PLACE OF DELIVERY AND ITS CORRELATES IN JANJGIR...

PLACE OF DELIVERY AND ITS CORRELATES IN

JANJGIR-CHAMPA DISTRICT, CHHATTISGARH: A

CROSS SECTIONAL STUDY

DIVYA FLORENCE G

Dissertation submitted in partial fulfilment of the

requirement for the award of the degree of

Master of Public Health

ACHUTHA MENON CENTRE FOR HALTH SCIENCE STUDIES

SREE CHITRA TIRUNAL INSTITURE FOR MEDICAL SCIENCES AND

TECHNOLOGY, TRIVANDRUM

Thiruvananthapuram, Kerala. India-695011

October 2017

i

Acknowledgements

“You never really understand a person until you consider things from his point of

view…until you climb in his skin and walk around in it”- Atticus Finch, To Kill A

Mockingbird

First I would like to thank the participants for opening up their homes and sharing

their stories with me who helped me understand them better.

I would like to express my sincere gratitude to my guide Professor Mala

Ramanathan for her patient guidance and encouragement throughout the study. She

has personified the word „systematic‟ and has taught me lessons beyond the

confines of a classroom for which I am eternally grateful.

I thank Dr K.R Thankappan, Dr V. Raman Kutty, Dr TK Sundari Ravindran, Dr P.

Sankara Sarma, Dr Srinivasan, Dr Manju Nair, Dr Biju Soman, Dr Ravi Prasad

Varma, Miss Jissa V and Dr Jeemon for their valuable inputs.

I thank Mr Nand, for his support in transportation by carefully navigating the mushy

roads so that I could reach the women in various villages and bringing me back

home safely every day.

I would like to thank Sajitha and Dhanashri for their help during the various stages

of dissertation. My parents, Elina and Sujith for being my support through hard

times.

Finally, I thank the Almighty for bringing me this far.

ii

DECLARATION

I hereby declare that this dissertation titled Place of delivery and its correlates in

Janjgir-Champa District, Chhattisgarh: a cross sectional study is the bonafide

record of my original research. It has not been submitted to any other university or

institution for the award of any degree or diploma. Information derived from the

published or unpublished work of others has been duly acknowledged in the text.

DIVYA FLORENCE G

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala, India -695011

October 2017

iii

CERTIFICATE

Certified that the dissertation titled “Place of delivery and its correlates in

Janjgir-Champa district, Chhattisgarh: a cross sectional study” is a record of

the research work undertaken by DIVYA FLORENCE G in partial fulfillment of

the requirements for the award of the degree of “Master of Public Health” under my

guidance and supervision.

Dr. Mala Ramanathan

Professor

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala, India -695011

iv

TABLE OF CONTENTS

LIST OF FIGURES

LIST OF TABLES

LIST OF ABBREVIATIONS

ABSTRACT

Chapter No Page No

Chapter 1 Introduction 1-4

1.1 Background 1-2

1.2 Rationale 3

1.3 Research Questions 3

1.4 Objectives 3

1.4.1 Major objectives 4

1.4.2 Minor objectives 4

1.5 Chapterization plan for dissertation

4

Chapter 2 Review of literature 5-14

2.1 Introduction 5

2.2 Period and search strategy for literature review 5-6

2.3 Indian scenario 6

2.4 Maternal health 7

2.5 Accessibility 8

2.5.1 Economical access and the place of delivery 8

2.5.2 Geographical access and the place of delivery 10

2.5.3 Relationship with the healthcare provider 12

2.6 Socio-cultural factors 13

2.7 Summary of review of literature

14

Chapter 3 Methodology 15-25

3.1 Study design 15

3.2 Study setting 15

3.3 Study population 15

3.4 Study subjects 16

3.4.1 Inclusion criteria for in-depth interviews 16

3.4.2 Exclusion criteria 16

3.5 Sampling strategy 16

3.6 Sample selection procedure 17

3.6.1 The sample frame 18

3.7 Data collection 19

3.8 Data collection tool 19

3.8.1 Quantitative component 19

3.8.2 Qualitative component 20

3.9 Variables and codes 20

3.9.1 Dependent variables 20

3.9.2 Independent variables 22

3.10 Data entry 24

3.11 Data analysis 24

v

3.12 Data storage 25

3.13 Ethical considerations

25

Chapter 4 Results 26-55

4.1 Characteristics of the respondents 26

4.1.1 Socio-demographic characteristics of the

households

26

4.1.2 Socio-demographic profile of the respondents 28

4.1.3 Selected village characteristics 29

4.1.4 Obstetric history 30

4.1.5 The intention to use institutional facility for

delivery and the events following labour

32

4.2 Factors associated with institutional delivery 36

4.2.1 Place of delivery and its associated factors 37

4.2.2 Place of delivery and obstetric history 40

4.2.3 Intention to have an institutional health care facility

for delivery and related activities

44

4.3 Reasons for „unplanned‟ home deliveries and

institutional deliveries: analysis of in-depth

interviews

48

4.3.1 Common themes identified 48

4.3.2 Reasons for home delivery 51

4.3.3 Reasons for facility delivery 53

4.4 Reasons for home and institutional deliveries

55

Chapter 5 Discussion and conclusion 56-61

5.1 Introduction 56

5.2 Summary of key findings 56

5.3 Factors associated with institutional delivery 58

5.4 Reasons for choice of place of delivery 59

5.5 Limitations of the study 60

5.6 Strengths of the study 60

5.7 Conclusions 60

5.8 Policy implications 61

References 62

vi

Annexures

Annexure I Checklist – English

Annexure II Research information sheet for interview schedule – English

Annexure III Research information sheet for in-depth interview – English

Annexure IV Informed consent for interview schedule – English

Annexure V Informed consent for in-depth interview – English

Annexure VI Assent form for interview schedule – English

Annexure VII Assent form for in-depth interview – English

Annexure VIII Questionnaire – English

Annexure IX Checklist –Hindi

Annexure X Research information sheet for interview schedule – Hindi

Annexure XI Research information sheet for in-depth interview – Hindi

Annexure XII Informed consent for interview schedule – Hindi

Annexure XIII Informed consent for in-depth interview – Hindi

Annexure XIV Assent form for interview schedule – Hindi

Annexure XV Assent form for in-depth interview –Hindi

Annexure XVI Questionnaire - Hindi

LIST OF FIGURES

Figure No Title Page No

1 Flowchart of review process to identify relevant material

for inclusion in the review of literature

5

vii

List of tables

Table No Title Page No

4.1 Socio-demographic profile of the households of women who

delivered during the past one year, Janjgir-Champa district,

Chhattisgarh, 2017

27

4.2 Socio-demographic profile of the women of women who

delivered during the past one year, Janjgir-Champa district,

Chhattisgarh, 2017

28

4.3 Profile of the of women who delivered during the past one

year by village level health care facilities, Janjgir-Champa

district, Chhattisgarh, 2017

30

4.4 Profile of the of women who delivered during the past one

year by their obstetric history, Janjgir- Champa district,

Chhattisgarh, 2017

31

4.5 Distribution of women who delivered during the past one

year by their intention to use an institutional facility for

delivery and their subsequent actions, Janjgir-Champa,

Chhattisgarh, 2017

33-34

4.6 Associations between intention to use an institutional health

care facility for delivery and actual place of delivery, Janjgir-

Champa district, Chhattisgarh, 2017

36


year by place of delivery and its individual, household and

village level correlates, Janjgir-Champa, Chhattisgarh, 2017

37-38


year by place of delivery and obstetric history, Janjgir-

Champa district, Chhattisgarh, 2017

41-42


year by place of delivery and the components of the intention

to have an institutional delivery, Janjgir-Champa district,

Chhattisgarh, 2017

45


year by place of delivery and actual events related to delivery

care, Janjgir-Champa, Chhattisgarh, 2017

46-47

viii

ABBREVIATONS

AHS Annual Health Survey

ANC Antenatal check-up

ASHA Accredited Social Health Activist

DLHS District Level Household Surveys

EAG Empowered Action Group states

GoI Government of India

HSC Health Subcentres

ICPD International Conference on Population and Development

IFA Iron and Folic Acid

JSSK Janani Shishu Suraksha Karyakaram

JSY Janani Suraksha Yojana

MDG Millennium development goals

MoHFW Ministry of Health and Family Welfare

NFHS National Family Health Survey

NHM National Health Mission

NRHM National Rural Health Mission

NUHM National Urban Health Mission

OOPE out of pocket expenditure

PHC Primary Health Centres

PI Principal Investigator

RCH Reproductive and Child Health programme

RMNCH+A Reproductive, maternal and child health including

adolescence

RSBY Rashtriya Swasthya Bima Yojana

SDG Sustainable Development Goals

TBA Traditional birth attendant

TT Tetanus Toxoid

WHO World Health Organization

ix

ABSTRACT

Introduction –Since the launch of national programmes like NRHM and the

introduction of the ambulance services for transporting patients, institutional

delivery rates have increased dramatically. However, there are several factors there

prevent women from utilising institutional facilities for delivery. This study aims to

identify some of the factors that hinder such utilization.

Methods - The study used a mixed methods approach including a community based

cross sectional study in Janjgir-Champa district. Women in the reproductive ages

15-39 who delivered in the past one year were recruited using multistage cluster

sampling strategy (N=392). Data collection used an interview schedule and in-depth

interview guide.

Results – About 14.3% (n=56) of all deliveries were home deliveries. Close to

85%of the women reporteda definitive intention to use a facility for delivery and

about 90 percent of them converted this intention to action. Younger age during the

first pregnancy, increasing birth order, women whose partners were daily wage

labourers, greater distance to a health facility (>9km) along with inadequate

maternity services were associated with non-institutional delivery. History of

pregnancy related accident and the positive influence of mitanin were the catalyst

for women to deliver in a health facility.

Conclusions- A small proportion of women intend to and do not reach and others

attempt to reach the facility and fail due to inadequate facilities in their

neighbourhood or greater distance to the nearest facility. This gap needs to be

bridged to ensure safe delivery for women who may as a consequence, have an

unsafe home delivery.

1

CHAPTER 1

INTRODUCTION

1.1 Background

Becoming a mother is considered an important role for women in most societies.

During the preparation of childbirth, women tend to make decisions either formally

negotiated or otherwise with regard to the childbirth (Cook and Loomis, 2012). The

choice of a woman‟s desired place of birth is an important determinant of the safe

delivery and the outcome of the childbirth experience. In developed countries, there

has been a near universal utilization of institutions for delivery, with a gradual shift,

in the recent years depicting a trend for preference of home delivery. This is

influenced by the availability of skilled health personnel and their ease of access to

a health facility in the event of an untoward outcome. In comparison to developed

countries, in developing countries, it is the decreased access to the skilled health

personnel and the poor infrastructure that govern the choice of place of delivery

(Anthony et al., 2005; MacDorman et al., 2011; WHO,2015.).

Since the Millennium development goals (MGD 5a, 5b) were established in 2000

focused on improving maternal health and universal access to reproductive health,

the maternal mortality ratio has reduced from over 500 in the period 1998-2000 to

174 in 2015 as per the World Health Organization, missing the target of 139 per

1,00,000 live births by 2015 (Open Government Data Platform India Blog, UN

Millennium Indicators,2015.). Currently, we are under the Sustainable Development

Goals (SGD) with the aim „to leave no one behind‟ and collectively all the health

2

goals are under goal 3 and the indicator for maternal health is to reduce the maternal

mortality to less than 70 per 1,00,000 live births (Koblinsky et al., 2016).

The Governement of India (GoI) launched the Janani Suraksha Yojana (JSY) under

the National Rural Health Mission (NRHM) in 2005, which was a conditional cash

transfer programme to facilitate the use of health institutions for delivery, which is

known as Janani Shishu Suraksha Karyakaram (JSSK) since 2011. Ambulance

services (102) were also introduced to improve access to the public health facility

for the maternal, newborn care services and thereby improving access to safe

delivery services (Janani Suraksha Yojana,2005.). National Urban Health Mission

(NUHM) was introduced to address the health concerns of the urban-poor, NRHM

and NUHM is collectively today known as National Health Mission (NHM) with

the aim to strengthen health systems and promote reproductive, maternal, neonatal

and child health and work towards achieving the SDGs( Shah,2016).

