Abstract
BackgroundOver the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities.MethodsThis paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women’s experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities.ResultsThe exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust.ConclusionsThe results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices.
Highlights
Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system
While the scheme has persuaded women to begin accessing health facilities for antenatal services and delivery care, we find that the health system has not been able to adapt to women’s needs
The tribal approach to childbirth as a normal event In contrast to the government’s promotion of institutional delivery guided by the belief that every childbirth could potentially lead to complications, we found that in this community pregnancy and childbirth is perceived as a natural process, not requiring much external intervention
Summary
Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities. The percentage of mothers who had at least four antenatal care visits increased from 37% in 2005–06 to 52% in 2015–16 and the proportion of institutional births increased from 39% in 2005–06 to 79% in 2015–16 [3]. This overall improvement masks inequities across geographic and socioeconomic groups (Fig. 1). Successive rounds of the Annual Health Surveys (2010–11 and 2011–12) showed that 207 out of the 284 high focus districts remained in the same range of MMR [4]
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