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Utilization of maternal health care services and their determinants in Karnataka State, India Vidler, Marianne; Ramadurg, Umesh; Charantimath, Umesh; Katageri, Geetanjali; Karadiguddi, Chandrashekhar; Sawchuck, Diane; Qureshi, Rahat; Dharamsi, Shafik; Joshi, Anjali; von Dadelszen, Peter; Derman, Richard; Bellad, Mrutyunjaya; Goudar, Shivaprasad; Mallapur, Ashalata Jun 8, 2016

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RESEARCH Open Accessincluded their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poorquality of health care facilities, and the costs of care.Pregnancy,Vidler et al. Reproductive Health 2016, 13(Suppl 1):37DOI 10.1186/s12978-016-0138-8Research Unit, University of British Columbia, Vancouver, BC, CanadaFull list of author information is available at the end of the article* Correspondence: Marianne.vidler@cw.bc.ca1Department of Obstetrics and Gynaecology, and the Child and Familyensure a consistent power supply and improved cleanliness on the wards.Trial registration: NCT01911494Keywords: Pregnancy, Rural population, Hypertension, Maternal Health Services, Postnatal care, Prenatal care,High risk, India, Focus groups, Qualitative methods, Maternal Health Care UtilizationConclusions: Rural south Indian communities reported regular use of health care services during pregnancy and fordelivery. Uptake of maternity care services was attributed to new government programmes and increased availability ofmaternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-basedinitiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community informationregarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced toUtilization of maternal health care servicesand their determinants in Karnataka State,IndiaMarianne Vidler1*, Umesh Ramadurg2, Umesh Charantimath3, Geetanjali Katageri4, Chandrashekhar Karadiguddi3,Diane Sawchuck1, Rahat Qureshi5, Shafik Dharamsi6, Anjali Joshi3, Peter von Dadelszen1, Richard Derman7,Mrutyunjaya Bellad3, Shivaprasad Goudar3, Ashalata Mallapur4 and for the Community Level Interventions forPre-eclampsia (CLIP) India Feasibility Working GroupAbstractBackground: Karnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000live births, but lower than the national estimates of 190–220/100,000 live births. Various barriers exist to timely andappropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe thepatterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India.Methods: This study was conducted in Karnataka in 2012–2013. Purposive sampling was used to convene twenty threefocus groups and twelve individual interviews with community and health system representatives: Auxiliary NurseMidwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, Districthealth officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups andinterviews, these researchers were not known to community participants. All discussions were audio recorded,transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematicframework as well as inductive identification of themes.Results: Most women in the focus groups reported regular antenatal care attendance, for an average of four visits, andmore often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers.Participants reported that sought was care women experienced danger signs of complications. Postpartum care wasreportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women’s care-seeking© 2016 Vidler et al. Open Access This articleInternational License (http://creativecommonsreproduction in any medium, provided you gthe Creative Commons license, and indicate if(http://creativecommons.org/publicdomain/zeis distributed under the terms of the Creative Commons Attribution 4.0.org/licenses/by/4.0/), which permits unrestricted use, distribution, andive appropriate credit to the original author(s) and the source, provide a link tochanges were made. The Creative Commons Public Domain Dedication waiverro/1.0/) applies to the data made available in this article, unless otherwise stated.BackgroundHealth care utilization overall, and for maternal healthspecifically, has improved in India. Much of the progressmade has been attributed to the National Rural HealthMission (NRHM) that has increased the number of com-munity health workers and community level facilities, andresulted in more institutional deliveries [1, 2] (see Table 1).These community health workers (Accredited SocialHealth Activists, Auxiliary Nurse Midwives, Anganawadiworker, staff nurses) provide routine antenatal care in thehome or government run centres (sub-centre, primaryhealth centre, community health centre). Anganawadiworkers provide the most basic health services, whileAccredited Social Health Activists (ASHA) are facilitatorsfor care, providing prevention and education.The timing and frequency of visits in pregnancy andpostpartum is not well known, there is also a paucity inthe literature regarding the indications for which womenand families feel necessary to seek care and the culturalbeliefs guiding these decisions. Rural areas, such as thewhen it