Since the introduction of these national programmes, the proportion of institutional

deliveries has increased from 38.7% in 1998-99 to 78.9% in 2016 as per the

National Family Health Survey (NFHS) round 4 (NFHS,2016 ; WHO,2015).

However, with all the efforts of the existing programmes to facilitate safe delivery,

institutional deliveries increased from 16 percent to 45 percent out of the 20

percent births that occurred in the poorest districts while in the richest districts it

increased from 40 to above 60 percent, indicating the disproportionate use of the

government schemes (Randive et al., 2014).

3

1.2 Rationale

In India, nine states accounted for 48 percent of the total population, 61 percent of

births and 62 percent of maternal deaths as per the Census 2011 and these states are

collectively called the Empowered Action Group states (AHSpr.pdf, n.d.). Among

these states, Chhattisgarh was reported to have the highest level of home deliveries

at 59.4 percent despite having the maximum number of women (83.9%) registering

for antenatal check-ups (ANC) as per the Annual Health Survey 2012-2013(Annual

Health Survey,2013.). Timely access to skilled health personnel and quality care

during pregnancy were found to reduce the maternal deaths as per World Health

Organization (WHO) (WHO, 2015.). But it seems in these states, inspite of the best

efforts by the state, the programmes are not as effective in increasing institutional

deliveries, as they are elsewhere. Therefore, the present study aims to identify the

extent of home deliveries occurring in Chhattisgarh, one of the EAG states and

identify the factors leading to it.

1.3 Research Questions

1. What proportion of all deliveries are home deliveries in this EAG state?

2. What are the individual, household and village level factors associated with

home deliveries?

3. What are the reasons for „unplanned‟ home deliveries?

1.4 Objectives

1.4.1 Major Objectives

In keeping with the research questions, the major objectives of this study are:

4

1. to estimate the extent of home delivery among the women in the

reproductive ages 15 – 39 years in the past one year (May 2016 – May

2017) in Janjgir-Champa district, Chhattisgarh and

2. to identify the individual, household and village level factors associated with

the occurrence of home delivery.

1.4.2 Minor Objective

A minor objective of the study is:

3. To identify the reasons for „unplanned ‟ home deliveries.

1.5 Chapterization Plan for Dissertation

The first chapter of this dissertation gives a brief overview of the introduction,

rationale, research questions and objectives of the study. The second chapter

includes the review of literature that is in keeping with the study objectives. The

third chapter describes the methodology used for the study. It outlines the study

design, population, sampling strategy and selection, data collection, entry and

analysis and ethical consideration. The fourth chapter explains the results along

with descriptive tables and binary analysis. It also discusses the results of the

qualitative exploration aimed at identifying the process that results in a home

delivery. The fifth chapter includes the discussion of the results, conclusions,

strengths and limitations of the study.

5

CHAPTER 2

REVIEW OF LITERATURE

2.1 Introduction

This chapter gives a summary of the literature reviewed to identify the factors that

influence the place of delivery globally, nationally at the individual and household

level for women. The main themes identified were accessibility to a health facility,

socio-cultural practices childbirth practices and individual preferences.

2.2 Period and search strategy for literature review

A literature search was done on Google Scholar and PubMed from the year 2000 till

2017.

Figure 1. Flowchart of review process to identify relevant material for

inclusion in the review of literature

*4 articles were not included since access to those articles were not available after writing

to the authors

The key words „home delivery‟, „facility delivery‟, „institutional delivery‟, „place of

childbirth‟, „place of delivery‟, „planned home births‟, „unplanned home births‟,

Search from PubMed and Google Scholar yielded

1382 results for articles dated between 2000-2017

344 relevant full text articles were selected after

reading through the abstracts

21 important articles identified* 6 articles included by

referring original sources

and expert recommendation

27 articles included for the literature

review

6

„accidental home births‟ was used to identify the articles. This was further

narrowed down to „home delivery India‟, „institutional delivery India‟, „home

delivery Chhattisgarh‟, „institutional delivery Chhattisgarh‟.

2.3 Indian scenario

India was one of the signatory of the International Conference on Population and

Development (ICPD) held in Cairo, 1994 which declared that population was

beyond numbers and women‟s health, education, employment and empowerment

vital to sustainable future(Roseman and Reichenbach, 2010). Since the introduction

of the ICPD, the Ministry of Health and Family and Welfare (MoHFW), India had

launched Reproductive and Child Health programme (RCH) which was a targeted

programme. The aim of RCH was to reduce maternal and infant mortality and total

fertility rates across the country. This was followed by the RCH phase-II with the

aim of achieving the Millennium Development Goal 5 (MGD) by 2015

(Implementation of Reproductive and Child Health Programme under Nation Rural

Health Mission,2015.).With RCH as a platform against the backdrop of MGD goal

5a, Reproductive, maternal and child health including adolescence (RMNCH+A)

was launched to address the causes of mortality among women and children

including the causes of delay and patterns of utilization of health care services

(Shah, 2015., Reproductive, Maternal, Newborn, Child and Adolescent Health |

National Health Portal Of India,2015.)

The year 2015 marked the end of the MDG era and the Sustainable Development

Goals (SGDs) was launched with the aim „to leave no one behind‟ which projected

7

its targets for 2030. Goal 3 of SGD to ensure healthy lives and promote well-being

for all, directly addresses health. Under this, the indicators for maternal health were,

3.1 - to reduce maternal mortality to 70 per 1,00,000 live births and 3.7- universal

access to sexual and reproductive health care services, including family planning,

information and education and integration of reproductive health into national

strategies and programmes (Sustainable Development Goals Fund, 2014, WHO,

2015.).

2.4 Maternal health

Maternal mortality ratio is an important indicator of maternal health and also the

quality of maternal health care services. The maternal mortality ratio as per

MoHFW in 2013 was 167 which missed the target of the 140 under MGD by a wide

margin. However, it is indicative of progress from 212 in 2009 (Achievements

Under Millennium Development Goals,2015.). Quality of maternal health services

can be assessed by the ease of accessibility to care and the effectiveness of

treatment received (Campbell et al., 2000; Nair and Panda, 2011). Accessibility to

health care services has three crucial entry points, viz. financial access or insurance

coverage, geographical access and relationship with the health care provider.

Maternal health largely depends on the timely and quality health care and is

influenced by the socio-demographic factors such as age, education, occupation,

social support and previous health status (Vega, 2013; WHO,2015.). The

accessibility and availability of health care services coupled with the socio-

demographic factors determine the choice of place of delivery.

8

2.5 Accessibility

2.5.1 Economical access and the place of delivery

Janani Suraksha Yojana (JSY), is a conditional cash transfer programme for women

availing antenatal, delivery through postpartum care in the healthcare facilities. For

women in the EAG states every institutional delivery is covered by the programme

while in the high performing states it covers the first two institutional deliveries

(Janani Suraksha Yojana - Guidelines for implementation - Ministry of Health and

Family Welfare, 2005). This programme is supplemented by Janani Shishu

Suraksha Karyakaram (JSSK), which provides cashless treatment for mother and

child (upto thirty days) including free transport during referral between the

healthcare facilitates and back to the place of residence from the healthcare

institutions(JSSK,2011.). Accredited Social Health Activist (ASHA) is a trained

female health activist who acts as a link between the health systems and the

community. In the state of Chhattisgarh, the female health volunteers are known as

Mitanin. They perform the same duties as ASHAs(Baghel et al., 2017).

Rashtriya Swasthya Bima Yojana (RSBY) is another health insurance programme

for families with income below the poverty line, which was started in 2008. The

RSBY programme covers a maximum of five members per household. While JSSK

is exclusive to women and children, RSBY provides insurance to men, women and

children. For the women, it covers normal and c-section deliveries that occur in the

institution and registration with name in the smart card are necessary

(RSBYPolicy,2013.).

9

Secondary data analysis of the District Level Household Surveys (DLHS-3) was

done to estimate the out of pocket expenditure (OOPE) across with the type and

place of delivery which reported that the mean OOPE associated with c-section was

eight times more than normal delivery. The average OOPE of a normal delivery in a

public health facility (1,624INR) was three times than a normal delivery at

home(466INR) and a normal delivery in a private institution was three times that of

a public health facility (4458INR)(Modugu et al., 2012a). The cash amount given to

a woman from the rural community who delivers in a healthcare facility is 1400INR

while for women from the urban area it is 1000INR (JSY guidelines,2011.).

People‟s assessment of health, education and livelihood (PAHELI), a household

survey done across eight districts of rural India, reported that out of the 48 percent

of deliveries that occurred in the government institutions, 94.5 percent of the

women were covered by JSY scheme by payments in the institutions (95%) and

cheques (86%) (Dongre and Kapur, 2013). The findings reported in the PAHELI

study were consistent with those of a study in Rajasthan, among the women who

delivered in the institution, where there was a universal coverage by the JSY

scheme and availability of JSY influenced the place of delivery (Sidney et al.,

2012).A study done in rural Haryana reported 2.7 times increase in the institution

deliveries since the introduction of JSSK in that locality within a five km distance

from the institution. The reasons for the utilization of health care institution for

delivery were the availability of ambulance services, benefits of the JSSK scheme

and the cordial behaviour of the healthcare staff (Salve et al., 2017). These studies

resonated with the findings of a study done in Ghana which reported that the

women who were covered by the national insurance scheme were more likely to use

10

healthcare institutions for maternal care when compared to the women who did not

have insurance coverage (Mensah et al., 2010).

A qualitative study done across three low performing states, reported that the net

value of JSY was less than the monetary and the intangible costs related to

institutional deliveries rendering it as a non-motivating factor for institutional

deliveries unlike the above mentioned studies. The JSY benefits were found to be

confined to the public institutional deliveries (43%) and one in every three women

who had a delivery in either public or private facility borrowed money for their

expenses. However, the motivating factor for institutional deliveries was the

influence of ASHAs in the community. If the women were convinced to use the

institution for delivery then the JSY acted as a catalyst. Therefore, JSY in itself did

not increase the proportion of institutional deliveries(Modugu et al., 2012b;

Vellakkal et al., 2017). About 70 percent of the women reported at least one visit

from the ASHA during their pregnancy, however, only 13 percent received support

from the ASHA while deciding the place of delivery (Sidney et al., 2012).

2.5.2 Geographical access and the place of delivery

The public health sector in India is based on a three tier model, primary, secondary

and tertiary centres. Health sub-centres cater to 3000 to 5000 population and is

manned by auxiliary nurse midwife or a female health worker, one male health

worker and a health visitor. The sub-centres provide maternal and child health care,

disease control and prevention. Primary health centres are the first point of contact

between physician and the community of 20,000 to 30,000 population. The private

health sector is unregulated and concentrated in the urban areas as compared to the

11

rural areas. This has led to a disparity in the accessibility of the health facility in

terms of geographical as well as economic access (India : International Health Care

System Profiles, n.d.).

A study in Brazil compared maternal health before and after the introduction of a

basic health unit which consisted of a team of health care professionals. The level of

medical assistance during childbirth increased from about 17 percent to more than

65 percent(Guimarães et al., 2016). A study in Nepal reported that economic access

did not influence the place of delivery but the distance and the availability of

transport services did along with the women‟s birth preparedness did; causing the

women to have a delivery outside the healthcare facility (Chaudhary, 2005).

A study done in Madhya Pradesh evaluated the effect of the availability of

ambulance services and the place of delivery. The median time spent waiting for the

ambulance was about two hours as compared to women who used their own

transportation (one hour) and women who hired a transport (1.25 hours). Time spent

in waiting for the transport was the most common reason reported for delay (70%)

and 13 percent reported poor roads or weather conditions as a reason for delay in

accessing healthcare (Sidney et al., 2014). Greater distance to the health facility,

poor availability of reliable transport and reduced availability of transport during off

hours were identified as barriers to seeking healthcare and justified the decision to

deliver at home (Bohren et al., 2014).

