each

    other. For the home based deliveries assistance by the Doctor, Nurse/Midwife etc along with Dai

    (Trained Birth Attendant) have been included. It was found during the study that the percentage

    of deliveries assisted by the Dai (TBA) is very high. Approximately more than 50 percentages of

    the deliveries are assisted by the Dai (TBA), which was found in the bivariate analysis of the

    multiple responses of the women and those who assisted the deliveries.

    Literature review

    A healthy woman breeds a healthy race. This can only be significant where the woman knows

    the importance of health and its implications upon her life and others. Specifically during

    pregnancy where due to unavailability of the quality services may lead to loss of life or

    disability, either or both of the women and child. Reducing maternal mortality and morbidity has

    a major focus for the developing world since the launch of the safe motherhood initiative in 1987

    (WHO, 1987). It has been said that with increase participation and utilization in the maternal

    health care services can bring significant changes in the maternal health of the women. With this

    the question arises why there has been a low performance among a bunch of states referred as

    EAG (Empowered Action Group). The study done here is to analyze the utilization pattern of the

    maternal health services in the EAG states. With the introduction of NRHM in the year 2005,

    and its one of the important goal is bring improvement in the Maternal and child health. With

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    regard to the health care utilization there are two aspects implying the availability and quality of

    the health care system. This is also influencing the health seeking behavior of the clients.

    Under the NRHM there is provision for Accredited Social Health Activists. The name itself

    suggests Ray of Hope acts as a connecting link between the community and the public health

    system. One of the core strategies of National Rural Health Mission is to promote access to

    improved healthcare at household level through ASHA.

    Since the early days of independence, strengthening of maternal health care services has been an

    essential component of all development programmes and has received attention in all Five years

    plans with an objective to improve the availability, accessibility and quality of health care

    services in India. The Maternal and child health services were identified as priority during 1983,

    National health policy, and also in the recently announced NHP 2000.

    The maternal health component of the maternal and child health after a long time in 1990s when

    government of India launched child survival and safe motherhood programme (Government of

    India 1991). The major paradigm shift in the delivery of maternal and child health was with the

    introduction of the reproductive and child health approach in 1997 for the implementation of the

    National Family Welfare Programme following the recommendations of the World Bank and the

    consensus arrived at the International conference on Population and development at Cairo


    Despite the fact that Maternal and child health services have been an essential component of all

    health care development plans and activities in India since inde