is accessed, its poor quality (such as shortages ofsupplies and staff, mistreatment by staff, or poor trainingor limited experience of staff ) [1, 3–9]. These have beendemonstrated overall and within Karnataka State, Indiaspecifically [1, 3].As suboptimal levels of utilization are considered tocontribute to poor maternal health, [1, 8, 10, 11], thisstudy was designed to explore the patterns of maternalhealth care utilization in rural Karnataka, as well as toidentify the barriers that must be addressed to raise levelsof that utilization with the ultimate goal of improving ma-ternal and perinatal outcomes. This study further contrib-utes to the literature by providing many community andhealth system perspectives. Previous studies have focusedon the perspectives of health care providers, pregnantwomen and at times husbands, seldom has research onthis topic included the views of other important decision-makers, particularly mothers-in-law.MethodsVidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 56 of 97study areas of Belgaum and Bagalkot, have poorer cover-age and access to maternal health care services and de-serve targeted review.Explanatory factors for under-utilization of maternalcare services are numerous, and include: young maternalage; religion (Muslims in Karnataka were less likely toreceive the recommended four antenatal visits); pooreducation; unskilled occupation; poverty; low caste; par-ity (higher birth order were less likely to access antenatalservices); lack of autonomy; poor familial support; lackof access to transport; and the high cost of care andTable 1 Site characteristicsIndiaSite characteristicsPopulation 1,236,687# States 35Dominant religion Hindu cWomen’s literacy 55 % cEmployment 36 % currently employed cRural/urban 32 % urban aFertility rate 2.8 cMaternal mortality ratio 178 per 100,000 live births bMaternal health care utilizationAny ANC 76.4 % c≥4 ANC 48 % cFacility delivery (%) 39 % cSkilled attendant at delivery 47 % caWorld Health Organization Country Profile: India 2012bOffice of the Registrar of India, 2013cDemographic Health Survey 2013dRural Health Statistics in India 2012Study settingThis qualitative study was conducted in two rural Dis-tricts of Karnataka State (Belgaum and Bagalkot) (Fig. 1)where women have higher birth order, lower maternalage, and are more likely to be illiterate than women inother southern states [3]. These differences reflect vari-able political commitment to maternal health, poor im-plementation of the NRHM, and decentralization ofservices [12].This study was conducted as part of a feasibility studyfor a cluster randomized controlled trial of a community-South India Karnataka61,130,704 dHindu c Hindu c68 % c 58 % c41 % currently employed c 40 % currently employed c39 % urban d1.9 c 2.1 c105 per 100,000 live births a 144 per 100,000 live births a94 % c 89 % c89 % c (3+) 76 % c (3+)79 % c 65 % c84 % c 70 % cVidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 57 of 97based treatment package for pre-eclampsia administeredby community health care workers in Karnataka State(NCT01911494) [13]. This formative research focused onexploration of the knowledge, attitudes and beliefs ofcommunity groups as well as facility assessments; the de-tailed methods are provided in [14].Data collectionData were collected from January to March 2013through focus group discussions and one-to-one inter-views with community members and health care pro-viders. Purposive sampling was used; focus groupparticipants were recruited by invitation of primaryhealth centre staff, some during routine antenatal visits.Each focus group was assembled separately by type ofrespondent with the exception of Auxiliary NurseMidwives (ANM) and staff nurses who participated to-gether. All focus groups were conducted in the local lan-guage, Kannada, at primary health centres which arefamiliar to participants and have minimal distractions.Fig. 1 Map of study sites, Karnataka State, IndiaAll concerned senior health administrators, private con-sultants, and obstetricians at teaching institutes were re-cruited for in-depth interviews. All interviews wereconducted in English. Local researchers conducted inter-views and focus groups, these facilitators have back-grounds in community or obstetric medicine andunderwent qualitative research training prior to thecommencement of the study. Interviewers were notknown to community participants. However, some inter-viewees had prior interactions with interviewers, thiswas avoided when possible. Interview participants wereprovided a small compensation for work time lost. Focusgroups discussions lasted on average 60–90 min, whileinterviews were 45–60 min.Focus group and interview guides were semi-structured and designed to focus on maternity careutilization and the challenges to it, key areas includedroutine antenatal care, pregnancy complications or dan-ger signs, delivery, and postpartum care, decision-making power, transport, and quality of services. Allwere emerging repeatedly; therefore no additional data col-principal investigators (MB, AM). This review included“No