A study in Nepal reported that women tended to use a healthcare facility for

delivery with increasing level of education particularly secondary section and above

and who lived within a 30 minute distance from the health facility were twelve

12

times more likely to deliver in a health facility as compared to women who lived

more than 60 minutes away. The reasons for unplanned or accidental home delivery

were early start of labour, lack of transport or a facility nearby and the uncommon

reasons were family custom and others (Karkee et al., 2013).

2.5.3 Relationship with the healthcare provider

When the institutional health care is unavailable, the short term alternative is

ensuring availability of skilled birth attendant at the place of residence so as to

manage maternity related complications. In most developing countries, traditional

birth attendant is the main source of maternity care (Sibley and Ann Sipe, 2004).

Globally one in every five births occurs without assistance from a skilled birth

attendant. Traditional birth attendant (TBA) who has received a short course of

formal training through modern health sector to upgrade her skills is known as a

trained TBA.

A study in Matlab, Bangladesh reported the increase in institutional delivery

following behavioural change communication to the women during their antenatal

period regarding the danger signs of pregnancy which was implemented by the

health staff. Women with the knowledge of the pregnancy danger signs were 13

times more likely to deliver in an institution as compared to women who were

unaware of the danger signs (Rahman and Anwar, 2013).

A study in Odisha explored the influence of ASHAs in the maternal care for the

women. Women reported that the easy accessibility to ASHA for their antenatal and

post natal care were vital in creating awareness among the women about the

benefits like the JSY, available for the women by the government. However,

13

ASHAs also reported the barriers in their work such as unavailability of a van

devoted to JSY in the primary health centre. They also had to depend on the number

of pregnancies in the community for their pay which is not consistent with their

livelihood issues(Roy and Sahu, 2013).

One of the barriers to accessing the healthcare facility for maternal care is the fear

of mistreatment by the healthcare personnel. A systematic review by Bohren et.al

illustrated the negative experience of the women during their childbirth experience

in the healthcare facility. The various domains of the abuse experienced by the

women were verbal which the women expressed as rude or harsh behaviour,

physical, viz. pinching the women during the examination, inability of the women

to exercise their autonomy and the neglect (Bohren et al., 2015). This was found to

resonate with the findings of a study in Varanasi which reported the range of abuses

experience d by the women who accessed healthcare facility for maternal care

(Bhattacharya, 2015). These experiences also determine the potential utilization of

the healthcare facility by the women subsequently.

2.6 Socio-cultural factors

The availability of the healthcare services does not only influence its utilization. It

is also determined by the characteristics of the potential users. Andersen and

Newman identified societal, system and individual determinants as the influencing

factors for utilization of healthcare services. However, unlike the system

determinants; individual determinants such as age, educational level, birth order,

religion, economic status, directly influence the decision to utilize a healthcare

service(Andersen and Newman, 2005).

14

With increasing age, birth order increases. Primi mothers, education level above

secondary section of either spouse or mother and women who had a high standard

of living were found to have excellent use of facility for their delivery while women

who were older and had a higher birth order were found to have poor use of facility

for delivery (Sunil et al., 2006). Education of the partner was found to be positively

correlated with the utilization of healthcare facility for delivery. A meta-analysis

demonstrated that teenagers had a 1.7 to 3.4 times higher odds of using a health care

facility for delivery when compared to older women. Women from higher wealth

index were two times more likely to deliver in a health facility as compared to the

women from lower wealth index. This study is consistent with the findings from a

study in Haryana (Berhan and Berhan, 2014; Salve et al., 2017).

2.7 Summary of review of literature

As per NFHS-4, in Chhattisgarh, about 21 percent of the women were married

before legal age, nearly three fourth of all women in the reproductive age group had

at least one ANC but less than one fourth had completed their ANC visits, 63

percent of the women were beneficiaries of JSY and 70 percent of them utilized a

facility for their delivery (NFHS, 2016). Individual factors such as the age of

women at the first pregnancy, education of women, ANC coverage among mothers

and the awareness of government schemes available to the women including the

availability of the healthcare facility with their available resources and access to the

healthcare facility were explored in the literature review.

15

CHAPTER 3

METHODOLOGY

3.1 Study Design

The study used a nested mixed method approach for data collection. It had both the

quantitative and the qualitative components, as a single method would only satisfy

the major objectives of the study and not the minor ones. For the quantitative

component, a survey was used to estimate the proportion of home deliveries,

institutional deliveries and the „unplanned‟ home deliveries. Data collection used a

structured interview schedule. The variables to identify the factors associated with

the place of delivery were also obtained using the same interview schedule. The

qualitative component of the study used in-depth interviews to identify the reasons

for unplanned home delivery. These interviews were undertaken by using an in-

depth interview guide to facilitate the process.

3.2 Study Setting

The study was conducted in Janjgir-Champa district of Chhattisgarh.

3.3 Study Population

Target population: The target population consisted of all women in the reproductive

age group 15-39 years who had delivered in Janjgir-Champa district, Chhattisgarh.

The study aimed to generalise the findings to only this group.

Source population: Women in the reproductive age group 15-39 years who had

delivered in the past one year (1-May-2016 to 30-April-2017) in Janjgir-Champa

district, Chhattisgarh, were considered as the source population.

16

3.4 Study Subjects

The inclusion criteria for the survey was all the women in the reproductive age

group 15-39 years who had delivered in the past one year (1-May-2016 to 30-April-

2017) in Janjgir-Champa district, Chhattisgarh.

3.4.1 Inclusion criteria for in-depth interviews

Women from the survey who had a planned or an unplanned home delivery

were included for the in-depth interviews.

Women from the survey who fulfilled the intention to use a facility for

delivery were included for the in-depth interviews.

Among them, women who consented for the in-depths interview were

included.

3.4.2 Exclusion criteria

Women who died in childbirth or who were not in a mentally stable state for

the in-depth interviews were excluded.

Women who delivered out of the district for were excluded from the

interviews.

Women who did not consent for the in-depth interviews were also excluded.

3.5 Sampling Strategy

Sample size was estimated as 330 using OpenEpi Version 3, taking the prevalence

of home deliveries as 60% according to the Annual Health Survey 2012-2013,

absolute precision as 7%, design effect as 2 and 95% confidence interval.

Accounting for 20% non-response rate, the estimated sample size was 396 and

17

rounded to 400. The actual sample size was 392 and this corresponded with a

response rate of 91.8%. This was better than the expected rate of non-response.

3.6 Sample Selection Procedure

Sample selection was done using multistage cluster sampling. Janjgir-Champa

district consists of four municipalities, 11 nagarpalikas and 575 grampanchayats.

They were grouped into nine community development blocks and each block was

further divided into 892 revenue villages. The blocks had both urban and rural

villages. As per Census of India 2011, 86.1% of the district is rural and the total

population was 1,619,707(Census of India Website : Office of the Registrar General

& Census Commissioner, India, n.d.).

The list of villages along with the population for each village was collected and

grouped according to their blocks from Census of India 2011. The blocks were

numbered one to nine and using OpenEpi Version 3.03, randomly 4 blocks were

selected from the list. The selected blocks were Baloda, Nawagarh, Jaijaipur and

Bamnindih. From these selected blocks, the villages were listed and 14 villages

from each block were selected as per the random number generated by OpenEpi

Version 3.03. From each selected village, seven respondents who fulfilled the

inclusion criteria were interviewed. The seven respondents formed one cluster.

When the cluster size could not be achieved from a single village, then the

respondents were selected from the following village from the list of selected

villages until the required cluster size of seven was achieved.

18

3.6.1 The Sample Frame

District

Sample selection from the district

From each cluster, subjects were recruited using systematic random sampling. The

first household was identified randomly and from there in the clock wise direction

every third household was selected. If there were no women as per the inclusion

criteria the following household that had a woman in the inclusion criteria was

selected until the seven women were recruited from the village.

When there was more than one woman who fulfilled the inclusion criteria in the

household, the woman who had the most recent delivery was selected to reduce

recall bias. However, if there was one woman in the household who fulfilled the

inclusion criteria then she was recruited for the study if she consented to participate.

Women population in

the district 693245

4 municipalities

11nagarpalikas

575grampanchayats

Baloda

1 cluster = 7

subjects

14 villages visited

98 subjects

Nawagarh

1 cluster = 7

subjects

14 villages visited

98 subjects

Jaijaipur

1 cluster = 7

subjects

14 villages visited

98 subjects

Bamnindih

1 cluster = 7

subjects

14 villages visited

98 subjects

19

3.7 Data Collection

Data collection was carried out by the Principal Investigator (PI) from 20-July-2017

to 25-August-2017. A total of 615 households in 56 villages were visited. From

among these villages, 427 women who fulfilled the inclusion criteria were identified

and 392 women were recruited for the study after the consent was obtained. To the

extent possible, the cluster size was maintained within the village but when that was

not possible then the participants were recruited from the next village. Across the 56

villages, there were three villages where the cluster size could not be achieved and

participants were recruited from the next village until the cluster size was achieved.

Research information sheet was explained and provided to every participant.

To identify the participants, first, the women in the household were screened if they

fulfilled the inclusion criteria. All the women in the household were listed in the

screening list. If they consented to participate then the signature was obtained. If

they refused, then the reason was refusal was sought and noted.

During the survey, the respondents for the in-depth interview were identified and

permission was taken from them to re-contact them for an in-depth interview. After

the survey for each block was completed then the in-depth interview was conducted

in keeping with the convenience of the respondents. A total of six such interviews

were done.

3.8 Data Collection Tool

3.8.1 Quantitative component

Data was collected using an interview schedule, which was specifically developed

for the study. The interview schedule was initially developed in English then

20

translated to Hindi and back translated to English by an identified local person from

the community. Hindi version of the interview schedule was used as a reference but

the responses were marked in the English version. The interview schedule had five

sections that focused on the general information, household characteristics, which

captured the living environment of the respondents, village characteristics that

captured the availability of medical facility if any. Obstetric history included the

antenatal history, illness during pregnancy and the intention of the women to deliver

in a facility followed by their fulfilment of the intention for facility delivery and the

place of delivery.

3.8.2 Qualitative component

In-depth interview guidelines were used to capture the reasons for the selected place

of delivery. The guidelines were developed in English, translated to Hindi and back

translated to English. For the in-depth interview, the assistance of a local member of

the community was sought to better understand the local phrases. The same person

helped to translate all the six interviews.

3.9 Variables and Codes

3.9.1 Dependent variables

The dependent variables used in this study are detailed.

1. Women‟s intention to use facility for delivery was identified using the

following predictors:

Women who had two or more antenatal check-ups, received atleast

one dose of injection tetanus toxoid and was on iron and folic acid

supplements during the pregnancy.

21

Women who had an established relationship with the local health

worker or dai or mitanin.

Women who had decided their birth companion by name.

Women who knew the name of the health facility and who were

aware of the distance of the health facility from their place of

residence.

Women or the family of the women who made transport

arrangements to reach the health facility for the time of delivery.

Predictors for the women‟s intention to use facility for delivery included the place

of delivery as decided by the family or the women, reason to use the identified place

of delivery, intended birth companion for the women during labour, arrangements

for transport, clothes for both mother and child and the expenses related to delivery.

the intention to use a facility for delivery was measured as a score based on the

questions E13.1 to E13.8 in the interview schedule.

E13.1 Intention to deliver in a

facility

Yes= 1

No =0

E13.2 Intended place of

delivery

Options 1-5 = 1

Options 6/7 = 0

E13.3 Reason for the intended

place of delivery

Response favouring facility delivery = 1

Response favouring home delivery = 0

E13.4 Intended birth

companion

Options 1-6 = 1

Option 7 = 0

E13.5 Transport arrangements Yes = 1

No = 0

E13.6 Arrangements for

clothes (mother)

Yes = 1

No = 0

E13.7 Arrangements for

clothes (child)

Yes = 1

No = 0

E13.8 Financial arrangements Options 1 to 4= 1

If option 5 is indicative of making any financial

arrangement = 2

If option 5 is indicative of not making any

financial arrangement = 0

Option 99 in all question scored 0.

