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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, 2005–12) 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 ANC’s 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 ANM’s LHV’s 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

MDG’s. 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

Vaccine

Institutional

Delivery

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 it’s 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 other’s. 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 it’s 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 1990’s 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

(1994).

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 independence, the current Maternal

Health scenario cannot be termed as satisfactory (Ranjan, A. Obstetric care in central India.

2004). Considering the situation in India where women lag far behind as compared to males, her

health preferences and perception are difficult to understand. Many of the so called “female

Conditions” are not considered health problems, either by the health professionals or by the

women itself (Mishra, 2006, Women in India).

Nearly of all maternal deaths is developing countries occur during labour or delivery, or in the

immediate postpartum period. Key factors influencing programs aimed at reducing these deaths

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are who delivers the woman and where she delivers (Koblinsky, Campbell and heichelheim

1999). The social distance between the women and a health centre due to her religion, caste,

class, level of autonomy is an even greater gulf than physical distance.

Education is a powerful determinant of health (Berkman et al., 2004; Cutler and Lleras-Muney,

2006; Gakidou et al., 2010; Skolnik, 2007). Poorly educated women are more likely to get

married and have children at an earlier age.

Culturally too the women are taught to accept and mould themselves into the culture of silence.

Regarding physical access to healthcare, travel time is also an important factor influencing in

several ways the utilization of the maternal health services.

Clover et al. (1967) and Griffiths et al. (2001) stated that distance from the place of living or

house is also highly influencing her utilization pattern and preferences for maternal health

services. Education which is a vital factor influencing positively the utilization of the maternal

health services (Singh et al., (2007), Tiwary and Prasad, (2002); khan et al., (1997). Millions of

the Indian women lack autonomy to go outside the home and look for the health facility and

services they need. (R.C Mishra.) The health status of both women and children, particularly

female children, suffers in relation to that of males in areas where patriarchal kinship and

economic systems limit women’s autonomy (Caldwell 1986).

Marge Koblinsky and Nirali Shah have identified the importance of the health system in order to

deliver the healthcare services (2011).Roemer (1991) defined health systems as the combination

of resources, organization, financing and management that culminates in the delivery of health

services to the population. Hurst (1991), in his definition of health systems, focused on financial

flows and payment methods between population groups and institutions. Cassels and Jonovsky

defined health systems in terms of the economic relationship between demand, supply and

intermediary agencies influencing the demand-supply relationship (Cassels, 1995; Jonovsky and

Cassels, 1996).

Hsiao (2003) proposed to conceptualize a health system as “a set of relationships in which the

structural components (means) and their interactions are associated and connected to the goals

the system desires to achieve (ends).” He limited the boundaries of a health system to the

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“components” that “can be utilized as policy instruments to alter the outcomes.” The World

Health Report 2000 described health systems as all the activities whose primary purpose is to

promote, restore or maintain health (World Health Organization, 2000), which is the definition

now widely used.

1.2 Need for the study: -

Various demographic indicators of the EAG states show the low health status of the women from

various aspects. Since the NRHM has been launched several studies have been made to

understand the utilization pattern among the women. In this paper along with the utilization of

the maternal health care role of ASHA in promoting the same has also been focused. In the EAG

states considering institutional delivery as a maternal health indicator we find very low

percentage with regard to its utilization. In Jharkhand institutional deliveries is only 13.4 in the

rural areas (DLHS 3, 2008-09) and deliveries at home raises upto 86.2 (DLHS 3, 2008-09).

Along with this there are lot more variation among the EAG states too such as in Orissa

institutional deliveries is around 40.4 and home deliveries is approximately 58.5.

With such a huge differences while coming under the umbrella of EAG raises the question of

“why such a great disparity”. It is crucial to explore why the women still prefer home delivery

when they can take benefit of the institutional deliveries and receive incentives at the same time.

Situation of maternal health is very poor in the states such as Bihar, Jharkhand, Madhya Pradesh,

Chhattisgarh and Rajasthan needs drastic improvements at state level. (AHS 2010-11).

Similar to the Institutional delivery the percentage of the women receiving full ante natal care is

extremely low in most of the EAG states. At national level the percentage is 14.7 for rural areas,

and among EAG except Orissa all other states are having very poor or low performance. On

comparing Uttar Pradesh (only 2.4) is at bottom and at the top Jharkhand comes with 7.2 percent

(DLHS 3, 2005-06). Considering the disparity it’s crystal clear that Orissa is almost ten times

above the Uttar Pradesh.

Along with these when ASHA is considered as the interface between the community and

healthcare system what are her contributions and what changes are required to bring for the

better implementation of any policy and to promote health care of the citizen, specifically

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women and child. In the paper the roles fulfilled by ASHA have been matched with the roles

and responsibilities assigned to her. Specifically those related to the Maternal Health and during

pregnancy.

1.4: Objectives of the Study:

The present paper mainly revolves around two major objectives: -

To understand the utilization pattern of the maternal health services in (Seven) EAG

states of India.

To understand the role of ASHA in promoting the maternal health services.

1.5: Data Source

The present study used the National Rural Health Mission (2005-12) concurrent evaluation data

to complete the study. The concurrent evaluation of the NRHM, conducted during May to

December 2009. The concurrent evaluation was completed in 187 districts and covering 33 states

and union territories. Of the total 2, 13,067 eligible women were interviewed of which 79,200

belong to the Seven EAG states. Due to unavailability of the data I was unable to include the

eighth state i.e. Uttarakhand.

1.6: Methodology

In order to analyze maternal health Utilization among the women in EAG states, three indicators

namely, Tetanus Toxoid (TT) Vaccine, Place of Delivery and Skilled Birth Assistance has been

taken.

Tetanus Toxoid (TT) Vaccine: Women were asked whether they were given the injection or not

when they were pregnant in order to prevent them and their babies from getting tetanus. Along

with this they were also asked about how many injections they received.

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Place of Delivery: The place of delivery is an important determinant for reducing the risk of

Infant and Maternal death. Women were asked about the last three births that they were born at

home or institute.

Assistance during Delivery: In addition to the question asked about the place of delivery women

were also asked about the Birth assistance provided if the delivery took place at home.

Assistance during delivery is an important component in the maternal health services. It can

significantly reduce the risk of obstructed labour during delivery.