Dais working now, all that has decreased now”Vidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 58 of 97the identification of new and emergent themes as well asconfirmation of the data interpretation. At the time ofthis review, any misinterpretations of the data were cor-rected after review of the original transcript and groupconsensus was reached. Themes were developed andlection was done. Respondent characteristics within eachstakeholder group were relatively homogeneous but therewere some between group differences (Tables 2 and 3). Allcommunity health workers were actively providing care inthe community at the time of data collection.AnalysisAn a priori thematic framework was used as an initialguide and supplemented as novel themes emerged fromthe data (Fig. 2). English interview and focus group tran-scripts, after initial analysis and de-identification, weresent to the study co-ordinating office, University of Brit-ish Columbia (UBC), where they were reviewed andcoded by the study qualitative research manager (MV).Once coded, all transcripts were returned to the relevantlocal research teams at Jawaharlal Nehru MedicalCollege (JNMC), Belgaum and S Nijalingappa MedicalCollege (SNMC), Bagalkot. This stage was followed by adetailed review of the transcripts and preliminary ana-lysis findings between the coder (MV) and in-countrystudy co-ordinators (UC), focus group/interview facilita-tors and transcribers (GK, UR, SB, SB, CK), as well asdiscussions were audio recorded, photographs and fieldnotes were also taken. All recordings were reviewed toensure accuracy; responses were then transcribed verba-tim into English.ParticipantsA total of twenty-three focus groups were held with com-munity health workers (ANMs and staff nurses) (n = 48),Accredited Social Health Activists (ASHA) (n = 53), com-munity leaders (n = 27), male (n = 19) and female (n = 41)decision-makers, women of reproductive age (n = 132),and one with medical officers (n = 12) (Table 2). Twelveinterviews with two of each of the following stakeholders:medical officers (each of whom is responsible for one pri-mary health centre that usually serves as the entry pointto the health system), private consultants, senior healthadministrators, District health officers, and four obstetri-cians from tertiary level health care centres.Data saturation was judged to be sufficiently met in theplanned number of focus groups and interviews, as prelim-inary analyses revealed that similar themes and findingsgrouped to reflect wider concepts; to provide insight intothe subjective experiences of participants.[ANM/staff nurse]. Similarly, though many women usefolk remedies in pregnancy, the use of traditional pro-viders is rare – “In older times there were many suchpeople [traditional healers]”; “[pregnant women] arescared […] if they take such medicine […] and if some-thing goes wrong” [male decision-makers]; “NowadaysEthical approvalThis study was approved by the ethics review commit-tees at the University of British Columbia, VancouverCanada (H12-00132) and KLE University, Belgaum India(MDC/IECHSR/2011-12).ResultsMaternal health care utilizationAntenatal careThe timing of the first antenatal care visit varies;according to providers there is now a trend topresent earlier in gestation, by the end of the thirdmonth. Still, women described cultural beliefs thatimplore them to conceal pregnancies, this includesthe belief that one should not cross a river early inpregnancy: “It is a blind belief (superstition) [that it isbest] not to disclose” [ANM/staff nurse]. Identificationof pregnancies may be limited by availability of preg-nancy tests: “Many times ANMs or ASHAs do nothave a free supply of pregnancy kits” [ANM/staffnurse]. Women do not systematically track their men-strual cycle, and have difficulty recalling their lastmenstrual period; as a result, asymptomatic womenmay not know they are pregnant. ASHAs attempt totrack women of reproductive age in the communityto identify their pregnancies early, but are challengedby women’s concealment.Once the pregnancy is disclosed, women generally at-tend antenatal care. “During pregnancy we visit forcheck-up” [woman of reproductive age]. The frequencyof visits varies significantly between respondents, withwomen reporting an average of four antenatal care(ANC) visits. More visits are reportedly made near termand for those at high-risk of complications. Very few re-ported coming for fewer than three visits. This is congru-ent with and attributed to government programs andrecommendations: “Nowadays antenatal visits are morebecause of incentives” [medical officer]. Government pro-grams guided by the National Rural Health Mission in-clude cash incentives for antenatal care visits andinstitutional deliveries.Antenatal care occurs at all levels of the health system(public and private). In these communities, there is nolonger regular use of Dais (traditional birth attendants):[traditional medicines] are not used, they prefer hospitaltreatment” [female decision-makers].Table 2 Characteristics of focus group participants# NparticipantsAge (yr) Occupation Child <5 yr Pregnant Education Relationship towomanMedian[range]1.Housewife2.Labourer3.Employee4.Self-employed5.Other1.No formal schooling, cannot read orwrite2.No formal schooling, can read and write3.Primary school incomplete4.Primary school complete5.Secondary school incomplete6.Secondary school complete7.Pre-university incomplete8.Pre-university complete9.University incomplete10.University complete11.Postgraduate12.Don’t know1.Husband2.Father3.Father-in-law4.Mother-in-law5.Mother6.OtherCommunity leaders1 7 36 [31,48] 1 = (N = 1) Not asked Not asked 1 = (N = 1) Not asked2 = (N = 6) 6 = (N = 1)8 = (N = 2)10 = (N = 3)2 10 36 [24,51] 1 = (N = 3) Not asked Not asked 1 = (N = 1) Not asked4 = (N = 3) 3 = (N = 1)5 = (N = 4) 4 = (N = 1)5 = (N = 1)6 = (N = 3)8 = (N = 1)9 = (N = 1)10 = (N = 1)3 10 Not known Not known Not asked Not asked Not known Not askedMale decision-makers1 8 26 [18,57] 2 = (N = 4) NotapplicableNotapplicable1 = (N = 4) 1 = (N = 4)3 = (N = 1) 3 = (N = 2) 3 = (N = 2)4 = (N = 1) 6 = (N = 2) 6 = (N = 2)5 = (N = 2)2 11 49 [33,59] 3 = (N = 2) NotapplicableNotapplicable3 = (N = 4) 2 = (N = 4)5 = (N = 9) 5 = (N = 1) 3 = (N = 3)6 = (N = 1) 6 = (N = 4)10 = (N = 1)12 = (N = 4)Female decision-makers1 10 45 [30,60] 1 = (N = 9) NotapplicableNotapplicable1 = (N = 8) 4 = (N = 6)2 = (N = 1) 4 = (N = 2) 5 = (N = 2)6 = (N = 2)2 18 45 [28,65] 1 = (N = 5) NotapplicableNotapplicable1 = (N = 3) Not known3 = (N = 1) 2 = (N = 1)4 = (N = 1) 3 = (N = 1)5 = (N = 11) 12 = (N = 13)3 13 48 [30,65] 1 = (N = 13) NotapplicableNotapplicable3 = (N = 1) 4 = (N = 7)5 = (N = 1) 5 = (N = 1)Vidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 59 of 97Table 2 Characteristics of focus group participants (Continued)12 = (N = 11) 6 (N = 5)Women of reproductive age1 55 Not known Not known Not known Not known Not known Not known2 16 25 [20,30] 1 = (N = 16) 56 % 75 % 3 = (N = 3) Not applicable4 = (N = 1)5 = (N = 1)6 = (N = 2)8 = (N = 2)10 = (N = 1)12 = (N = 6)3 14 23 [18,30] 1 = (N = 9) 36 % 86 % 1 = (N = 3) Not applicable2 = (N = 5) 3 = (N = 3)4 = (N = 1)5 = (N = 1)6 = (N = 3)8 = (N = 2)10 = (N = 1)4 17 Not known 1 = (N = 17) 88 % 100 % Not known Not applicable5 14 22 [18,58] 1 = (N = 12) 71 % 50 % 3 = (N = 3) Not applicable3 = (N = 2) 5 = (N = 3)6 = (N = 3)10 = (N = 2)12 = (N = 3)6 16 20 [19,26] 1 = (N = 16) 69 % 63 % 3 = (N = 7) Not applicable4 = (N = 4)5 = (N = 1)6 = (N = 3)8 = (N = 1)Auxiliary nurse midwives and staff nurses1 8 36 [24,56] Not known Not asked Not asked 6 = (N = 3) Not applicable8 = (N = 1)10 = (N = 1)11 = (N = 3)2 9 41 [23,58] 5 = (N = 9) Not asked Not asked 6 = (N = 2) Not applicable7 = (N = 1)8 = (N = 3)10 = (N = 3)3 19 39 [25,58] SN (N = 7) Not asked Not asked Not known Not applicableANM (N = 10)4 12 30 [24,53] SN (N = 4) Not asked Not asked Not known Not applicableANM (N = 4)Accredited social health activists1 10 32 [26,36] Not known Not asked Not asked Not known Not applicable2 11 Not known Not known Not asked Not asked Not known Not applicable3 15 Not known ASHA (N = 15) Not asked Not asked Not known Not applicableVidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 60 of 97ComplicationsIt was widely agreed that care should be sought if awoman is at high-risk of complications or if she dis-played danger signs, such as eclampsia. The responsesfocused on what is recommended, which may not reflectthe reality of practice: “when a pregnant woman feelspain she should come to the hospital immediately”[ANM/staff nurse]. Almost all women in the area deliv-deliveries: “Nowadays women are all aware of medicalcare so they go to the hospital” [male decision-maker];“During delivery time also we go, we have to go” [womanof reproductive age]; “Everyone goes to the hospital”[woman of reproductive age]. Participants often attributedfacility birth to government financial and material incen-tives, such as small remuneration and basic items (Madilukit) for care of the newborn. An ANM/staff nurses inTable 2 Characteristics of focus group participants (Continued)4 17 33 [21,44] ASHA (N = 17) Not asked Not asked Not known Not applicableMedical officers1 15 Not known Not asked Not asked Not asked Not asked Not applicableareVidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 61 of 97ered institutionally and reported using services for compli-cations or emergencies. One woman described herfeelings regarding accessing services for emergencies:“[We] do not have any problem in going to hospital duringemergency, if [we] are not feeling alright then only they goto the hospital” [woman of reproductive age]. Generally, ifcomplications are perceived to be minor, women accesscare at the primary health centre; however, if they are per-ceived as more serious, care is sought at a higher-level fa-cility where specialists are available: “If it is severe we maytake her to the hospital” [community leader]. Much of thediscussion was related to pre-eclampsia and eclampsiaas this was a topic of interest for researchers andprobed directly: “I had fits in the home so I went to thehospital” [woman of reproductive age]. Bleeding andthe absence of