22

The maximum score was 10 and the minimum score was zero with the cut off as six

to determine the definitive intention to use an institutional facility for delivery care

and scores below six indicated no or inadequate intention to use an institutional

facility for delivery care. The variable used to capture the financial arrangements

was given a higher score than all the other predictors.

2. Place or site of delivery referred to delivery in the identified health facility

or home or the delivery enroute to or from the health facility.

3. Unplanned home delivery was the delivery that occurred out of facility

among the women who had intended to use a facility for delivery but could

not convert their intention to action.

3.9.2 Independent variables

1. Socio-demographic profile of the women - This included current age, age at

marriage, age at first pregnancy, educational status, occupation, community,

marital status and religion.

Age of the women was captured in completed years. It was regrouped into

two categories to examine its association with the outcome variable.

Education qualification of the women was initially coded as not enrolled in

school, not formally educated, primary (class I-V), secondary (class VI-X),

high school and over.

2. Household characteristics – it included the type of family, occupation of the

partner, decision makers for general and maternity related treatment and the

wealth index.

Type of family was classified as nuclear, joint and extended family.

23

o Nuclear family was defined as a family consisting of man and spouse

who lived along with their children.

o Joint family was defined as man and spouse living with their

children and including the parents of either the man or his spouse.

o Extended family was defined as man and his spouse living with their

children, along with the parents of either the man or his spouse and

including their siblings and the siblings‟ family.

Wealth index was modified from National family health survey- 4 (2015-

2016) household questionnaire. The highest possible score that could be

obtained was 25 and the lowest possible score was nine. This score was

regrouped as low, middle and high wealth index on the basis of percentiles

(National Family Health Survey, n.d.).

3. Village characteristics – it included the nearest health facilities, distance of

the health facilities from the residence of the participant which was

measured in kilometres, type of maternity services provided by the facilities

and the availability of trained birth attendant in the village.

Health facility was initially coded to identify the specific type of health facilities

like health subcentres (HSC), primary health centres (PHC), district hospital,

private hospital which were regrouped as government health facilities and private

health facilities for further analysis.

4. Obstetric history of the women captured information on gravidity, total live

births, place of previous delivery, antenatal history for the most recent

delivery and illness during pregnancy.

24

5. Events following the labour – It included the time labour started, time

women left their residence to go to the health facility, type of transportation

used to reach the health facility and the time spent on making transport

arrangements, total number of health facilities approached and the person

conduction delivery, mode of delivery, benefits of Janani Suraksha Yojana

(JSY).

3.10 Data Entry

Data was entered in Excel in a csv format and analysis was undertaken using IBM

SPSS version 21. Any form of identifiers such as name, address or any other

personal identifiers were removed and only the unique ID was used.

All transcripts for the in-depth interviews were entered in MS word after translating

them from the regional language to English.

3.11 Data Analysis

Data was analysed using IBM SPSS version 21. Univariate analysis was done to

describe the socio-demographic profile of the women, household and village

characteristics by the site of delivery, and the intention of the women to use health

facility for their delivery. Bivariate analysis was performed to find the association

between the identified independent variables and the outcome of interest.

The in-depth interviews were analysed using WEFT QDA version 1.0.1 to generate

codes.

25

3.12 Data Storage

All data sheets, consent forms, interviews schedules, audio recordings and

transcripts have been kept with the PI. Data will be preserved for a minimum of

three years following the completion of the study.

3.13 Ethical Considerations

The study was carried out after obtaining approval from the Ethics Committee of

SreeChitra Tirunal Institute for Medical Sciences and Technology (SCTIMST)

[SCT/IEC/1054/MAY-2017]. Permission to approach mitanin to identify mothers

was obtained from the Chief Medical Health Officer of the Janjgir-Champa district.

Written informed consent was obtained from every participant before the interview.

In the case of illiterate subjects, thumb impressions were obtained. When a

participant provided verbal consent but was hesitant to sign the consent form, a

witness signature was obtained by a person identified by the participant. The

interviews were conducted in an environment where the respondent felt secure and

comfortable. The information collected will be kept secure and not shared with

anyone during or after the interview. Care was taken to protect the identity of the

respondent; no identifiers were included in the data entry process, only aunique

code was used.

26

CHAPTER 4

RESULTS

This chapter consists of the results of the analysis outlined in the earlier chapter on

methodology. It includes the description of the women and their individual,

household and village level characteristics along with their intention to use a health

facility for delivery. This is followed by a description of the appropriate bivariate

analysis undertaken to identify the covariates for the outcome of interest, viz.

institutional delivery. The last section outlines the reasons for „unplanned‟ home

deliveries or institutional deliveries, as identified from the qualitative component of

the study.

4.1 Characteristics of the respondents

4.1.1 Socio-demographic characteristics of the households

A total of 615 households were visited among 56 randomly selected villages from

the four out of the nine blocks of Janjgir-Champa district, Chhattisgarh. Among the

households visited, 427 women were identified who met the inclusion criteria. A

screening tool was used to identify the women who fulfilled the eligibility criteria

of having delivered in the district in the past one year. If two or more women were

found to be eligible for the study, then the woman who had the most recent delivery

in the household was chosen for the interview. Seven such women were excluded

from the study in this process. If there was only one woman in a household who

delivered in the past one year then that woman was selected for the study after her

consent was obtained. Twenty eight women did not consent for the interview. The

27

most common reason for non-response was „time constraint since they had chhatti

puja‟ and the fact that no monetary benefits were being offered for participation.

The final sample size was 392 with a response rate of 91.9%. Table 4.1 illustrates

the socio-demographic profile of the households. All of the households were Hindus

in terms of religious denomination.

Table 4.1 Socio-demographic profile of the householdsof women who delivered

during the past one year, Janjgir-Champa district, Chhattisgarh, 2017

Socio-demographic profile

of the households

Categories N=392 (100%)

Community

Schedule caste

Schedule tribe

Other backward class

General

124 (31.6)

43 (11.0)

218 (55.6)

7 (1.8)

Religion

Hindu

392 (100)

Type of family Nuclear family 86 (21.9)

Joint family 202 (51.5)

Extended family 104 (26.5)

Occupation of the partner Daily wage earner 138 (37.2)

Private 213 (57.1)

Government 19 (5.1)

Student 1 (0.3)

Ration card holder None 63 (16.2)

BPL 299 (76.7)

APL 28 (7.1)

Wealth index* Low (9-14) 24 (6.2)

Moderate (15-20) 236 (60.5)

High (21 and above ) 130 (33.3)

*Wealth index was modified from NFHS-4 household questionnaire and recomputed.

A little more than half of the women were from the other backward classes (55.6%)

followed by the scheduled caste (31.6%). Half of the households lived in joint

families (51.5%). Partners had a private salaried job in 57.1% of the households and

37.2% were daily wage earners. Majority of the households (76.7%) had a BPL card

while 7.1% had APL and 16.2% of them did not have either BPL card or APL card.

28

Wealth index was based on the type of housing, ownership of the house, drinking

water facility available, distance from the source of drinking water, type of toilet

facility, lighting facility and fuel used for cooking available in the household and

ownership of any transport among any member of the household. The highest

possible score was 25 and the lowest possible score was 9. The scores were then

classified as low (9-14), moderate (15-20) and high (>25) wealth index. About

60.5% of the household were found to be in the moderate wealth index.

4.1.2 Socio-demographic profile of the respondents

Table 4.2 describes the socio-demographic characteristics of the respondents. The

mean age of the respondents was 24.4 years (sd 3.8) with a range of 18 to 38 years.

Table 4.2 Socio-demographic profile of the women of women who delivered

during the past one year, Janjgir-Champa district, Chhattisgarh, 2017

Socio-demographic

characteristics

Categories N=392(100%)

Age of the respondent 24 years and less 219 (55.9)

More than 24 years 173 (44.1)

Educational qualification

of the women

Not formally educated

62 (15.8)

Primary 78 (19.9)

Secondary 175 (44.7)

High school and above 77 (19.6)

Occupational status of the

women

Daily wage earner

159 (40.6)

Private 16 (4.1)

Government 5 (1.3)

Student 3 (0.8)

Homemaker 209 (53.3)

Marital status Currently married 359 (91.6)

Not currently married 33 (8.4)

Out of the 392 respondents, 15.8% did not receive any formal education. Of the

remaining women who did receive any form of formal education, 44.6% of them

received education up to secondary level. Just about more than half of the

29

respondents (53.3%) reported that did not do any work outside the household and

they were classified as homemakers. Among the other women, 40.6% of them were

daily wage earners and 4.1% of them held salaried private jobs.

Among the respondents, less than 10% were not currently married and that included

women who were widowed, divorced or separated.

4.1.3 Selected village characteristics

In this section, table 4.3 describes the availability of a health facility in the village

for delivery related services in terms of distance of the health facility from the

village and the type of maternity services provided as identified by the respondents.

The nearest identified health facility for maternity care by more than a third of the

respondents was the sub-centre (37.8%), 34.9% identified the primary health centre

and about 3.3% of them identified traditional healer as a health care provider. The

distance to the identified health facility for maternity services was categorized as

less than or equal to two kilometres and more than three kilometres and 62.2% of

them reported the identified health facility to be more than three kilometres away.

Among the identified health facilities, 83.4% of them provided all maternity,

antenatal to postnatal care services. Close to 70% of the women reported the non-

availability of a traditional birth attendant in the village round the clock.

30

Table 4.3 Profile of the of women who delivered during the past one year by

village level health care facilities, Jangir-Champa district, Chhattisgarh, 2017

Village characteristics Categories n (%)

Nearest health facility Sub centre 148 (37.8)

Primary health centre 137 (34.9)

Community health centre 44 (11.2)

Taluk hospital 10 (2.6)

Private hospital/clinic 34 (8.7)

Traditional healer 13 (3.3)

Anganwadi 6 (1.5)

Distance from the residence

to the nearest health facility

<=2 km

148 (37.8)

>= 3 km 244 (62.2)

Preference of health facility

for maternity care

Sub centre

69 (17.6)

Primary health centre 155 (39.5)

Community health centre 63 (16.1)

Taluk hospital 29 (7.4)

Private hospital/clinic 60 (15.3)

Traditional healer 16 (4.1)

Availability of maternity

services in the identified

health facility (n=391)

None/ ANC

65 (16.6)

All servicesa 326 (83.4)

24 hours availability of

traditional birth attendant

(n=380)

Yes

117 (30.8)

No 263 (69.2) aantenatal through postnatal care services

4.1.4 Obstetric history

Table 4.4 describes the respondents‟ obstetric history and the decision maker at

home for maternal care services. The mean age of women during their first

pregnancy was 20.02 years (sd 2.19) with a range of 15 to 29 and median at 20. The

age at first pregnancy was categorized as less than 18 years (11.2%), 18 to 21 years

old (70.2%) and more than 22 years old (18.6%). About a third of the women

(30.0%) had more than 3 live births and 43.9% of them reported to have delivered

31

at home during the previous pregnancy, meaning the pregnancy before the most

recent one.