Information was gathered about who assisted during home based delivery: Doctor/ANM/ Nurse

or midwife, Trained Birth Attendant (Dai) or Non- Skilled Personnel (Friends/Relative etc.) As

per the NRHM Report, 2009 Dai has been referred as the unskilled, in this study attempt is to

show her relevance with regard to the birth assistance in case of home based deliveries.

The Binary Logistic analysis and cross tabulation is used in the study to understand the

utilization of the maternal health services in EAG states according to their background

characteristics. The independent variables used in the first objective are Women’s current Age,

Age at marriage, Educational Attainment, religion, Caste and total number of live birth of the

women. In the second objective including all the variables mentioned above role of ASHA as

“providing advice to the women” upon various maternal health services i.e. institutional delivery,

TT Vaccine, JSY has been taken.

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Chapter II

Utilization of Maternal Health Services in EAG States

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Chapter II

Utilization of Maternal Health Services in EAG States

II.1 Utilization of TT Vaccine among the women in EAG states in India.

Table1.1 explains the utilization of the TT vaccine among the women in EAG states with

background characteristics. The percentage distribution of women who have taken TT injection

at least one or more which is a component of ANC care is very high in almost all the EAG states.

If we consider the background variables there is not much variation which was seen as in the

women going for the institutional delivery. Considering the age groups, women in between 15-

19 years are having taken the maximum utilization of Any ANC in states such as Bihar,

Jharkhand and Uttar Pradesh. Similarly in states; Orissa, Chhattisgarh, Madhya Pradesh and

Rajasthan women in the age group 20-29 reports of highest utilization of the TT vaccine. Age at

marriage has also shown a wider disparity among the states but within states there is very less

disparity. But in almost all the states the percentage utilization of the women receiving TT

vaccine is higher among the women getting married after 18 years of age in contrast to those

getting married after that. In both the category of age at marriage Orissa is having the maximum

utilization with 94.6 and 97.4 respectively. In the lowest level of women getting married after 18

years of age appears Uttar Pradesh (76.7) and in the other category Jharkhand stands with 85.2.

With education there is also increase in the utilization of any ANC among the states. The

educational level have always had impact in the utilization of these services so from the table we

can observe almost all the states are above 75 with no education. The lowest percentage of

utilization in the Illiterate category is Uttar Pradesh (76.8), next to which comes Jharkhand with

77.5. Orissa is having the highest percentage of utilization in all the categories of education

(Illiterate, 5 years of education and more than 5 years of education). Approximately 85 of the

women have received TT vaccines that have completed a minimum of five years of education.

And in the same group Chhattisgarh (96) comes with the second highest utilization and is

followed by Bihar (94.6). Those women who have completed more than 5 years of education are

having the highest utilization pattern among all EAG states. All the states have a percentage

higher than 95 except Uttar Pradesh (93.1).

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Analyzing the percentage of women taking TT injection on the basis of religion very less

disparity exists among Hindus and Non-Hindu (comprises of Muslim, Sikh, and Christian etc.).

There is not very high disparity among the women in both Hindu and Non-Hindu category,

except Rajasthan where the difference is of 22.1 points. Rest in all other states very less disparity

exists. Scheduled caste women are having the higher percentage of utilization of TT vaccine in

comparison to the scheduled tribe women except in Rajasthan where the SC women are less than

2.9 points from ST. In the remaining states disparity exists with a maximum in Uttar Pradesh

then followed by Madhya Pradesh. The ‘Others’ category of Caste is having the Highest

utilization than the other two categories. In almost all the states this category is having the

maximum utilization of the TT vaccine with approximately 85 in all states.

A woman having two live births is having higher percentage of utilization than the women with

one live birth in states such as Rajasthan, Uttar Pradesh and Bihar on the other hand states such

as Jharkhand Orissa and Chhattisgarh women with only one live birth is having the higher

percentage of utilization. In states such as Orissa and Chhattisgarh the pattern is inverse where

the women with only one live birth is having the higher percentage of utilization than the women

with two live birth. At the same time in Madhya Pradesh no difference has been observed in the

utilization pattern of the women having either one or two live births. It must be mentioned that

Orissa is the only state where the women are having the utilization all other states irrespective of

any background features.

Table1.2 The number of TT vaccine received by the women in all the EAG states.

TT Injection Received by women

One Two Three & More

Rajasthan 11.2 63.2 25.6

Uttar Pradesh 7.7 74.0 18.3

Bihar 6.2 66.3 27.5

Jharkhand 10.2 51.1 38.7

Orissa 4.3 80.4 15.3

Chhattisgarh 12.8 54.9 32.2

Madhya Pradesh 9.8 58.1 32.1

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Table 1.2 is explaining the number of TT vaccine received by the women in the EAG states.

Under the standard ANC number of TT is considered to be two, with regard to that Orissa is at

the top. The performance of Orissa is almost better as compared to the other states among the

EAG. Orissa is followed by the Uttar Pradesh (74%) and Bihar (66.3%) where the women have

reported of taking upto two TT vaccines during pregnancy. At the bottom level Jharkhand comes

with 51.1% but on the other hand women who have received more than 2 TT vaccines are

maximum in Jharkhand. Madhya Pradesh and Chhattisgarh are the two states which are followed

after Jharkhand with regard to the women who have received three and more TT vaccines.

II.2 Utilization of Institutional delivery among the women in EAG states of India.

Table1.3 explains the pattern of the Institutional deliveries among the EAG states with

background characteristics. In order to understand the pattern of institutional delivery among the

women in the EAG states some background characteristics have been taken from the eligible

women. The main objective here is to analyze the differentials existing among the women

regarding the utilization of the maternal health services among the EAG states. At the national

level the percentage of the institutional delivery is approximately around 47.3 and in the previous

table we have seen variations and levels of the institutional deliveries in the EAG states of India.