fetal movements were also commonlymentioned as reasons for care seeking at the higher fa-cility: “If pain in the abdomen is there, if the fetus doesnot move properly” [woman of reproductive age].DeliveryMany women stated that they visit the hospital at the timeof delivery, supported by the high rates of facilityTable 3 Characteristics of interview participants# Stakeholder Training Level of c1 Medical officer MBBS Primary2 Medical officer MBBS Primary3 Private practitioner MD OBG Tertiary4 Private practitioner MBBS & MD OBG Tertiary5 Senior health administrator MS General Surgery –6 Senior health administrator MBBS & PG in OBG –7 District health officer Speciality DGO Secondary8 District health officer MBBS & Diploma OBG Secondary9 Obstetrician MD OBG Tertiary10 Obstetrician MBBS & DGO & MD Tertiary11 Obstetrician MBBS & Diploma OBG Tertiary12 Obstetrician MD OBG TertiaryBagalkot described the influence of these demand side ini-tiatives: “Women don’t deliver at home now at least for thesake of Madilu Kit” [ANM/staff nurse].PostpartumFew respondents mentioned postpartum health careutilization, during discussion of ‘when to seek care re-lated to childbirth’. When they did, care was usuallysought for newborn care or feeding difficulties: “If thebaby cannot breastfeed” [ANM/staff nurse]. Some com-munity health care providers stated that women rarelyaccessed services after delivery until the infant requiresimmunizations: “For immunization of the child” [womanof reproductive age].How providers encourage women to seek careHealth care providers have adopted a number of strat-egies to encourage women to better access services.Some providers stated that they offer to: accompanywomen to referral facilities, provide services in thehome, and supply financial assistance or even free ser-vices. In addition, providers stated that they encouragewomen to access appropriate and timely facility services,Pregnancies/Week Catchment pop Pre-eclampsia/12 months50–60 19,000 5–610–15 35,000 2040–50 200,000 50–100280–300 300–400,000 20–25– 1,950,000 –– 4,800,000 –200–250 25,000 12–2550–60 270,000 200–220250 Unknown 80–100200–300 300,000 500+45 Unknown 150–200– 800–900,000 15–17 %Vidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 62 of 97particularly for delivery. This health care information istargeted at the entire family, particularly husbands andmothers-in-law, regarding available facilities and services,possible pregnancy complications, and the importance ofantenatal care. One medical officer described the compo-nents of this education: “If you get a check-up, whatwill happen, if you don’t get a check-up, that we willtell and convince and will make them to come to thehospital. Calling the mothers-in-law and whatever re-lations they will be having call them and explain therisks and everything and what happens in the regularANC check up and take iron tablets” [medicalofficer].Determinants of health care utilization in pregnancy andpostpartumFig. 2 Thematic analysis structureDecision-making powerRespondents confirmed that the autonomy of women inpatriarchal Indian communities remains limited. Re-spondents almost unanimously claimed that womenhave restricted decision-making power concerning theirown health, and few mentioned that this may be chan-ging: “Nowadays [women] take their own decisions” [fe-male decision-maker]. Mothers-in-law and husbandshold the decision-making power, and they often resistfacility-based care: “The elders say why waste money ingoing to hospital, they can deliver at home without anyproblem” [ASHA]; “Sometimes elders in the family insistfor home delivery” [male decision-maker]. Stated reasonsfor this included the family’s history of successful homebirths, as described by many participants: “I delivered 10to 12 times without any problems, why she should go tothe hospital for delivery?” [ANM/staff nurse]; “Elderlypeople don’t allow them to go to the hospital as theythemselves delivered at home” [ASHA]. As a result,women who are home alone must wait for a designateddecision-maker before appropriate action can be consid-ered: “If nobody is home, she cannot go alone” [ANM/staff nurse]. This lack of familial support was reported tobe widespread and to prevent or delay care-seeking. Attimes, neighbours may stand in if the householddecision-maker is unavailable: “If family members havegone out […] and the pregnant woman is home aloneand she starts getting pains, neighbours should get her tothe hospital” [ASHA].Availability of transportCommunities in Karnataka reported awareness of ‘108’ -the robust ambulance system available free of charge foremergencies: “If we have to go to Bagalkot they provideambulance free of cost, previously it was not good, now itis good” [community leader]. The challenges expressedrelated to transport for routine care. Women may needto hire private vehicles, but some villages do not haveaccess to these as backup and some families cannot af-ford this. The price of private transport varies dependingon the mode, time of day and distance, some state it canbe as little as 100 Rupees (equivalent to $1.50 