Table 4.4 Profile of the of women who delivered during the past one year by

their obstetric history, Janjgir Champa district, Chhattisgarh, 2017

Characteristics Categories n (%)

Age at first pregnancy Less than 18 years 44 (11.2)

18 -21 years 275 (70.2)

22 and above 73 (18.6)

Gravidity 1 pregnancy 134 (34.2)

2 pregnancy 135 (34.4)

>= 3 pregnancy 123 (31.4)

Live births 1 child 163 (41.6)

2 children 143 (36.5)

>=3 children 86 (21.9)

Previous place of delivery Government facility 103 (40.4)

Private facility 40 (15.7)

Home 112 (43.9)

Antenatal checkup None /1 ANC 5 (1.3)

2 ANC 60 (15.3)

>= 3ANC 327 (83.4)

Injection TT received None/1 dose 37 (9.4)

2 dose 355 (90.6)

Iron and folic acid tablets

consumed

Daily for 3 months

159 (40.2)

2-3 months 92 (23.5)

1-2 months 82 (20.9)

Did not consume 59 (15.1)

Diagnosed illness during

pregnancy

Anaemia

137 (83.0)

Gestational diabetes mellitus 8 (4.8)

Pregnancy induced

hypertension

19 (12.0)

Decision maker for

maternity related

treatment

Father / father-in-law

67 (17.1)

Mother/mother-in-law 121 (30.9)

Partner 200 (51.0)

Self 4 (1.0)

Majority of the women reported having more than three antenatal check-ups

(83.4%) and they identified the anganwadi as the primary facility for their antenatal

check-up. However, 1.3% of them reported that they either had no ANC care or at

the most one antenatal check-up. A small proportion of the women reported that

they either received either one or no dose of injection tetanus toxoid during their

32

pregnancy, the most common reason being they had migrated to the other states to

work and during their work they hardly had any antenatal check-ups until they were

back home. Just about 40.2% of the women reported that they consumed the

prescribed iron and folic acid tablets daily for next three months whereas 15.1% of

the women never consumed iron and folic acid tablets due to the feeling of nausea

and actual nausea. Majority of the women (83%) were diagnosed to have anaemia

followed by pregnancy-induced hypertension (12%).

4.1.5 The intention to use institutional facility for delivery and the events

following labour

This section describes the intention of the women to use an institutional health

facility for delivery and the actions taken by the women from the time the labour

pains started. To capture their intention to use an institutional facility for delivery;

questions like the place they intended to use, reasons for choosing the identified

facility, arrangements for transport, clothes for both mother and baby and the type

of financial arrangements were noted and then were compiled to obtain a score. If a

women scored six and higher, then she was classified as having a definitive

intention to use institutional facility for delivery. The scoring method is described in

Chapter 3, Methodology.

33

Table 4.5 Distribution of women who delivered during the past one year by

their intention to use an institutional facility for delivery and their subsequent

actions, Janjgir-Champa, Chhattisgarh, 2017

Variables Responses N=392(%)

Intent to go to facility for delivery Yes 333(84.9)

Intended place of delivery Sub centre

Primary health centre

Community health centre

Taluk hospital

Private hospital

Home

68 (17.3)

140 (35.7)

55 (14.0)

24 (6.1)

53 (13.5)

52 (13.3)

Reason for choosing the place of

delivery

Not favouring facility delivery

Favouring facility delivery

73 (18.6)

319 (81.4)

Intended birth companion Mother/mother-in-law

Sister/sister-in-law

Partner

Friend/neighbour

Local dai

Mitanin

No one

137 (34.9)

62 (15.8)

26 (6.6)

4 (1.0)

5 (1.3)

135 (34.4)

23 (5.9)

Transport arrangements made Yes 111 (28.3)

Clean clothes arranged for mother Yes 382 (97.4)

Clean clothes arranged for baby Yes 373 (95.2)

Financial arrangements No arrangements made 46 (11.8)

Savings 140 (35.7)

Borrowings 85 (21.0)

Bank loan 4 (1.0)

Mortgaging property 22 (5.6)

RSBY 95 (24.2)

Total score for intention Not adequate intention for

facility delivery

Definitive intention for facility

delivery

62 (15.8)

330 (84.2)

Time labour pains began Morning 165 (42.9)

Afternoon 137 (35.6)

Night 83 (21.6)

Time of leaving house to go to

facility

Morning

134 (34.2)

Afternoon 132 (33.7)

Night 70 (17.9)

Did not leave house 56 (14.3)

Transport used (N=336) Own 57 (17.0)

Borrowed 101 (30.1)

Public 10 (3.0)

102 158 (47.0)

Waiting time for transport

(N=344)

108

Less than 1 hour

10 (3.0)

250 (72.7)

1-2 hour 80 (23.3)

34


their intention to use an institutional facility for delivery and their subsequent

actions, Janjgir-Champa, Chhattisgarh, 2017 cont’d…

Variables Responses N=392(%)

3-4 hours 11 (3.2)

More than 4 hours 3 (0.9)

JSY beneficiary Yes 262 (66.8)

Expenses met No expenses 227 (57.9)

Savings 78 (19.9)

Borrowings from the family 39 (9.9)

Loan from the bank 4 (1.0)

Mortgaging property 11 (2.8)

RSBY 33 (8.4)

Total facility approached (N=336) 1 278 (82.7)

2 48 (14.3)

>=3 10 (3.0)

Admission to the first facility

approached (N=336)

Yes

328 (97.6)

Person conducting delivery Doctor 83 (21.2)

Nurse 238 (60.7 )

Dai 25 (6.4)

Family member 26 (6.6)

MPHW 13 (3.3)

EMT 7 (1.8)

Mode of delivery Normal vaginal delivery 288 (73.5)

Episiotomy/instrumental 61 (15.6)

LSCS 43 (11.0)

Post natal follow up after out of

facility delivery (N=76)

Did not go to facility

62 (81.6)

Same day of delivery 14 (18.4)

Among the women who intended to use an institutional facility for delivery

services, 35.7% reported that they intended to deliver in primary health centre and

13.5% in a private hospital. Among all the government facilities available, primary

health centre was most preferred over the community health centres (14%) and

taluk hospitals (6.1%). About 15% of the women did not intend to use an

institutional health facility for delivery services. The reasons for not preferring an

institutional facility were the previous experience of a safe delivery within the home

and the inability to take care of the other children who were at home, fear that a

35

procedure will be performed on them while the reasons favouring facility delivery

were primi mothers, fear of complicated delivery, JSY benefits and the road

connectivity that had become better in the past two years. About 80% of the women

cited clear reasons favouring an institutional health facility for delivery. Most

women intended to for their mothers or mothers-in-law to be their birth-companion

(34.9%), followed by 34.4% of them who intended to take the mitanin as their birth-

companion. However, 5.9% of the women who reported that they had not chosen

any birth-companion. A small proportion of them reported that they made

arrangements for transport (28.3%) and over 95% of them reported that they kept

clean clothes for both mother and child ready to take to the hospital. For the

financial arrangements, most of the women reported that they had kept money from

their savings (35.7%), had borrowed from friends and family (21%) and 5.6% of

them reported that they mortgaged their property to money lenders to arrange for

any delivery related expenses. Majority of the women (84.2%) were found who had

a definitive intention to deliver in an institutional health care facility.

There is a trend seen with regard to time the labour started and time women left

their house to go to the facility. A higher proportion (34.2%) of the women left their

home during the morning hours (04:00-12:00) as compared to night (17.9%).

Mahatari express(which is an ambulance service for pregnant women), 102, was

utilized by 47% of the women to reach the facility. A greater proportion (72.7%) of

women reported that the time they spent to get any form of transport ready was less

than an hour while less than four percent of them reported that they spent more than

three hours getting transport arrangements ready. Close to two thirds of them (65%)

36

reported that they were beneficiaries of JSY and 8.4% of them used the RSBY to

meet the expenses related to delivery. Almost all (97.6%) women reported that they

were given admission in the first health facility that they approached and close to

15% of them approached more than 2 health care facilities for their delivery. Most

of the deliveries were conducted by a nurse (60.7%) and a small proportion of the

delivery was conducted by a emergency medical technician and multipurpose health

worker. Among the women who had a non-institutional delivery, 81.6% of them did

not go to a facility for a check-up. They did not perceive a need to go to a facility

because they had a normal vaginal delivery.

4.2 Factors associated with institutional delivery

Bivariate analysis was done to determine the association between the outcome

variable - place of delivery and selected individual, household, and village level

factors. Table 4.6 shows the associations between the intention to use an

institutional health care facility for delivery and the actual place of delivery.

Table 4.6 Associations between intention to use an institutional health care

facility for delivery and actual place of delivery, Janjgir-Champa district,

Chhattisgarh, 2017

Intention to use

institutional facility

for delivery

Place of delivery

Total

N=392

(100%)

Chi-square

p-value Non-institutional

delivery*

n (%)

Institutional

delivery

n (%)

No definitive

intention

46 (74.2) 16 (25.8) 62 (100)

<0.0**

Definitive intention 30 (9.1) 300 (90.9) 330 (100)

Total 76 (19.4) 316 (80.6) 392 (100) *-

this includes both home deliveries and deliveries enroute to and from the facility**

where p-value is

statistically significant

37

Place of delivery is categorized into institutional and non-institutional (home

delivery, delivery that occurred on route to or from the facility). Among the women

62 who had no definitive intention for facility delivery, 74.2% of them had a non-

institutional delivery and among the 330 women who had a definitive intention for

facility delivery, 9.1% of them had a non-institutional delivery. Identified intention

to use institutional facility for delivery was found to be associated with actual place

of delivery.

4.2.1 Place of delivery and its associated factors

Bivariate analysis, Chi-square test of association was done for the factors associated

with the place of delivery at various levels – individual, household and the village

level. The confidence interval was maintained at 95%. The independent variables

were regrouped to fewer categories so that none of the cell values were less than 5.

Table 4.7 gives the distribution of the various factors with the place of delivery.


place of delivery and its individual, household and village level correlates,

Janjgir-Champa, Chhattisgarh, 2017

Place of delivery

Correlates

Non-institutional

delivery* n (%)

Institutional

delivery n (%)

Total N

(%)

Chi-square

p-value

Age of the respondent

<= 24 years 36 (16.4) 183 (83.6) 219 (100)

>24 years 40 (23.1) 133 (76.9) 173 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.097

Education

Not formally educated 13 (21.0) 49 (79.0) 62 (100)

Primary level 18 (23.1) 60 (76.9) 78 (100)

Secondary 35 (20.0) 140 (80.0) 175 (100)

>=high school 10 (13.0) 67 (87.0) 77 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.417

Women’s occupation

Wage earning 37 (20.6) 143 (79.4) 180 (100)

Homemaker 39 (18.4) 173 (81.6) 212 (100)

38


place of delivery and its individual, household and village level correlates,

Janjgir-Champa, Chhattisgarh, 2017 cont’d

Place of delivery

Correlates

Non-institutional

delivery* n (%)

Institutional

delivery n (%)

Total N

(%)

Chi-square

p-value

Total 76 (19.4) 316 (80.6) 392 (100) 0.590

Community

SC/ST1

35 (21.0) 132 (79.0) 167 (100)

OBC/General2

41 (18.2) 184 (81.8) 225 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.498

Marital status

Currently married 72 (19.7) 293 (80.3) 365 (100)

Not currently married 4 (14.8) 23 (85.2) 27 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.533

Occupation of

partner

Daily wages earner

and others

40 (28.8) 99 (71.2) 139 (100)

Salaried3 34 (14.7) 198 (85.3) 232 (100)

Total 74 (19.9) 297 (80.1) 371 (100) 0.001**

Wealthindex4

Low 7 (29.2) 17 (70.8) 24 (100)

Middle 50 (21.2) 186 (78.8) 236 (100)

High 19 (14.4) 113 (85.6) 132 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.131

Nearest health

facility

Government hospital 62 (18.0) 283 (82.0) 345 (100)

Private hospital 14 (29.8) 33 (70.2) 47 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.055**

Distance to the

nearest facility from

home

< 9 km 63 (17.6) 294 (82.4) 357 (100)

>=10 km 13 (37.1) 22 (62.9) 35 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.005**

Maternity services

provided

None/ ANC5

19 (29.2) 46 (70.8) 65 (100)

All services 56 (17.2) 270 (82.8) 326 (100)

Total 75 (19.2) 316 (80.8) 392 (100) 0.024**

Availability of 24

hours delivery

services

Yes 50 (16.6) 251 (83.4) 301 (100)

No 23 (26.4) 64 (73.6) 87 (100)

Total 73 (18.8) 315 (81.2) 388 (100) 0.039**

39

*this includes both home deliveries and deliveries enroute to the facility, ** statistically significant, 1SC/ST is

schedule caste and schedule tribe, 2OBC means other backward caste, 3 salaried includes private and

government job, 4 wealth index was modified from the NFHS-4 household questionnaire and recomputed for

this study 5 ANC denotes antenatal check-up

The women were categorized in terms of current age as less than 24 years and more

than 24 years old since the mean age of the group was 24 years. Among the women

who were less than 24 years of age, 16.4% had a non-institutional delivery as

compared to 83.6% of them who had an institutional delivery. Education of the

women and the place of delivery although did not have any statistical significance it

showed a trend with increasing level of education the proportion of women who had

a non-institutional birth declined. The occupation of the women, ie, whether or not

they were wage-earning does not result in any variation in institutional delivery

rates, about one fifth of them (18.4% to 20.6%) (20.6%) had a non-institutional

delivery while majority of them had an institutional delivery. Again about one fifths

of the women, regardless of the community they belonged to had a non-institutional

delivery. Among the women who were not currently married, 14.8% of them had a

non-institutional delivery as compared to 85.2% of them who delivered in the

institution. However, while comparing in absolute number, majority of the women

from among those currently married delivered in the institution.