Women in the age group 20-29 are having the highest percentage of utilization than the women

in other age groups except Madhya Pradesh, Chhattisgarh and Jharkhand where the utilization

pattern is more among the women in the age group 15-19. According to the women’s age at

marriage those getting married after 18 years of age are having higher percentage of institutional

delivery than the women getting married prior to that. Though in Chhattisgarh we observe

women whose marriage age was less than 18, 71.4 of women prefer to deliver at institution

whereas those getting married after 18 percentage of institutional delivery is 62.3. Similarly

Chhattisgarh is having the highest percentage of Institutional delivery for those getting married

after 18 years of age followed by Orissa (60.3) and Uttar Pradesh (48.2). On the other hand states

comprising lowest percentage are Jharkhand (20.9) and Madhya Pradesh (25.2). Those women

getting married after 18 years of age, Chhattisgarh are still having the highest percentage (62.3)

and followed by Orissa (60.3). On the other hand Jharkhand (24.2) stands at the bottom level

after Madhya Pradesh (35.5). Thus here we can conclude that on the basis of age at marriage

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both the upper and lower ends are similar with regard to the percentage of women opting

institutions for the delivery.

Considering the education we found that Jharkhand is having the lowest percentage of

institutional delivery in all the three categories of educational attainment. Whereas taking the

highest percentage of institutional delivery with no education Chhattisgarh (64.6) followed by

Orissa (56.1). And in the other categories also the pattern is same, in other words Chhattisgarh

stands at top followed by Orissa and bottom position is taken by the Jharkhand. It is understood

that there is a positive relationship between the educational attainment and involvement or

percentage of people taking benefit of any services. With education as an independent factor

affects the individual behavior and health seeking behavior of people at large.

The table (1.3) shows with increase in education there is also increase in utilization pattern too.

Among all, Jharkhand is at the lowest, with increase in education there is increase in the

percentage of women taking institutional delivery but very low as compared to other EAG states.

Religion as a factor provides us with disparity among Hindu and Non-Hindu women, where the

former is going for institutional deliveries at higher rate than the latter except Chhattisgarh and

Rajasthan where the Non-Hindu women prefer to deliver at home. Maximum disparity has been

found in Bihar with Hindu (37) women and Non-Hindu (22.6) prefers to deliver at institution.

Similar to religion in Chhattisgarh the percentage of women going for institutional deliveries

belonging to SC, ST and other category Chhattisgarh stands at the top followed by Orissa and

then Uttar Pradesh. Whereas, Jharkhand is at the lowest position irrespective of all the categories

among the EAG states.

Performance of Jharkhand in utilization of maternal health services in the form of Institutional

Delivery is lowest; on the other hand we can also say that Chhattisgarh is on the top among all

the EAG states in terms of percentage distribution of women according to the background

characteristics going for institutional delivery. The women having two live births are having

higher percentage of utilization than those who have only one live birth. Minor differences were

found in case of, Orissa and Chhattisgarh where the women with single live birth is having

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higher utilization pattern than the women with two live births. Among the variation in the state

irrespective of live births women in Jharkhand is having the lowest utilization pattern

II.3 Utilization of Birth Assistance among the women in EAG states of India.

Table 1.4 explains the percentage distribution of the women in EAG States taking birth

assistance. Here along with the birth assistance provided by the doctor, Nurse, and midwife who

are considered as the skilled birth attendant Dai (trained birth attendant) is also included.

Comparing the women receiving the birth assistance Chhattisgarh (79.1) is having the highest

percentage of utilization in the age group less than 20 and followed by Jharkhand (78.8) and

Chhattisgarh (73.3). At the lowest stratum Orissa stands with 25.4. Similarly in the age group 20-

29 Jharkhand is having the maximum utilization of birth assistance with 80.6 which is also

highest among all other age groups. Jharkhand is also having the highest percentage in the age

group 30-49. Considering the age at marriage women in both less than and more than 18 years of

age Jharkhand stood at top with 81.3 and 81.1 respectively. In the similar way Orissa is in the

bottom.

With higher educational attainment we find a higher birth assistance received by the women in

almost all the EAG states. On the basis of religion we can find diverse results where the Non-

Hindu religion women are receiving more the birth assistance than the Hindu women in states

such as Rajasthan, Uttar Pradesh, Bihar, Orissa and Madhya Pradesh. Remaining two states i.e.

Jharkhand and Chhattisgarh where we have the lowest percentages of Institutional deliveries,

Hindu women are utilizing higher birth assistance.

Caste as an independent do not give us a diverse results but in some states such as Uttar Pradesh,

Bihar and Orissa where the OBC women are at higher level with regard to receive the birth

assistance. Rest in all other states SC is higher than the OBC women in seeking birth assistance.

The women who is having only one live birth is receiving birth assistance more as compared to

the women having two or more live birth in almost all the states. With respect to all EAG states it

can be said that Jharkhand is having the highest birth assistance percentage and Orissa is at the

bottom.

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II.4 Logistic regression Analysis of the women utilizing the TT injection with background

characteristics:

Table 1.5 is explaining the odds ratio for the women receiving TT Vaccine with regard to the

background characteristics. The women in the age group 30-49 are (.598 odds ratio) less likely to

receive Any ANC as compare to the women in the age less than twenty. Women whose age at

marriage is above 18 years are more likelihood of taking tt vaccine when compared to those

getting married prior to the age 18. In education as the women is gaining educational attainment

her likelihood of receiving any ANC (TT vaccine).

According to the results, the women who are having completed minimum of 5 years of education

are more than two times likely to receive TT vaccine and those having more than five years of

education are around four times likely to receive TT vaccine than those women who are illiterate

or are having no education. Similar to the institutional delivery Non-Hindu women are having

less likeliness to have TT vaccine as compared to the Hindu women. The Non-Hindu women are

at least three times less likely to receive TT vaccine. Scheduled tribe women are approximately

50 percent less likely to receive TT vaccine than the scheduled caste women. On the other hand

women belonging to ‘other’ category are 1.223 times more likely to receive any ANC than the

scheduled caste women. Also the women who are having two or more live birth are 1.223 times

are more likelihood to take TT vaccine than those having only one live birth. In context to the

states receiving any ANC (TT vaccine) Uttar Pradesh is around 41 percent times less likely to

receive any ANC than Rajasthan. Similarly, Bihar and Jharkhand are 68 percent and 56 percent

less likely to receive TT vaccine as compared to the Rajasthan. Madhya Pradesh (.914) which is

very close to the value of Rajasthan, its percentage distribution for the TT vaccine is 88.7 which

are slightly higher than of Rajasthan i.e. around 87.1 percent. The remaining states, Orissa and

Chhattisgarh we found that the former is more than two times likely and latter is more than one

and a half times more likely to receive TT vaccine than the Rajasthan.