USD) andas high as 3,000 Rupees (equivalent to $47 USD). Manyrespondents stated that at the community level, fundsare available for transport for those below the povertyline. Aside from availability and cost, access was de-scribed to be further complicated by the terrain, withnarrow roads and villages at long distances from urbancentres. These were stated to be barriers to seekingtransport and care, particularly at night: “Nobody will bethere at night, in villages we don’t have access to trans-portation at night” [community leader].Quality of services and providersMost respondents stated they were satisfied with thequality of services: “All are happy about the quality”Vidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 63 of 97[male decision-maker]. However, some complainedabout the poor maintenance of facilities as a barrier.Specific issues raised included lack of sufficient staffingand inadequate infrastructure, such as unreliable powerand poor level of cleanliness: “We need more rooms, goodwater, consistent electricity, and also tea and food shouldbe given” [woman of reproductive age]. Also, facilitiesare reportedly short of the necessary medical equipment,materials, lab services, blood, and medications.The majority of participants stated that they had beenwell treated by health care staff: “Our health care providersspeak nicely and they see us calmly and solve any doubt wehave, we are happy for that” [woman of reproductive age].Previous experiences were mentioned as influencing awoman’s service utilization in a subsequent pregnancy:“Wherever they have faith, they will go; it is dependent ontheir belief. They would have gone repeatedly before andthey have felt good at that time” [community leader]. Trustand respect are essential qualities in a health care provider,according to women of reproductive age. Obstetriciansthemselves claim when women have trust in the doctorthey will come to facility.Financial constraintsRespondents indicated that the costs of health care inhibitwomen’s ability to access health care services: “Fear of costat facility makes them think twice” [ANM/staff nurse].These costs are related to transport, medications, services,lost wages, and food. Respondents reported that the costof delivery ranges from 500Rs (equivalent to $8 USD) upto 100,000Rs (equivalent to $1,570 USD). The cost of de-livery largely depends on the type of facility (govern-ment vs private) and the services provided (mode ofdelivery and associated complications). The commu-nity may provide financial support to women in needthrough women’s groups (Stree Shakti Sangh), GramPanchayat (local self-government), and governmentprograms. Those who qualify as below the povertyline are provided these subsidies and additional bene-fits to encourage appropriate care-seeking.DiscussionSeveral underlying factors have been identified to playimportant roles in maternal health care seeking: auton-omy, access to transport, quality of facilities, incentive-based programs and poverty. It has been shown thatwomen in rural areas present later in gestation whichmatches these findings [5, 15]. Previous research hasshown that women’s autonomy (decision-making powerrelated to her own health, buying household items, goingto stay with family, and access to funds) is low in Indiawhich influences utilization of ANC, delivery and post-partum examination [16, 17]. Similarly, this studyhighlighted the influence of husbands and mothers-in-law in the decision to seek care. Many of the responseselicited may reflect what should be done, and not the ac-tual behaviour of women.Health care providers and community members alikeclaim there is routine use of antenatal care, though thenumber of visits is sometimes insufficient. Nearly two-thirds of women complete four antenatal visits, as recom-mended by the World Health Organization [1, 3, 18].Two-thirds of women in Karnataka receive postnatal care[15]; however, as is true globally, most postnatal care isfocussed on the neonate [19, 20] and the percent womenwhom receive maternal care after delivery is unknown.This may reflect a societal prioritization of caring for theinfant and family over the mother. Case studies indicatethat a lack transport is associated with maternal deaths inKarnataka [7]. Health care facilities are reportedly in-adequate in Karnataka, with health personnel vacan-cies up to 52 %, weak information systems, lack ofcontinuity of care, haphazard referral systems and dis-torted accountability mechanisms [7].Efforts have been made to fill health service gaps withsubstantial success through free transport to facility,more community-based facilities, and financial subsidies.Further progress is, however, needed to avoid delays andensure utilization of postpartum care.As other studies have hypothesized the lack of suffi-cient progress on maternal mortality in India may be re-lated to the strong emphasis on utilization of specifichealth services, namely ANC attendance and institu-tional deliveries [7]. Emphasis must equally be placed onother health services along the continuum of pregnancyand postpartum as