Two indicators at the household level have been used to examine their associations

with institutional delivery, viz., partners‟ occupation and household wealth index.

Among the women whose partners had a daily wage-earning job, 28.8% of them

had a non-institutional delivery while among the women whose partners had a

salaried job, 14.7% of them had a non-institutional delivery. Wealth index was

recomputed from NFHS-4 household questionnaire and categorized as low (9-14),

40

moderate (15-20) and high wealth index (>21). The lowest possible score was 9 and

the highest possible score was 25. In the low wealth index group 29.2% of the

women had a non-institutional delivery while in the high wealth index group, 14.4%

of them had a non-institutional delivery.

Out of all the women, 345 women identified a government facility to be nearest to

their place of residence. Out of the 345 women, 18% of them had a non-institutional

delivery and out the 47 women who identified private hospital as the nearest health

facility, 29.8% of them had a non-institutional delivery. Distance to the nearest

identified health facility was categorized as less than nine kilometres and more than

10 kilometres. Among the women who reported that the nearest health facility was

less than nine km, 17.6% of them had a non-institutional delivery and among the

women who reported that the nearest health facility was more than 10 km away,

37.1% of them had a non-institutional delivery. The available maternity services

were classified as none or only ANC services and all services. Among the women

who reported that the identified health facility provided all maternity services,

17.2% of them had a non-institutional delivery and 82.8% of them had an

institutional delivery. Three hundred and one women reported that the identified

health facility provided round the clock delivery care services, among whom 19.7%

of them delivered out of facility. The type of facility, distance and the availability of

maternity care services were found to have an association with the place of delivery.

4.2.2 Place of delivery and obstetric history

This section describes the distribution of women by their place of delivery and its

association with obstetric history. In the table 4.8, among the women who were

41

married before the age of 18 years, 23.9% of them had a non-institutional delivery

and among the women who were married after the 19 years of age the proportion of

women who had a non-institutional delivery was found to be 15.7%. The same

direction of association was seen with the age of the women‟s first pregnancy. The

women who had their first pregnancy before the age of 18, 29.4% out of 85 women

had a non-institutional delivery and while women who had their first pregnancy

after the age of 19 years 16.6% of them had a non-institutional delivery. Both age at

marriage and at first pregnancy were found to be associated with the place of

delivery.


place of delivery and obstetric history, Janjgir-Champa district, Chhattisgarh,

2017

Obstetric characteristics

Place of delivery

Total

n (%)

Chi-square

p-value Non-

institutional

delivery*

n (%)

Institutional

delivery

n (%)

Age at marriage

<= 18 years 42 (23.9) 134 (76.1) 176 (100)

>19 years 34 (15.7) 182 (84.3) 216 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.043**

Age at first pregnancy

<=18 years 25 (29.4) 60 (70.6) 85 (100)

>19 years 51 (16.6) 256 (83.4) 307 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.008**

Number of pregnancies

1 pregnancy 18 (13.4) 116 (86.6) 134 (100)

2 pregnancy 27 (20.0) 108 (80.0) 135 (100)

>= 3 pregnancy 31 (25.2) 92 (74.8) 123 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.057

Number of live births per

woman

1 live births 21 (12.9) 142 (87.1) 163 (100)

2 live births 29 (20.3) 114 (79.7) 143 (100)

>=3 live births 26 (30.2) 60 (69.8) 86 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.004**

Previous place of delivery

42


place of delivery and obstetric history, Janjgir-Champa district, Chhattisgarh,

2017 cont’d…

Place of delivery

Obstetric characteristics Non-

institutional

delivery*

n (%)

Institutional

delivery

n (%)

Total

n (%)

Chi-square

p-value



Home 39 (34.8) 73 (65.2) 112 (100)

Total 58 (22.7) 197 (77.3) 255 (100) <0.001**

ANC done1

No or 1 ANC 2 (40.0) 3 (60.0) 5 (100)

2 ANC 22 (36.7) 38 (63.3) 60 (100)

>=3 ANC 52 (15.9) 275 (84.1) 327 (100)

Total 76 (19.4) 316 (80.6) 392 (100) <0.001**

Injection TT received2

None or 1 dose 10 (27.0) 27 (73.0) 37 (100)

2 dose 66 (18.6) 289 (81.4) 355 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.217

IFA consumed3

Daily 27 (17.0) 132 (83.0) 159 (100)

2-3 months 18 (19.6) 74 (80.4) 92 (100)

1-2 months 11 (13.4) 71 (86.6) 82 (100)

Never 20 (33.9) 39 (66.1) 59 (100)

Total 76 (19.4) 316 (80.6) 392 (100) 0.015**

Illness during pregnancy

Anaemia 28 (20.4) 109 (79.6) 137 (100)

GDM/PIH4

7 (25.9) 20 (74.1) 27 (100)

Total 35 (21.3) 129 (78.7) 164 (100) 0.525

Preference of health

facility for maternal care



Total 76 (19.4) 316 (80.6) 392 (100) <0.001**

*this includes both home deliveries and deliveries enroute to and from the facility, ** statistically

significant, 1ANC is antenatal check-up, 2 injection tetanus toxoid, 3 is iron and folic acid tablets, 4

is GDM means gestational diabetes mellitus and PIH means pregnancy induced hypertension

Gravidity is the total number of pregnancy a woman has had. Among the 123

women who had more than three pregnancies 25.2% of them had a non-institutional

delivery while among the 134 women who had one pregnancy, 13.4% of them had a

non-institutional delivery. There is a increasing trend seen in the level of

43

institutional deliveries with number of live births with the institutional delivery rate

being 87.1% for women with one live birth and 69.8% for women with three or

more live births. A total of 255 women had more than one pregnancy and among

them, 112 women reported to have delivered at home during their previous

pregnancy and 103 women reported to have delivered in a government health

facility. Spontaneous and induced abortions and stillbirths were not captured during

the interview. Out of the 112 women who had their previous delivery at home,

34.8% of them had a non-institutional delivery and 65.2% of them had an

institutional delivery.

Majority of the women (327) reported to have more than three antenatal check-ups

during their pregnancy, 15.9% of these women had a non-institutional delivery and

among the women who had none or one antenatal checkup, 40% of them had a non-

institutional delivery. Thirty seven women reported that they received one or no

doses of injection tetanus toxoid (TT) during their pregnancy. The most common

reason stated for not receiving the appropriate number of TT doses was that the

women tended to migrate to other states for work and they hardly had any form of

medical checkup done once they realised they were pregnant. The common practise

was for them to return to their hometown for their delivery and they usually did so

during the last trimester and then they were administered the injection during the

check-up. Out of 37 such women, 27% of them delivered out of facility while

among the women who received two doses of injection TT, 18.6% of them had a

non-institutional delivery. Out of 159 women who reported to have consumed iron

and folic acid (IFA) tablets daily for three months, 17% of them had a non-

institutional delivery and out of 59 women who reported to have not consumed IFA

44

tablets, 33.9% of them had a non-institutional delivery. Anaemia was the most

commonly reported illness during pregnancy followed by other illness, 21.3% of the

women who were diagnosed with any illness during their antenatal period had a

non-institutional delivery while majority, 78.7% of them delivered in an institution.

Among the women who preferred a private facility for their delivery, 39.5% of

them had a non-institutional delivery. Gravidity, number of live births, ANC

including the doses of injection TT received, IFA consumed and the women‟s

preference of health facility were found to be associated with place of delivery.

4.2.3 Intention to have an institutional health care facility for delivery and

related activities

This section is divided into two parts. The first part illustrates the distribution of the

women by the place of delivery and the women‟s intention to use an institutional

health care facility for delivery and the second part describes the action taken by the

women and the family to implement the intention. Table 4.9 describes the

distribution of women who had delivered during the last one year by place of

delivery and the components of their intention to use an institutional health care

facility for delivery. There are eight components that collectively determine the

women‟s intention to use an institutional facility for delivery.

Except for the component that dealt with the arrangement of clean clothes for both

mother and child, all the other predictors were found to be associated with the place

of delivery. However, there is a chance that this is the resultant of post facto

rationalisation by the women.

45


place of delivery and the components of the intention to have an institutional

delivery, Janjgir-Champa district, Chhattisgarh, 2017

Components of the

intention to use an

institutional facility for

delivery

Place of delivery

Total

N=392

(100%)

Chi-square

p-value Non-institutional

delivery* n (%)

Institution

delivery n

(%)

Intention to go to

facility for delivery

<0.05** Yes 30 (9.0) 303 (91.0) 333 (100)

No 46 (78.0) 13 (22.0) 59 (100)

Intended place of

delivery

<0.05**



Home 44 (84.6) 8 (15.4) 52 (100)

Reason for choice of

place of delivery

<0.05**

Response favouring

facility delivery

46 (63.0)

27 (37.0)

73 (100)

Response not favouring

facility delivery

30 (9.4)

289 (90.6)

319 (100)

Intended birth

companion

<0.05** Known person planned1 59 (16.0) 310 (84.0) 369 (100)

No one planned 17 (73.9) 6 (26.1) 23 ()100

Transport

arrangements made

0.001**

Yes 10 (9.0) 101 (91.0) 111 (100)

No 65 (23.2) 215 (76.8) 280 (100)

Clothes arranges for

mother

0.960

Yes 74 (19.4) 308 (80.6) 382 (100)

No 2 (20.0) 8 (80.0) 10 (100)

Clothes arranged for

baby

0.851 Yes 72 (19.3) 301 (80.7) 373 (100)

No 4 (21.1) 15 (78.9) 19 (100)

Financial arrangements

made

<0.05**

No arrangements made 23 (50) 23 (50) 46 (100)

No arrangement needed

due to RSBY2

7 (7.4)

88 (92.6)

95 (100)

Arrangements made 46 (18.3) 205 (81.7) 251 (100)

*this includes both home deliveries and deliveries enroute to and from the facility, ** statistically significant, 1 = known person means any member that the woman identified by relation or name, 2 RSBY is Rashtriya Swasthya Bima Yojana

46

The second part of this section describes the actual events that took place following

the labour pains of the women. Table 4.10 describes the distribution of women by

place of delivery and the specific events of delivery care.


place of delivery and actual events related to delivery care, Janjgir-Champa,

Chhattisgarh, 2017

Events

Place of delivery

Total

n (%)

Chi-square

p-value

Non-institutional

delivery*

n (%)

Institutional

delivery

n (%)

Time mother left house for

the facility

NA1

Morning (04:00 – 12:00) 7 (5.2) 127 (94.8) 134 (100)

Afternoon (12:00 -07:00) 5 (3.8) 127 (96.2) 132 (100)

Night(07:00 – 04:00) 8 (11.4) 62 (88.6) 70 (100)

Never left 56 (100) - 56 (100)

Total 76 (19.4) 316 (80.6) 392 (100)

Transport used to reach

facility

<0.001**

Own/borrowed/public 2 (1.2) 166 (98.8) 168 (100)

102/108 ambulances 18 (10.7) 150 (89.3) 168 (100)

Total 20 (6.0) 316 (94.0) 336 (100)

Time spent on waiting for

transport to be arranged

<0.001**

< 1 hour 8 (3.2) 242 (96.8) 250 (100)

1-2 hours 13 (16.3) 67 (83.8) 80 (100)

