Institutional Deliveries In India - A Socio Economic And Cultural View

Institutional Deliveries



A socio Economic and cultural view



In developing country like India with various cultures and with different languages and world largest country in population the impact of these social and cultural aspects on institutional deliveries is important as India has the largest no. of births in the world (27 million)and with high maternal mortality of 300-500 per one lakh births .this is about 20% of the global burden .hence progress in the reduction in the maternal mortality is crucial to global achievement of millennium development goal 5.There are so many factors influences the utilization of maternal health services  in India. The WHO and Magadi et al listed some obstacles for low utilization of delivery services, they are,



•        Distance from health services;

•         Costs, including user fees

•        The cost of transport,

•        Quality of care,

•        Drugs availability & Supplies

•        Attitudes of health personnel,

•         Multiple demands on women's time;

•         Women's lack of autonomy indecision-making.



Poverty plays an important role in utilization of maternal health services. There is a disparity in utilization of delivery services between   rich and poor countries as well as in individuals as evidenced by world bank report by Gwatkin et al. India with high growth rate and yet a developing country having significant number of BPL families , in spite of all the efforts made by  the Govt. and NGO agencies there are only 3 states having more than 75% of institutional deliveries (NFHS3).Poverty itself acts on poor utilization of  maternal services and also related to other causes which in turn influence the maternal health services like literacy, availability of health services .



Norms and beliefs in different parts of India affect significantly the health seeking behavior of women. In rural India there are some false beliefs like prolonged labor is a punishment for the past infidelity, and unassisted delivery is a sign of courage. Traditionally in rural India pregnancy is considered to be a natural state of being rather than a condition requiring medical attention and care. Such perception constrains a lay - health culture which is an intervening factor between the presence of morbidity condition and its corresponding treatment.(NFHS3). These traditional beliefs about child birth coupled with misconceptions fears of medical institutions, have led many women to maintain reliance on home births in India. (American Journal of Public Health 2006). Even in this high IT development and industrialization in some parts of India women rely on traditional birth attendant and some state govt. also supporting the TBA (mithani) system in Chattisgadh thus indirectly supporting the home deliveries.



Shame in the first birth and newly pregnant girls are expected to exihi9bit modest behavior by remaining calm in their vital condition and not talk at all about the pregnancy, the social pressure may create a major barrier to seeking antenatal care or delivering in hospital. Wall (1998 ).This is further strengthened by some religions and illiteracy , some cultures. these type of beliefs and norms are not only confined to India and also seen in some African and Latin American and south Asian cultures pain and illness are considered to be natural part of women , therefore it is deemed unnecessary to9 seek medical care including delivery care. (Ascadi and Johnson-Ascadi (1993)



Literacy has a strong association in utilizing the maternal health services. woman's education is a major factor affecting utilization of maternal health services in both north and south India (Govindasamy and Ramesh 1997). Literacy is also related with other factors like poverty and overcoming some old norms and beliefs and knowing herself about the physiology of pregnancy. when a girl is in studies it prolongs the age at marriage preventing early marriages which is associated with major problems like LBW,IMR and also contributing to the low utilization of maternity health services .(NFHS1,2,3). High levels of husbands' education increase the likelihood of health service (American   Journal of Public Health 2006)



In India transport cost and the opportunity cost of the patient and care givers where necessary have a significant negative impact on utilization of delivery care services. In real, most of the rural women in India land in a health care facility with advanced stage of labour or after developing the complications. This is also influenced by factors like transport availability, availability of care givers, distance from health care facility and the cost including the user fees. The wages lost to the accompanying pregnant women will play a major role in care givers and their attitude towards the pregnant lady delays the utilization of delivery services.



The quality of health care in India with shortage in human resource in health sector and the attitude of health personnel towards the patient and their higher absenteeism to the duties questioning the improvement of utilization of maternity health services. A woman with a complication is likely to delay or avoid accessing care from a health facility where she has experienced a good but disrespectful treatment in a previous normal birth. Hulton et al (2000) .This may be one of the cause, parity as it increases women are less likely to come to health care facility. The quality of care  has proved to have impact on utilization of maternity health services by those women who receive  one or more antenatal check-ups is the strongest predictor of institutional delivery.(NFHS2)



Rural mothers belonging to scheduled caste and scheduled tribe are much less likely to give birth in medical institutions than the others (NFHS2). This is associated with many other causes like accessibility ,customs , affordability to health care services .interestingly same religion having different levels of institutional deliveries in different parts of India as seen below. Muslim mothers are more likely than Hindu mothers to give birth in a medical institution in Andhra Pradesh and Gujarat, but Muslim mothers are much less likely than Hindu mothers to do so in Bihar and Rajasthan. (NFHS2) . There is a difference in utilization of health services scheduled caste and scheduled tribes between rural and urban areas. Scheduled caste and scheduled tribes mothers living in urban areas are more utilizing the maternal health services. According to the NFHS data there is a study growth in utilization of maternal health services in both rural and urban areas. Growth is more rapid in urban areas than rural but growth must be more in order to achieve IMR and MMR goals set by NRHM.





The inability of women in some developing countries to make decisions in relation to choice of medical care severely affects their choice of delivery care. A conflict between biomedical and traditionally perceived causes of health conditions also limits women's access to delivery care. Surprisingly woman's autonomy, as measured by decision making about her own health care, shows little association with institutional delivery in India. (NFHS2).



Institutional deliveries were also influenced like some demographic factors, some of them are, Increase in the Maternal age has a strong positive effect in utilizing delivery services, Increase in the birth order has a negative in the          maternal service utilization,(NFHS-2) in Andhra Pradesh,  53 percent of first-order births but only 24 percent of fourth or higher-order births took place in medical institutions. Unmarried pregnant girls are less likely to utilize the maternity health services. High fertility may also reflect a lack of reproductive health services and a lack of awareness of such services, both of which have obvious implications for maternal health service use. (American Journal of Public Health 2006). Working urban mothers are less likely to deliver in a medical institution than nonworking mothers.NFHS2.



The role of Mass media  should not be forget, Instructional delivery are higher for mothers who are regularly exposed to the electronic mass media than mothers who are not regularly exposed(NFHS2)



It's a bitter part that no political party is interested in maternal health and has maternal health on its agenda. If India wants to reach the NRHM goals it needs strong political commitment with more focus on health sector which it turn contribute towards "HEALTHY INDIA''

- Dr.V.Sudhakaram,M.B.B.S(PGDPHM)