well as the barriers to their use.As with any study there are a number of strengths andlimitations of this study and the methods used. The back-ground of data collectors makes them well suited to con-duct and record discussions in these communities;however their prior interaction with some intervieweesmay have led to altered responses. Participants may havebeen inclined to respond more favourably or have beenhesitant to share concerns or faults. To minimize this so-cial desirability bias, the study provided a clear explan-ation that all information is confidential, and would haveno impact on their health care services or employment.The purposeful sampling approach may have resulted in askewed population as community members were recruitedthrough health staff and therefore those attending primaryhealth centres were more likely to be chosen for participa-tion; nevertheless, this approach was necessary due tobudgetary and time constraints. Self-reported behavioursare often less reliable, yet is a common approach toobtaining information about health care utilization. Repre-sentation from many community and health system stake-holders provided a holistic view of these communities andbreadth of beliefs and practices. The use of an a priorileaders for their participation and their efforts in motivating communityVancouver, BC, Canada. 7Department of Obstetrics, Christiana Care, Newark,Wallace DD, Sloan NL, Patel A, Hibberd PL, Koso-Thomas M. InstitutionalVidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 64 of 97framework for analysis is limited by the deductive natureof the approach; however, inductive identification ofthemes was also included to supplement this framework.The responses elicited about use of maternity services areconsistent with larger survey data from the area and withqualitative studies regarding the barriers to use of mater-nity care from other lower and middle income countries.ConclusionsSignificant barriers exist to timely maternity and post-partum care, particularly related to transport, perceivedquality of facilities, the cost of care, and the lack of rec-ognition that a large proportion of maternal morbidityand mortality occurs in the postpartum period. Thesefindings can be used for a number of purposes. Inad-equacies were raised regarding quality of hospitals, theseproblems have been identified on a broader scale [9] andshould be targeted by the health care system and admin-istrators to encourage quality maternity care throughtraining, hiring of additional staff and improvements tofacility infrastructure. While maternity care use is nearlyuniversal, timely care for complications and educatingwomen and decision-makers about the importance ofquality antenatal early in pregnancy and postpartum careshould be targeted and strategies to overcome barriersshould be developed through awareness raising pro-grams. Such strategies should be incorporated into fu-ture health care worker training, communityengagement activities, policy development and research.Although this study did not elicit information regardingdisparities in utilization, others have found there is acontinued need to overcome the barriers to utilization ofmaternity services among the most vulnerable groups,including culturally appropriate messages to target andengage them.Peer reviewPeer review reports for this article can be found inAdditional file 1.Additional fileAdditional file 1: Peer review reports. (PDF 1014 kb)AbbreviationsANC: Antenatal care; ANM: Auxiliary Nurse Midwives; ASHA: Accredited SocialHealth Activists; JNMC: Jawaharlal Nehru Medical College; NRHM: NationalRural Health Mission; SNMC: S Nijalingappa Medical College; TBA: traditionalbirth attendant; UBC: University of British Columbia.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsMV drafted the manuscript and conducted qualitative analysis. DS and RQcontributed to the conception and design of the study. PvD, SG, MB, RD,and AM provided critically important revision of the manuscript anddeliveries and perinatal and neonatal mortality in Southern and CentralIndia. Reproductive Health. 2015:12(Suppl 2):S13.4. Navaneetham K, Dharmalingam A. Utilization of maternal health careservices in Southern India. Soc Sci Med. 2002;55:1849–69.5. Srivastava A, Mahmood S, Mishra P, Shrotriya V. Correlates of maternalhealth care utilization in Rohilkhand Region, India. Ann Med Health Sci Res.DE, USA.Published: 8 June 2016References1. Kassebaum N, Bertozzi-Villa A, Coggeshall M, Shackelford K, Steiner C,Heuton K, et al. Akademin Hälsa och samhälle, Medicinsk vetenskap andHögskolan Dalarna. Global, regional, and national levels and causes ofmaternal mortality during, 1990-2013: A systematic analysis for the globalburden of disease study 2013. Lancet. 2014;384(9947):980–1004. doi:10.1016/S0140-6736(14)60696-6.2. Adamson PC, Krupp K, Niranjankumar B, Freeman AH, Khan M, Madhivanan P.Are marginalized women being left behind? A population-based study ofinstitutional deliveries in karnataka, india. BMC Public Health. 2012;12(1):30–0.doi:10.1186/1471-2458-12-30. 