>= 3 hours 7 (50.0) 7 (50.0) 14 (100)

Total 28 (8.1) 316 (91.9) 344 (100)

Total health facility

approached

0.823

1 facility 17 (6.1) 261 (93.9) 278 (100)

>=2 facility 4 (6.9) 54 (93.1) 58 (100)

Total 21 (6.3) 315 (93.8) 336 (100)

Admission to the first

facility approached

<0.001**

Yes 20 (6.0) 311 (94.0) 331 (100)

No 3 (37.5) 5 (62.5) 8 (100)

Total 23 (6.8) 316 (93.2) 339 (100)

Person who conducted

delivery

NA

Doctor/nurse 14 (4.4) 307 (95.6) 321 (100)

Dai/family member 51 (100) - 51 (100)

MPHW/EMT2

11 (55.0) 9 (45.0) 20 (100)

Total 76 (19.4) 316 (80.6) 392 (100)

47

Table 4.10 Distribution of women who delivered during the past one year by place

of delivery and actual events related to delivery care, Janjgir-Champa,

Chhattisgarh, 2017 cont’d…

Place of delivery

Events Non-institutional

delivery* n(%)

Institutionl

delivery n(%)

Total n

(%)

Chi-sqaure p-

value

Expenses met

No expenses/RSBY3

27 (10.4) 233 (89.6) 260 (100)

Savings 34 (43.6) 44 (56.4) 78 (100)

Borrowings/loan/mortgage 15 (27.8) 39 (72.2) 54 (100)

Total 76 (19.4) 316 (80.6) 392 (100) <0.001**

Mode of delivery

NA

NVD4

76 (26.4) 212 (73.6) 288 (100)

Instrumental/episiotomy - 61 (100) 61 (100)

LSCS5

- 43 (100) 43 (100)

Total 76 (19.4) 316 (80.6) 392 (100)

JSY beneficiary

<0.001**

Yes 27 (10.3) 235 (89.7) 262 (100)

No 49 (37.7) 81 (62.3) 130 (100)

Total 76 (19.4) 316 (80.6) 392 (100)

*this includes both home deliveries and deliveries enroute to and from the facility,** is statistically significant,

1=NA means chi-square test was not done for these variables, 2=MPHW means multipurpose health worker,

EMT means emergency medical technician, 3= RSBY means Rashtriya Swasthya Bima Yojana, 4=NVD means

normal vaginal delivery, 5=LSCS means lower segment caesarean section

Time, for this analysis was divided into eight hours durations as morning, afternoon

and night. There was also a group of women who had not left the house to go to the

facility for delivery. Since all the cell values were not complete, the chi-square test

for this variable was not performed. Among the women who left the house to go to

the facility in the morning, more than 90% of them delivered in the institution.

There is a trend observed in this variable, the number of women leaving the house

at night is considerably lesser than the number of women who leave the house at

morning to reach the facility. Majority of the women used ambulances services to

reach the facility, Mahatari express, 102, and 108. Out of 168 women who accessed

the ambulance services to reach the facility 10.7% of them delivered out of facility.

The time spent waiting for a transport to be arranged, was categorized as less than

an hour, 1- 2 hours and more than three hours. Among the women who spent less

48

than one hour waiting for the transport, 96.8% delivered in the institution. Among

the women who approached more than two health facilities for delivery, 93.1% of

them delivered in the institution. 94% of the 331 women were admitted to the first

health facility that they approached. Most of the women had either no expenses or

used RSBY to meet their expenses. Out of the women who had virtually no

expenses, 10.4% of them had a non-institutional delivery and among the women

who met the expenses through borrowings from the family, loan from the bank and

mortgaging, 27.8% of them delivered out of facility. Among the women who were

not beneficiaries of JSY, 37.7% of them had a non-institutional delivery. Admission

to the first facility approached, the mechanisms of meeting expenses and women

who were beneficiaries of JSY were found to be associated with place of delivery.

4.3 Reasons for ‘unplanned’ home deliveries and ‘institutional deliveries:

analysis of in-depth interviews

The objective of in-depth interviews was to explore the reasons for the „unplanned‟

home delivery. „Unplanned‟ home delivery is delivery that occurred out of the

facility for the women who had intended to use the hospital facility for delivery.

The narratives were carefully read through and the various reasons identified.

4.3.1 Common themes identified

A few themes were identified to be common across both groups of women and a

few were found to be specific.

Multiple pregnancies due to preference of a male child

One of the general themes identified was the multiple pregnancies due to the

preference of a male child. This led to the women to endure multiple pregnancies

49

until they had a male child. Among these women, many of them had a higher birth

order, did not have any pregnancy related accidents and attributed the birth of a

male child as a means to solution to existing problems.

“I have five children now. I did not have any miscarriages until now

(ekbaarbhimera pet khalinahihua). So I knew I did not have to do anything

different from the other times. But I was hoping it will not be a girl because I have

four girls already”- 25 year old mother of five

“I have four children but they are all girls. You know how it is here without boys in

the house- they say you do not have blessing (ashirvad)”. – 33 year old mother of

five

Financial constraints or poverty

“Because I was pregnant (garbhvat), this decision (migrate to Punjab for work) was

made even faster. We needed money for the delivery of the second baby. If

something should happen and we have to go hospital and then we don‟t have

enough money. Because of that if the baby dies it will be bad name (kalanaam) to

all of us” – 24 year old mother

“It is a foreign place. Nobody will help you. We were living in a plastic sheet house

in Srinagar. Everything is so costly and we are from there so ration (BPL card) will

not work. We were buying food and spending on check-up did not seem reasonable.

More over these women knew what they were doing. I did not have to worry”- 24

year old mother who did not have ANC till her seventh month of pregnancy.

“I mentioned this (pregnancy) to my neighbour and I think she told mitanin about

me. Mitanin came to my home and made me to take Injection TT (tika) from the

50

nurse in anganwadi. The nurse told me to get my blood tested for anaemia. I did not

have any money to go to hospital and I did not have time to go also.” – 24 year old

mother

Traditional beliefs and practices

The concept of Chhatti is universal among the study participants. Chhatti is a

festival which is held on the sixth day after the delivery for both mother and child.

It is organized so that the family can repay any help they received during the

pregnancy and pay homage to their deity.

“I drank it (root based concoction) soon after I reached home from the hospital. But

I did not wait for chhatti to take a bath. I took bath at home. On the day of chhatti I

went to pool to take bath. Everyone should do that (drink a root based concoction) it

is for the benefit of the baby” – 21 year old mother of one

“I took kacchadawai (root based concoction) for three days because it is rainy

season and I could get cold. Enough heat should be made in the body to stop me

from falling ill. On the sixth day I went to pool to take a bath before sun was up.

Then we had chhatti puja.” – 24 year old mother

“It is customary for women who have taken help from traditional birth attendant

(dai) and rural medical practitioner (gaonka doctor) not right after delivery but

during chhatti. It is the sixth day from the day of delivery (jajki). Then whatever the

dai and gaonka doctor demands has to be given or if they do not ask for anything

then the family gives whatever they can. Till chhatti women should not take a bath

but they just wash themselves with water and get the blood stains away.” – 25 year

old mother

51

4.3.2 Reasons for home delivery

Family support

Family support is equal to spousal support in the case of women from nuclear

families and in the case of women from joint families it is indicative of any support

from a family member. Mothers-in-law were identified as the usual source of

support for the women.

“My husband is not always around and does not earn enough to support the family.

Whatever he earns, he first spends on alcohol and most times he comes home angry

and he curses me. He does not know that I am pregnant (garbhvat). He will get

angry if he finds out. After I told my husband that I was pregnant (garbhvat), he

beat me and shouted at me. So I did not want him near my baby if it was a girl” – 25

year old mother who delivered at home

“My mother-in-law lives in the next house so she used to come with me to the

hospital (for check-up). Who goes with mitanin to a hospital? We have to go with

everyone but nobody comes with use except family.” – 33 year old mother who is

also a mitanin

“For my first pregnancy (jajki) I was new to the village and I did not know a lot of

people. I also did not know who to approach and what to do. My mother-in-law

took me to the traditional birth attendant (dai). My mother-in-law did not let me eat

many things like green vegetables (bhaji) and we used to eat a lot of potato. I did

not like that. So when I became pregnant (garbhvat) second time I first told mitanin

even before I told my mother-in-law about it” – 24 year old mother who delivered

at home

52

Preference of rural medical practitioner for maternal care

“I went to anganwadi to see the nurse. She was also angry with me because I did not

go the hospital. She gave me three blister packets of iron tablets. I did not take that.

I went to the rural medical practitioner (gaonka doctor). He gave me medicine

water to drink. I have been taking that whenever I feel kamzor. I have been going to

gaonka doctor because he knows one daiwho is very good at delivery. I have been

doing this for years.” -24 year old mother

“There is a clinic which is in the next village. People go over the hill to see him.

The doctor is good. He gave us for free (treatment). Since then we go to him if

anyone of us falls ill” -24 year old mother

Previous positive experience of home delivery

“My first child was born at home. So I was not worried about the place of delivery.

Even if it happened at home or at Kendra.”-24 year old mother

“ I have five children now. Not even once I had garbhpat (no incident of

miscarriage). So I know that I did not have to do anything different from the other

times.”- 25 year old mother

Attitude of the health personnel

“These days there are places to go to hospital. I do not know if they are open and

how people are but they do not understand what is important to us. I did not have to

be cut open to deliver my baby. But in the hospital they will not wait. They will cut

you open and pull the baby out. They will scare you by telling

53

yehnahikaorgetohbacchakharabhosaktahai. I did not do any of those things my

baby is fine” – 24 year old mother

“Only if you cannot do it (deliver) at home, you should go to hospital. You don‟t

know when they will cut you open. They do not wait for the head (of the baby) to

show. They always tell the mother zorlagao and how much can she do? If it

happens at home the kids are usually healthy than when it happens at hospital.”- 24

year old mother

4.3.3 Reasons for facility delivery

History of pregnancy related accidents

“ This is my second pregnancy. The first one bacchagirgayithi (miscarriage). It

happened when I was three months garbhvat. Then six months later I got

garbhvatagain. Then we went to community health centre and got checked again.

Initial plan was to deliver in government hospital but my husband was not

comfortable so he made arrangements to go to Janjgir in case of emergency. “- 21

year old mother

“I came to know I became pregnant because of morning sickness...we did a urine

test at home. We went to Korba and got it confirmed there. They did a lot of blood

tests and gave me medicines. It cost me more than 1500INR. They told me my

pressure is very high and the medicines were to control the pressure. My husband

used to take me to community health centre for check-up because it is free. My

lower body (thighs and legs) became so big. I couldn‟t wear chappals, if I wear

them there is marks on my feet after I remove them.”-19 year old mother

54

“ I was in Jammu the whole time before the delivery and I did not have any check-

up. I was scared that something will happen to the baby. I did not do sonography or

anything. After I came back home only I got injection TT and iron tablets. I had one

garbhpatafter my first pregnancy. I was scared for so many things. I did not want

anything to go wrong.” – 24 year old mother

Influence of mitanin

“Nurse tells the women to go home and she will conduct delivery at home. If I am

around I will take them to another hospital. The other mitanin and I usually take

primi mothers to jilla hospital or community health centre because first delivery is

more difficult. When there is facility for better care, cleaner place and you are

getting money also to deliver there...then if you are not using that I feel it makes no

sense.”- 33 year mother who is also a mitanin

“Mitanin told us to keep clothes ready for me and the baby and she will take us to

Dharam hospital. When the labour pains started, we informed mitanin and she

informed the ambulance driver. Mitanin does not take women to the subcentre or

primary health centre as the nurses are not very good there. They always shout at

the patients. They want to sleep at night and they don‟t clean bed after delivery.