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II.5 Logistic regression Analysis of the women utilizing Institutional Delivery with

background characteristics:

Table 1.6 explains the logistic regression analysis of background factor affecting utilization of

maternal health services among the currently married women in the EAG states of India. With

regard to the institutional delivery women in the age group less than 20 are having the highest

likelihood of taking institutional delivery than those in other age group. Women in the age group

20-29 are 68 percent and those in 30-49 are less likely to deliver in the health institutions than

those in the age of less than 20. In age at marriage those women who got married below 18 years

of age have been considered as the reference category and according to the results, those who got

married after 18 years of age are more than 1.362 (Odds ratio) times likely to deliver at hospitals/

institutions.

Education as an independent factor gave us results showing that those women who completed at

least five years of education are approximately one and a half times more likely to deliver at

institutes than those who have no education or are illiterate. Similarly those women having

education more than five years of education are two and a half times more likely to prefer

delivery at hospital/institutions. With the increase in education we have increase in the pattern of

institutional delivery too in almost all the EAG states. Religion which have been broadly

classified into Hindu and Non-Hindu and as per the results of the logistic regression we have

latter .806 times less likely to prefer the institutional delivery. The Hindu women in the table 1.1

are also having a higher proportion to deliver at institutes when compared to the Non-Hindu

women. With respect to caste the scheduled tribe women are less likely to deliver at hospitals

than the scheduled caste women. According to the results, the ST women are approximately 50

percent less likely to deliver at hospitals. Similarly the women belonging to other caste including

VJNT, OBC and others are 1.156 times more likely to prefer delivery at institutes than the

scheduled caste women. Thus women in scheduled tribe are at bottom in terms of preferring

institutional delivery. Women having the total number of two or more live birth are more likely

to deliver at institutes than those women who have only one live birth. According to the results

the women having two and more live births are 1.215 times more likely to take institutional

delivery. Comparing the states on the basis of logistic regression regarding institutional delivery

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women at Rajasthan are more likely than any other states in order to have institutional delivery

rather than home based deliveries.

In context of the values of the states coming through the logistic regression, Jharkhand is almost

five times less likely to deliver at institutes which are also at the lowest of all the EAG states in

the percentage distribution of Institutional delivery. Similarly Chhattisgarh which is having the

institutional delivery of 21.1 is also approximately five times less likely to deliver at hospitals.

The states such as Bihar (.420) and Uttar Pradesh (.311) are around three times less likely to

prefer delivery at institutes than home based deliveries. In contrast the remaining two states i.e.

Orissa (.999) and Madhya Pradesh (1.006) are close to the value of reference category but are not

significant according to the results of the logistic regression.

High rates of the maternal mortality and health problems in India are among the highest in the

world. At the same time a major challenge for the health care system too. Percentage distribution

for the institutional delivery at national level is approximately 47.3 which also mean more than

half of the deliveries take place at home, assisted by the skilled and unskilled health personnel.

Table 1.5: Percentage distribution of the Multiple responses of women regarding Birth Assistance across the EAG

States.

Doctor ANM/Nurse/Midwife Other Health Personnel

DAI

(TBA) Friends/Relative No One

Rajasthan 6.1 17.2 1.2 51.9 40.6 1.3

Uttar

Pradesh

6.7 2.6 0.6 52.2 53.2 3

Bihar 14.7 5.8 3.8 56.9 58.9 2.5

Jharkhand 17 8 1.7 70.2 61.1 0.6

Orissa 12.5 8.7 5.4 17.9 61.6 11.5

Chhattisgarh 14.8 14.1 4.2 60.9 65.5 5.1

Madhya

Pradesh

7 5.8 2.3 50.6 55.7 2.3

Total. 10.7 7.2 2.2 53.7 55.8 3

Table 1.5 explains the percentage distribution of the women taking birth assistance in the EAG

States with regard to Birth Assistance by the Doctor, Nurse/ Midwife, and Dai. The percentage

of the institutional deliveries is highly varying among the EAG states, for instance in Jharkhand

about 17.8 to Orissa with 60.4. The high proportion of home deliveries in India, unattended by

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professionals, implies a need to expand existing knowledge of factors that influence women’s

preferences and decisions of birth place. In almost all the states home based deliveries are

conducted maximum by the DAI (TBA) or friends/relatives. DAI is having the skill and training,

but in almost all the states Deliveries are also being assisted by the friends and relative who

cannot be considered as skilled or even semi skilled. Dai is existing informal health workers of

their villages, providing practice and sometimes emergency care and at a low cost at the

doorsteps of village women.

In the table 1.5 Jharkhand which is having the lowest percentage of institutional deliveries

among all EAG states has the highest percentage in Delivery assisted by doctor i.e. 17 and Dai

with (TBA) 70.2. Women also reported that highest percentage of ANM/Nurse/Midwife

deliveries assisted is in Rajasthan (17) followed by Chhattisgarh (14.8). The central reason for

such a high percentage of the deliveries assisted by the Dai revolves around two reasons;

assisting delivery as their social role and their experience regarding child birth it.

With regard to deliveries attended by unskilled personnel and the existence of the schemes such

as JSY providing incentives for institutional birth indicates lack of awareness and status of the

women’s autonomy in country specifically in the rural settings. In the table we find that the

home based deliveries are primarily dominated by the Dai (TBA) and Friends/Relatives

(Unskilled). In order to analyze the pattern of safe birth assistance among the EAG states table

(Birth Assistance) shows its distribution along with the background characteristics. The age

groups categorized into three, shows that maximum birth assistance received falls in the age

group ‘30-49’ in most of the states in EAG states.

II.6 Logistic regression Analysis of the women receiving Birth Assistance (Skilled and

Trained Birth Attendant) with background characteristics:

Table 1.6 explains the logistic regression analysis of the background factor affecting Birth

Assistance give the result unlike of the institutional delivery and any ANC (TT Vaccine).

According to the age we find as the age is increasing the likelihood of the utilization pattern is

also increasing. Those women who are in the age group 20-29 are 1.325 times more likely to

receive Birth assistance than those who are less than 20 years of age. Similar to that those

20 | P a g e

women in the age group 30-49 are around one and a half times more likely to receive birth

assistance. Marriage ages of the women who are more than 18 years of age are less likely (odds

ratio .981) times to receive any birth assistance.