2012.3. Goudar SS, Goco N, Somannavar MS, Vernekar SS, Mallapur AA, Moore JL,participation. We thank the research office staff for assisting in data translationand transcription. Finally, a special thanks to all the focus group and interviewparticipants.DeclarationsPublication charges for this supplement were funded by the University ofBritish Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Preventionand Treatment) initiative supported by the Bill & Melinda Gates Foundation.This article has been published as part of Reproductive Health Volume 13Supplement 1, 2016: Community insights from four low- and middle-incomecountries into normal and complicated pregnancies. The full contents of thesupplement are available online at http://reproductive-health-journal.biomedcentral.com/articles/supplements/volume-13-supplement-1.Author details1Department of Obstetrics and Gynaecology, and the Child and FamilyResearch Unit, University of British Columbia, Vancouver, BC, Canada.2Department of Community Medicine, S Nijalingappa Medical College,Bagalkot, Karnataka, India. 3KLE University’s Jawaharlal Nehru Medical College,Belgaum, Karnataka, India. 4Department of Obstetrics and Gynaecology, SNijalingappa Medical College, Bagalkot, Karnataka, India. 5Division of Womenand Child Health, Aga Khan University, Karachi, Sindh, Pakistan. 6Departmentof Family Practice, Faculty of Medicine, University of British Columbia,interpretation of the data; in addition they provided final approvals. SDprovided critical intellectual input to manuscript development. UC, GK, UR,AJ and CK oversaw all data acquisition and analysis, as well as involvementin revision of the manuscript. All authors read and approved the finalmanuscript.AcknowledgementsThis work is part of the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by theBill & Melinda Gates Foundation. We gratefully acknowledge contributions ofthe Community Level Interventions for Pre-eclampsia (CLIP) India FeasibilityWorking Group: Shashidhar Bannale, Beth Payne, Zulfiqar Bhutta, Laura Magee,Chirag Kariya, Sharla Drebit, Sheela Naik, Sangmesh Rakkareddi, and AmitRevankar. We also acknowledge the support of KLE University, JN MedicalCollege, SN Medical College, University of British Columbia, Governmentof Karnataka, the district health administration of Belgaum and BagalkotDistricts, the local medical officers, staff nurses, auxiliary nurse midwives,accredited social health activists, and other health centre staff and community2014;4(3):417. doi:10.4103/2141-9248.133471.6. Bhatia JC, Cleland J. Determinants of maternal care in a region of southindia. Health Transition Rev. 1995;5(2):127–42.7. Bloom SS, Wypij D, Gupta MD. Dimensions of women’s autonomy and theinfluence on maternal health care utilization in a North Indian City.Demography. 2001;38(1):67–78. doi:10.1353/dem.2001.0001.8. George A. Persistence of high maternal mortality in koppal district,karnataka, india: Observed service delivery constraints. Reprod HealthMatters. 2007;15(30):91–102. doi:10.1016/S0968-8080(07)30318-2.9. Kumar C, Singh PK, Rai RK. Coverage gap in maternal and child healthservices in India: assessing trends and regional deprivation during 1992-2006. J Public Health. 2013;35(4):598.10. Pasha O, McClure E, Wright L, Saleem S, Goudar S, Chomba E, et al. Acombined community- and facility-based approach to improve pregnancyoutcomes in low-resource settings: a global network cluster randomizedtrial. BMC Med. 2013;11:215. doi:10.1186/1741-7015-11-215.11. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc SciMed. 1994;38(8):1091–110. doi:10.1016/0277-9536(94)90226-7.12. Bustreo F, Say L, Koblinsky M, Pullum T, Temmerman M, Pablos-Mendez A.Ending preventable maternal deaths: The time is now. Lancet Global Health.2013;1(4):E176–7. doi:10.1016/S2214-109X(13)70059-7.13. Smith SL. Political contexts and maternal health policy: Insights from acomparison of south Indian states. Soc Sci Med. 2014;100:46–53.14. von Dadelszen P, Magee MA, Payne BA, Bhutta Z. The CLIP (Community-Level Interventions for Pre-eclampsia) cluster randomized controlled trial.The Lancet. In Press.15. World Health Organization. Trends in Maternal Mortality: 1990 to 2013. 2014[in press].16. World Health Organization. WHO technical consultation on postpartum andpostnatal care. 2010.17. Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in ruralindia: a contextual analysis. Soc Sci Med. 2009;69(6):926–33. doi:10.1016/j.socscimed.2009.07.008.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services Submit your next manuscript to BioMed Central and we will help you at every step:Vidler et al. Reproductive Health 2016, 13(Suppl 1):37 Page 65 of 9718. Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the keyto maternal mortality. Int J Gynecol Obstetr. 1996;54(1):1–0.19. International Institute for Population Sciences (IIPS) and Macro International.National Family Health Survey (NFHS-3), 2005–06: India. Int Institute PopulatSci. 2007;1:195.20. Li X, Fortney J, Kotelchuck M, Glover L. The postpartum period: the key tomaternal mortality. 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