Opposite to the Institutional delivery and TT vaccine the women with increase in age are less

likely to take birth assistance. Similarly those women with education are less likely to receive

birth assistance than the illiterate women or women with no education. According to the results

women upto five years of education are 87 percent and those having more than five years of

education are 63 percent less likely to receive birth assistance than the women who is with no

education.

Non-Hindu women when compared to the Hindu women are 1.285 times more likely to receive

birth assistance compared to the Hindu women. In context of the caste both the categories i.e. ST

and others are less likely to receive any birth assistance which was not the case with the other

category in terms of Institutional delivery and receiving any ANC (TT Vaccine). The woman

who is having more than one live birth is less likely to receive any birth assistance than those

who have only one live birth. It clearly shows that the women who have given birth previously

are less likely to receive any birth assistance than those who are having one live birth or no

previous birth experience.

With regard to the states birth assistance is highly diverse, as majority of the states are in the

higher than the reference category which was not seen in the case of institutional delivery and

birth assistance. Only Orissa (.346) and Madhya Pradesh (.654) are less likely to Rajasthan to

receive birth assistance. Uttar Pradesh and Bihar are 1.065 times and 1.237 times more likely to

receive birth assistance. Similar to that Chhattisgarh is around three times more likely to receive

birth assistance and Jharkhand is more than three and a half times more likely to receive birth

assistance than Rajasthan. Jharkhand and Chhattisgarh which are having the lowest percentage of

institutional delivery are having more likelihood than all other states in order to receive birth

assistance.

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II.7 Logistic regression Analysis of the women receiving Birth Assistance (Skilled) with

background characteristics:

Table 1.6 is also explaining the logistic regression results for the birth assistance provided to the

women by skilled health personnel including Doctor, Nurse and Midwife, unlike the previous

logistic results where along with skilled birth attendant trained Birth attendant was also included.

The differences have been found in the educational attainment and the states receiving birth

assistance. Stating the educational attainment, a woman with upto 5 years of education are more

likely (1.316 odds ratio) to seek birth assistance than the women with no education. Similarly

those women who are having education more than 5 years are 1.131 times more likely to receive

birth assistance than the women who is not having education.

Here we can conclude that the women with education are more likely to receive birth assistance

from the skilled personnel than the unskilled personnel. The odds ratio for the two states i.e.

Jharkhand and Chhattisgarh have declined when compared to the odds ratio for seeking birth

assistance from both skilled and unskilled attendant.

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Chapter Three: -

Role of ASHA in Promoting Maternal Health Services in EAG States.

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Chapter III

Role of ASHA in Promoting Maternal Health Services In EAG States.

III.1 Introduction:-

Accredited social health activist (ASHA) are the community based health workers established by

the government of India’s (MoHFW) as a part of National Rural Health Mission (NRHM).

ASHA must be a female resident of the village and married, widowed and divorced women are

preferred. The minimum education requirements to serve as ASHA is at least 8th pass and should

be in between the age group of 25-45. There is also provision that if no suitable literate candidate

is available then a woman with a formal education of less than 8th

standard may be selected.

The ASHA is selected by the Gram Panchayat and is accountable to that only. ASHA is expected

to play some specific roles such as providing information to the women on the existing health

services and mobilizing the women to utilize them, registering the pregnant women in the village

and escorting or assisting her to the health institution at the time of delivery. The most significant

role of the ASHA is to counsel the women on issues such as birth preparedness, safe delivery,

care of the young child etc.

Table 2: Showing the percentage distribution of the people heard about ASHA and her

availability in the Villages of EAG states.

Total Number of ASHA in Village

Heard About

ASHA No ASHA

Single

ASHA More than One

Rajasthan 64.1 4 92.6 3.4

Uttar Pradesh 81.4 4.5 81.9 13.6

Bihar 75.3 6.5 86.8 6.7

Jharkhand 58.5 5.7 87.2 7.1

Chhattisgarh 96 1.6 98 0.4

Orissa 93.1 1.7 60.9 37.4

Madhya Pradesh 65.4 4.5 93.9 1.6

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In order to understand the role of ASHA in promoting utilization of maternal health services

table shows the percentage distribution of the women who have heard about ASHA which varies

significantly from 58.5 (Jharkhand) to 96 (Chhattisgarh). It has to be stated that at all India level

the awareness percentage is 55.8 and all the EAG states are above it. As mentioned earlier

Chhattisgarh with maximum level of women ‘heard about ASHA’ is followed by Orissa (93.1)

and Uttar Pradesh (81.4) and at the bottom level comes Jharkhand and prior to which are

Rajasthan (64.1) and Madhya Pradesh (65.4). Table Illustrates the Availability of ASHA in the

villages as per the information collected from the women. The places with no health activist in

any EAG states are very low for example; highest non availability exists in Jharkhand which is

only 5.7 and at the bottom Orissa exists with 1.7.

Almost in all the EAG state women reported that there is at least one ASHA in the village and at

the highest place Chhattisgarh (98) exists where maximum women have reported about the

availability of ASHA. Women have also reported in Orissa (37.4) that there is a maximum

percentage of more than one ASHA as compare to any other EAG states.

In order to understand the role of ASHA more specifically table presents the areas where the

ASHA creates awareness. There major areas where the ASHA creates awareness are Hygiene

and safety at home, JSY/Institutional Delivery & giving Information to the women about

ANC/NC/PNC, Child care, Nutrition and Family Planning, the ASHA also encourages and give

information to the women about the benefits and incentives to register under the JSY Scheme.

As per the table 73.5 of the women are reporting that the ASHA creates awareness about the

Services such as JSY/ JSY/Institutional Delivery & ANC/NC/PNC such as in states such as in

Jharkhand (81.2).

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Table 2.1 According to ASHA the multiple responses explaining the reasons why do women

prefer to deliver at Home.

According To ASHA percent distribution of women Prefer Delivering at Home

No Appropriate

Facility

No Transport

Available When

Required

Less

Expensive

In Appropriate

Behavior of

Staff

Family

&

Culture

No

Awareness

about JSY

Rajasthan 23 41.6 35.4 19.5 26.5 38.9

Uttar

Pradesh 40.8 43.6 47.8 34.5 40.5 33

Bihar 37.3 53.6 43.1 23 9.6 8.6

Jharkhand 50 44.2 20 5 14.2 23.3

Orissa 26.9 46.8 41.2 7.4 19.4 22.2

Chhattisgarh 33.3 46.9 47.9 16.7 61.5 34.4

Madhya

Pradesh 23.5 28.6 16 6.1 26.3 25.4

India 34.5 44.2 39.9 16.6 28.1 25.2

As mentioned above it’s very crucial to understand why the women prefer to deliver at home.

With regard to this questions were asked under the evaluation of NRHM, which have been

utilized in this paper to understand and explore the possible reasons. As per the information

gathered from the ASHA several reasons can be drawn regarding why do women prefer to

deliver at home. Since no exact and accurate time for the delivery can be decided majority of the

ASHA (44.2) at national level considers No transport facility available when required as the

major cause why women prefer to deliver at home. The maximum percentage of ASHA

reporting lack of transport facility is in Bihar (53.6) followed by Chhattisgarh (46.9) and Orissa

(46.8). At the bottom ASHA in Madhya Pradesh reporting lack of transport facility at 28.6. The

second most prominent cause to deliver at home is that women feel it’s less expensive to deliver

at home which is 39.9 at the national level and Chhattisgarh comprising the highest percentage

with 47.9 followed by Uttar Pradesh and Bihar with 47.8 and 43.1 respectively. Looking at the

state wise states such as Rajasthan, Bihar, Orissa and Madhya Pradesh lack of transport facility is

the major cause to prefer delivery at home. Among the remaining states i.e. Uttar Pradesh,

expense is the major reason for home delivery. In Jharkhand and Chhattisgarh no appropriate

facility and Family and Cultural reasons are dominant with 50 and 61.5 respectively. It must be

focused that in Jharkhand which is at the lowest level in terms of utilizing the maternal health

26 | P a g e

services such as any ANC and place of Delivery (Institutional), ASHA reports that there is no

appropriate facility. Other reasons for which women preferring delivery at home includes lack of

awareness about JSY (25.2), Family and cultural reasons (28.1) and inappropriate behavior of the

staff (16.6).

III.2 Roles defined for the ASHA with regard to the Maternal Health at grassroot level.

• Identifying all pregnant women in the village.

• Advice pregnant women regarding balanced diet, Signs of Danger during pregnancy,

Delivery care etc.

• Help eligible women to get benefit of the JSY.

• To help the marginalized women to get the services.

• Escort/Accompany the pregnant women to the Hospital.

• If required, stay at the hospital at the time of delivery.

III.3 Performance of the ASHA, an assessment of her responsibilities towards promoting

the Maternal Health Services.

III.3.1 Nishchay Pregnancy Test

Nishchay pregnancy test kits are made available free of cost to all women in rural areas through

the ASHAs, thus reaching out to women, who would otherwise have to travel great distances and

spend money to confirm a pregnancy. Role of ASHA is making available Nishchay kit to

community women and device those on how to use the device along with how to read the results.

Counsel the women & link them to health service provider are the secondary role for ASHA.

Table 2.2 indicates the percentage distribution of the ASHA who have received training for using

the Nishchay Pregnancy Test (NPT) and the percentage of the ASHA having their own kit. In

Orissa 92 of the ASHA reports that they have received any training on using the NPT followed

by Chhattisgarh (89.6) and Uttar Pradesh (83.5). If we compare the national level which is

approximately 77.2 states along with Orissa, Chhattisgarh, Uttar Pradesh, Bihar and Rajasthan

are above it only Madhya Pradesh and Jharkhand with 70.2 and 62.5 cascade behind national

level. In the table it has been also explained the usual follow up taken after knowing the results

of the NPT. The maximum percentage of the women is suggested for the ANC (76.4) or family

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planning services (52.9). Rajasthan with 92.1 of women being suggested for the ANC holds the

top position and followed by Bihar and Orissa with 86 and 80 which are also above the national

level. At the bottom we have Jharkhand which is having the lowest percentage of 41.2. With

regard to the family planning services Uttar Pradesh (70.4) is at the upper level followed by

Rajasthan (50) and Jharkhand (47.1). Bihar is at the lowest level where the women (29.8) are

advised to use any family planning services. Thus we can see that the states where the women

have largely advised or suggested for either ANC or Family Planning are Rajasthan with (92.1

and 50) also Uttar Pradesh (63 and 70.4). Women are also being advised for the MTP which is

29.8 at national level and among the EAG states Rajasthan (44.7) is at the top followed by

Chhattisgarh (32.8) rest all the states are below the national average. Even if the test was positive

there are also instances where nothing has been done such as in Jharkhand (17.6) almost three

times the national average which is around 6.5. Thus we can conclude that the ASHA is playing

a noteworthy role towards motivating women for ANC or Family Planning.

III.3.2 Advice pregnant women regarding balanced diet, Signs of Danger during

pregnancy, Delivery care etc.

The women in EAG have reported that they have received information and discussions regarding

the issues such as diet, signs of danger during pregnancy, Delivery care and Breast feeding.

Table 2.3 explains the percentage distribution of the women receiving the information from the

ASHA regarding the above mentioned issues. Approximately more than 50% of the women

report that they have received information upon the diet breastfeeding and delivery care. Women

in Jharkhand have reported lowest percentages of information received on issues for example

upon danger signs only 7.7% and Family planning only 11%. Similarly in Orissa, women have

received information on all the issues above the national average, except Danger signs and

Family planning. Chhattisgarh has also reported very higher percentages of receiving

information on issues such as diet (75.3%), Delivery Care (69.4%), new born Care (63.8%) and

Breastfeeding (70.8%), all these values are higher than all other states under EAG. Comparing

all the areas we find that the highest percentage of the information was delivered upon the Diet

and then followed by the breastfeeding and Delivery Care. Since we can conclude that the both

28 | P a g e

the states i.e. Chhattisgarh and Orissa are having very high percentages of receiving information

from ASHA, though the performance of the latter is much better than that of latter.

III.3.3: Women motivated by the ASHA to become the Beneficiary of JSY/ Accompanied at

the Time of delivery and Stayed at health facility:

Table 2.4 explains the contribution of the ASHA for encouraging and motivating the women to

become the beneficiary of the JSY Scheme and take benefit of it. The highest percentages for the

motivation for JSY can be found in Uttar Pradesh, Bihar and Orissa respectively with 82.5%,

80.7% and 73.9%. Remarkable thing is that the national average is approximately around 44.8%

which is very low when compared to the percentages of these states. There are also some states

such as Rajasthan (32.6), Jharkhand (31.5%) and Madhya Pradesh (37.1%) where the proportion

of the women motivated by the ASHA for JSY is very low.

Those women accompanied during delivery by ASHA is maximum in the Uttar Pradesh (80.4%)

followed by Orissa with 73.4% and Bihar (72%). Similar to the women motivated for JSY lowest

percentages for the women accompanied during delivery were Rajasthan Jharkhand and Madhya

Pradesh. Thus we can conclude that though the performance may not be very good in the states

such as Uttar Pradesh and Bihar but then also role of ASHA is very fine in these states.

III.3.4 ASHA Registering the JSY cases

Table 2.5 explains the number of JSY cases registered by the ASHA in between 1st October till

31st December, 2008. Total number of cases has been divided into four parts as less than 10,

between 10-30, more than 30 and none. Of the total, maximum percentage of ASHA have

registered cases under less than varying from 73.1 in Orissa to 45 in Bihar. On the other hand

ASHA registering cases Between 10 to 30 Bihar is the only state having the maximum

percentage with 38.3 followed by Uttar Pradesh with 27.8 and at the bottom we have

Chhattisgarh with 8.3. Of the total cases registered a fine percentage went for the institutional

delivery in most of the states of EAG that too above the national level which is 67.7. Only two

states Chhattisgarh (54.2) and Jharkhand (40.8) fall below the national level and are also at the

lowest place among the EAG states. We can clearly see in the table that a maximum share of the

29 | P a g e

cases registered went to the CHC/SC/PHC for institutional delivery. In Bihar and Rajasthan the

cases is maximum with 88.5 followed by the Uttar Pradesh (86.2). At the lowest level Jharkhand

stands with 46.7. After CHC/PHC/SC the women were taken for delivery at any Government

Hospital which is 26.2 at the national level and at Orissa it is around 30.6. Those women who

went to the private clinic and NGO’s for the institutional delivery Jharkhand has the maximum

percentage of 10 which is approximately 2.5 times more than the national level of 3.7. Women in

most of the states were either taken to the CHC/SC/PHC or Government hospital for delivery,

rest the share of private clinics and NGO is very Low.

Table 2.5 Logistic regression results showing the pattern of maternal health utilization in EAG

states along with the role of ASHA as providing advice for it. In this table along with the

institutional delivery and TT Vaccine JSY has been also taken, since the primary objective of

this table is to show the significance of ASHA in promoting these services. In the table 1.2 the

variables are same and their results are more or less similar to this table so the independent factor

of ASHA providing advice only have been explained with the output results. Those women who

have taken advice from ASHA are taken as the reference category. With regard to the

institutional delivery those women who have not taken advice from ASHA are approximately 52

percent less likely to deliver at institutions. In other words we can also imply it’s almost half

when compared to the women who are taking advice from Health activist. In the similar way

talking about the women who are not taking advice from ASHA are .462 times less likely to

receive TT vaccine than those who are taking advice from the ASHA. And finally taking the

JSY, we can find the similar results i.e. a woman is approximately 50 percent less likely to adopt

or be a beneficiary of the JSY scheme and take benefit of it if she is not taking advice from

ASHA. Through this table we can conclude apart from knowing about ASHA taking advice from

her can bring significant changes in the improvement of the maternal health of the women. Since

the ASHA is the local resident of the village her roles of counseling and providing Advice is

very essential.

30 | P a g e

Chapter IV

Analysis and Discussion:

31 | P a g e

Chapter IV

Analysis and Discussion:

If we look upon the areas in which the ASHA reported areas for intervention which may help her

to function well and strengthen the healthcare utilization at the grassroot level. According to the

table 2.7, Majority of ASHA reports that highest percentage falls in the category of requirement

for more training (59.9) followed by Fixed payment and requirement of more funds with (49.1)

each. States demanding for more training are Uttar Pradesh and Rajasthan with maximum

percentage of 68.3 and 68.1 respectively. At the lowest level Bihar exists with 34.9. Regarding

the payment at time and requirement of more funds Uttar Pradesh with 58.4 and 52.5

respectively and at the bottom Rajasthan stands with 24.8 and 14.2 respectively.

People must understand that good health is an important asset of livelihood and illness a major

cause of impoverishment. After analyzing all the data and interpreting it the discussion starts

with the status of Jharkhand which is at the bottom of all the EAG states. There are several

reasons for the poor performance of the Jharkhand such as the poor infrastructure of the Health

system. In the whole state required sub centre are 5057 but in position there are only 1099, which

is almost one fifth of the total requirement. Similarly there are only 330 primary health centre

and falls short of 476 in total.

The condition of the CHC is not good but compared to SC and PHC its condition is at better

place i.e. on the requirement of 201 CHC, 194 are functioning. Along with this, Health assistant

(Female)/LHV at PHC’s, Physicians at CHC and pediatricians at CHC are completely missing.

In the state, Nurse/ Midwife are around 429 which is almost three times less than the

requirement. Not avoiding the positive sides, requirement of male Health Assistant (PHC) is 330,

contrary to that 660 are in position and of 330 required doctors at PHC 330 are in position.

Similarly total required MPW worker (Female)/ ANM at sub centres & PHC is 4288 and in

position are 5011. (RHS Bulletin, March 2008, M/O Health & Family Welfare, GOI).

32 | P a g e

Similar is the case with Bihar which too is having poor infrastructure. Most importantly Health

Worker (MPW) at Sub-Centres lack as requirement is 8858 and functioning are only 1074. Bihar

is seriously missing the number of CHC, currently there are only 70 and total required numbers

are 622. Along with these there are severe lacking in the availability of Health Assistant (female

& male) at PHC’s and approximately more than 6000 Sub centre are missing in state.

Chhattisgarh is one of the youngest States of the Indian nation which was constituted on 1st

November 2000. Out of 18 districts of Chhattisgarh, 16 are high focus districts. As per the

population norms state require a total of 5049 Sub Health centres, 721 Primary Health Centres,

201 Community Health Centres, 18 District Hospitals and 6 Medical Colleges. Number of

institutions available in the state is 4741 SHCs, 719 PHCs, 143 CHCs, 18 District Hospital, and 3

Medical Colleges with overall deficit of 308 Sub centres, 2 PHC, 58 CHCs and 3 Medical

colleges. In terms of number of institutions and their geographical spread across the state is

reasonably good.

However, the 60% of Sub Health Centres, 50% of PHCs don’t have their own building.

Chhattisgarh is one of the state struggling with lack of skilled human resources. Though the

sanctioned posts by the department of Medical and Health is less than the population norms on

the top of it the vacancy of the staff ranges from 7.4 % for Staff nurses to 65% in specialists

cadre; though some of the positions are being occupied by the Post Graduate Medical Officers

providing specialist’s services. Irrational distribution of human resources adds to lack of

availability of specialists at the desired places. Women’s autonomy, as measured by the extent of

a woman’s freedom of movement, appears to be a major determinant of maternal health care

utilization. In other words we can see how the education has a positive relationship with the

utilization of the maternal health services. The similar kind of achievement can be also obtained

with the advancement in the social status of the women. Specifically in the areas which are

heavily and mostly dominated by the issues of patriarchy. Seven years of NRHM have made

impact on the health system; apart from rise in institutional deliveries. The Asha is a positive

feature of NRHM but it remains weak in training, accreditation, drug kit/refill, payment. This

reduces the activist (envisaged to be a committed worker) into a minion of the system; NRHM is

using the system of providing incentives for institutional births (and family planning). This is

33 | P a g e

neither sustainable nor wholesome. Home births will still be around for some time, and not

supporting dais is bound to hurt those home births seriously. Primary health care can be

sustainable, if embedded within broader development such as education, water and sanitation,

roads and transport as all these factors are inter-related and affect each other at several points.

34 | P a g e

Chapter V

Conclusion

35 | P a g e

Chapter V

Conclusion

India's economy is rising but health performance is rather low due to weak fundamentals like

nutrition, sanitation, hygiene, gender inequality, and helpless urban migration. The widening

India-Bharat divide has worsened these factors. In such a situation all pregnant women are at risk

and can develop various complications at any time during delivery, delivery and after delivery.

Institutional deliveries along with the other maternal health services are very crucial for both

mother and child. The cash benefit has helped to change the mindset of the people to prefer

institutional deliveries. According to the NRHM concurrent evaluation data women mostly

preferred to deliver at institute because of the money incentive which is provided to her.

According to the NRHM, 2009 almost more than 80 % women in Rajasthan and Bihar reported

that they accepted institutional delivery because of the incentive. In other words, the women still

lack knowledge and awareness about safe delivery. Then also considering only the increase in

the percentage of the institutional delivery, we are progressing. Yet slow and with diverse results

but the changes are occurring.

It is also important to mention that at the time of birth, presence of skilled healthcare personnel at

the institutes serves to provide better healthcare to the new born including immunization services

for BCG, polio and Hepatitis B. In almost all the EAG states we have found significant increase

in the institutional delivery pattern and approximately 85% women have received the TT

vaccine. Home based deliveries in majority are attended by the Dai’s and Friend’s/relative. If

some training programmes for the Dai (Trained birth attendant) are implemented under the

programme then we can have very huge increase in the percentage of safe deliveries. Table is

explaining explains the major cause for why the women do not prefer to deliver at institute. The

major cause for that was the unavailability of the Transport facility at the time of requirement.

The performance of Orissa is paramount among all as compared to the other EAG states in terms

of utilization of the Maternal Health services; on the other hand Jharkhand is the poorest state in

utilizing the health services.

36 | P a g e

The part of interstate disparity can be best understood in terms of availability and accessibility.

Evidence from Jharkhand, though sparse, suggests that rural women do not receive quality care

during pregnancy or childbirth. Most are not attended by a ‘skilled attendant’; they do not have

access to emergency obstetric care, or a referral system to ensure timely live saving care. The

recent jump in „institutional deliveries‟ is largely due to the introduction of financial incentives

to women from the government, and not due to significant changes in community awareness, or

in the improvement in levels of care in these institutions.

The poor cannot depend upon highly qualified people alone, to reduce maternal mortality and

morbidity. In order to save mothers lives we need to build upon the available resources in the

community – the women, their families, the traditional birth attendants, mobilizing and

organizing women’s groups. However highly qualified health care professionals are needed as

part of the referral system, to treat the obstetric emergencies. The community can be made aware

of the problems of childbirth, the dais can be taught to recognize emergencies.

Few poor village women are accessing any service from the government health system. Good

quality care, according to the perceptions of all (village women, doctors, health officials) is not

being provided. However there does not seem to be any expectation that the government ought to

provide quality health care. The government health personnel were found to be extremely

demoralized and frustrated. They themselves cannot convince the public to access their services,

since they do not feel they are providing a good service. There is a strong preference for home-

based delivery care amongst village women. The push for ‘institutional care’ in this situation

might not prove to be successful. The provision of infrastructure alone will not lead women to

the institutions.

There is a strong unwillingness of tribal’s in particular to access any institutional care, leaving

them vulnerable to exploitative and unscrupulous health care providers – both qualified and

unqualified. There are many misconceptions regarding the risks of contraception, though not of

abortion. Abortion is not provided in government hospitals in the district, even though this is an

important RH service.

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The identification of lack of transportation as a major constraint was identified by most women

in remote villages. This problem also prevents ANMs from visiting their health centres. While it

is true that health services should be made available to the intact population, there is a distinct

improvement in providing special services to mothers and children or making them the primary

focus of health services, especially when health resources are very limited. Improving maternal

and child health will reduce the number of medical consultation and hospital admissions due to

complications of pregnancy and childbirth and diseases among children. This will consequently

reduce the cost of medical care, disability & death, and the associated loss of productivity of

women and children who suffer disabilities or die.

The most valuable benefit that could be derived from improving maternal and child health is to

lessen the grief and suffering of countless families. If this is achieved, then it can be truly

claimed that quality of life has been improved.

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