They make us clean the bed.”-24 year old mother

Attitude of health personnel

“When we reached the hospital, the nurses cleaned me and cut the baby‟s nala and

checked the baby‟s weight. In the morning, they were asking about how many

injections I got during the pregnancy. My husband told that because we went to

work in Jammu we did not have any check-up. The nurses scolded my husband and

55

me. They told me that usually people die when they do not have any check-up.”- 24

year old mother

4.4 Reasons for home and institutional deliveries

The reasons identified for home deliveries were support of the family for a home

delivery and absence of spousal support in general, preference due to the

availability of a rural medical practitioner for maternal care by the women, positive

experience of previous home deliveries, fear of institutional procedures, and

negative attitude of health personnel from previous visits. The reasons identified for

institutional deliveries were history of pregnancy related accidents, positive

influence of mitanin and fear of untoward outcome as expressed by the health

personnel.

56

CHAPTER 5

DISCUSSION AND CONCLUSIONS

5.1 Introduction

The aim of the study was to estimate the extent of home deliveries out of all

deliveries and identify the factors associated with it. The study used a mixed

methods approach to estimate the extent of home deliveries and examine the

reasons for their occurrence.

5.2 Summary of key findings

The proportion of home deliveries out of all deliveries was (56)14.3 percent and the

proportion of institutional deliveries was 80.6 percent in the present study while the

proportion of institutional deliveries in Janjgir-Champa district was reported to be

62.4 percent as per the National Family Health Survey – 4 (NFHS-4). There seems

to be an increase in the proportion of institutional deliveries and this is a significant

increase when compared to the most recent district data (NFHS,2016.).

In this study the average age of the study participants was 24.4 years and about two

fifth of them (44.7%) had up to secondary level education and more than half of the

participants (53.3%) were homemakers. A little more than half of them were from

other backward classes (55.6%) and lived as joint families (51.5%). Majority of the

households had a BPL card (76.7%) and 63 (16.2%) of them had neither BPL nor

APL card.

The average age of the study group during their first pregnancy was 20.2 years. A

third of the women had more than three live births and about two fifth of them

57

(43.9%) had delivered at home during their previous pregnancy. Majority of the

women (83.4%) reported having more than three antenatal check-ups and 355 of the

392 women (90.6%) received two doses of injection TT while the proportion of

women who received ANC in Janjgir-Champa district as reported in NFHS-4 was

45.2% (NFHS,2016.). More than three quarter of the women 137 (83%) were

diagnosed to have anaemia during their pregnancy in the present study which is still

higher in comparison to a study done in rural Karanataka which reported 64% of

their study population as anaemic (Suryanarayana et al., 2016).

More than four fifth of the women reported having a definitive intention to use a

facility for delivery. Mahatari express, 102, was the most commonly used mode to

transportation to reach the facility for delivery and not more than three quarters of

the women had to wait for more than one hour to arrange a transport to reach the

health facility. More than three fifth of the women (66.8%) were beneficiaries of

JSY which was not very different from the study in Madhya Pradesh that reported

76 percent of the deliveries took place within the JSY(Sidney et al., 2012). This

could also indicate that most women had low wealth index and hence utilised the

JSY scheme to deliver in the institutional facility. Almost all the women were

admitted in the first health facility that they approached. About three quarters of the

women had a normal vaginal delivery. Among the women who did not deliver at a

facility, there was no difference in the proportion of deliveries conducted by the

traditional birth attendant and a family member. Among them (62) 81.6% of them

did not utilise a facility for follow-up after delivery. This is consistent with a study

among women who had home delivery reported that 51% of the women had an

58

unattended home delivery with post natal checkup while 48 percent of them had

home delivery without post natal checkup (Fadel et al., 2015).

5.3 Factors associated with institutional delivery

In this study, there was a decline observed in the proportion of women who had a

non-institutional delivery with increasing level of education and whose partners had

a salaried job. A study in the rural North India reported that there was not a

significant difference in the women‟s preference for a place of delivery and the

occupation of the spouse. However, 43 percent of the women whose spouses were

labourers had a home delivery(Sahoo et al., 2015). Non-institutional deliveries was

found to be directly proportional to the increasing distance to the nearest health

facility, the type of maternity services provided and the availability of full time

delivery services. A study in rural India reported that the probability of an

institutional delivery increased to 21 percent for the houses that were less than six

km from a health facility as compared to houses that were more than 31 km away.

This finding is in keeping with the present study where the proportion of

institutional delivery was 82 percent among women whose residence was less than

nine km from the health facility (Kesterton et al., 2010).

With increasing birth order there was an increase in the proportion of women

(30.2%) who had a non-institutional delivery. A study reported that women who

had a previous delivery in the institution were more likely to utilise institutional

facility for the subsequent delivery (Dixit and Dwivedi, 2017).Women who had a

previous home delivery and women who had less than three ANCs tend to have a

non-institutional delivery. Proportion of women who utilised the institutional

59

facility for delivery increased with readily available transport (98.6%), lesser time

spent on arranging transport (96.8%) and JSY benefits (89.7%). As per Census

2011, 52.2% of the women availed JSY assistance for institutional

delivery(NFHS,2016.). The results of the current study show that there is an

increase in the proportion of women covered by the JSY scheme in comparison to

the census 2011 data.

5.4 Reasons for choice of place of delivery

The findings of the in-depth interviews were consistent with a study done in

Karnataka, where ASHAs were seen as guides to facilitating access to health care

institutions and arrangement of transport (Bruce et al., 2015). In the current study

there was a common theme among narratives about the mothers‟ preference for a

boy child, which resonates with the findings from a study where about 45 percent of

women preferred a boy child over a girl child. However, the reasons for the

preference of a boy child was not explored but it led to women tolerating multiple

pregnancies due to the preference of a boy child (Pande and Malhotra,2006.).

Absence of support from family members and the need to provide for children were

also reasons for preferring home based deliveries. Women who did have

institutional deliveries seem to have done so either out of fear induced by adverse

events related to a previous pregnancy or under the influence of the local mitanin.

5.5 Limitations of the study

The study had a few limitations. First, the subjects were women who delivered in

the past one year and therefore there is a possibility of recall bias. Secondly, the

reasons for women who migrated out of the district for their delivery and the

60

women who died in childbirth were beyond the scope of the study. Thirdly,

multivariate analysis was not done as the independent variables had many

categories that could not be merged and the cell counts were less than five. Such

analysis would have yielded biased results.

5.6 Strengths of the study

The response rate of the participants was 91.9 percent as opposed to the expected

80%. Since the study was conducted by a single investigator, there was no inter-

observer bias. The findings of the study can be generalised to the women who are in

the reproductive age group in Janjgir-Champa district. This study used a mixed

method approach and was able to explore the reasons for the women‟s choice of

place of delivery.

5.7 Conclusions

The study identified the extent of home deliveries and the factors leading up to it. It

also explored the intention of the women to use a facility for delivery and the action

taken by the women based on their intention. The minor objective to identify the

reasons for unplanned home delivery was also explored.

Women who had their first pregnancy before 19 years of age, women with higher

birth order and poorer ANC coverage were more likely to have a non-institutional

delivery. The use of an institutional facility was found to be more among the

women whose spouses held salaried jobs and although not statistically significant,

with increasing wealth index the proportion of women who had institutional

deliveries increased. Among the women who had a definitive intention to use a

health care facility for delivery, 90.9 percent of them converted their intention to

61

action. However, there was a small proportion of women who intended to but were

unable to reach the facility due to the greater distance to the nearest health facility

and inadequate maternal services in their neighbourhood. Influence of mitanin and

history of pregnancy related accidents were found to have an influence of the choice

of place of delivery.

5.8 Policy implications

A large proportion of the women have been accessing the public sector for their

maternal care because of the availability of ambulance services and the coverage

under JSY. From the narratives, it was identified that there was a small proportion

of women who were refused admission to the health care facilities for various

reasons. Measures should be taken to strengthen the public sector so that the women

who access these facilities are not discouraged from the utilising them.

Nevertheless, there is still a small proportion of women who opted to deliver at

home for various reasons beyond their control and care should be taken to identify

such women – particularly those who have limited familial support, so that they

receive quality care by skilled health personnel so that there is reduced childbirth

related accidents and mortality.

62

References

Achievements Under Millennium Development Goals,2015. Available from:

http://pib.nic.in/newsite/PrintRelease.aspx?relid=123669 (accessed 24

October 2017).

Annual Health Survey press release, 2013. Available from:

http://censusindia.gov.in/vital_statistics/AHSBulletins/files/AHSpr.pdf

(accessed 8 October 2017).

Annual Health Survey, Chhattisgarh,2013. Available from:

http://www.censusindia.gov.in/vital_statistics/AHS/AHS_report_part1.pdf


Andersen R and Newman JF (2005) Societal and Individual Determinants of

Medical Care Utilization in the United States. The Milbank Quarterly 83(4).

Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690261/.

Anthony S, Buitendijk SE, Offerhaus PM, et al. (2005) Maternal factors and the

probability of a planned home birth. BJOG: An International Journal of

Obstetrics & Gynaecology 112(6): 748–753.

Baghel A, K. Jain K, Sachin P, et al. (2017) A study on awareness and practices of

mitanin (ASHA) in rural areas of Bilaspur district, Chhattisgarh, India.

International Journal Of Community Medicine And Public Health 4: 1637.

Berhan Y and Berhan A (2014) A Meta-Analysis of Socio-Demographic Factors

Predicting Birth in Health Facility. Ethiopian Journal of Health Sciences

24(0 Suppl): 81–92.

Bhattacharya S (2015) Nature and extent of reported disrespect and abuse by health

providers in facility-based childbirth among rural women of Varanasi

district, Uttar Pradesh. SCTIMST.

Bohren MA, Hunter EC, Munthe-Kaas HM, et al. (2014) Facilitators and barriers to

facility-based delivery in low- and middle-income countries: a qualitative

evidence synthesis. Reproductive Health 11: 71.

Bohren MA, Vogel JP, Hunter EC, et al. (2015) The Mistreatment of Women

during Childbirth in Health Facilities Globally: A Mixed-Methods

Systematic Review. PLOS Medicine 12(6): e1001847.

Bruce SG, Blanchard AK, Gurav K, et al. (2015) Preferences for infant delivery site

among pregnant women and new mothers in Northern Karnataka, India.

BMC Pregnancy and Childbirth 15: 49.

Campbell SM, Roland MO and Buetow SA (2000) Defining quality of care. Social

Science & Medicine 51(11): 1611–1625.

63

Census of India Website : Office of the Registrar General & Census Commissioner,

India (2011.). Available from: http://www.censusindia.gov.in/2011-

Common/Sample_Registration_System.html (accessed 18 October 2017).

Chaudhary P (2005) Accidental out-of-hospital deliveries: factors influencing delay

in arrival to maternity hospital.

Chhattisgarh_Factsheet_2011-12.pdf (2011).

Cook K and Loomis C (2012) The Impact of Choice and Control on Women‟s

Childbirth Experiences. The Journal of Perinatal Education 21(3): 158–168.

Dixit P and Dwivedi LK (2017) Utilization of institutional delivery services across

successive births in India. International Journal of Population Studies 2(2).

Dongre AA and Kapur A (2013) How is Janani Suraksha Yojana Performing in

Backward Districts of India? SSRN Scholarly Paper, Rochester, NY: Social

Science Research Network.

Fadel SA, Ram U, Morris SK, et al. (2015) Facility Delivery, Postnatal Care and

Neonatal Deaths in India: Nationally-Representative Case-Control Studies.

PLoS ONE 10(10).

guidelines_for_jssk.pdf. Available from: http://jknrhm.com/guidelines_for_jssk.pdf


Guimarães AS, Mantovani SAS, Oliart-Guzmán H, et al. (2016) Prenatal care and

childbirth assistance in Amazonian women before and after the Pacific

Highway Construction (2003–2011): a cross-sectional study. BMC Women’s

Health 16: 37.

IIPS (2016) NFHS-4, Chhattisgarh. Available from:

http://rchiips.org/NFHS/pdf/NFHS4/CT_FactSheet. (accessed 26 October

2017).

IIPS (2016) NFHS-4,Janjgir Champa.. Available from:

http://rchiips.org/NFHS/FCTS/CT/CT_FactSheet_405_Janjgir%20Champa.

pdf (accessed 23 October 2017).

Implementation of Reproductive and Child Health Programme under Nation Rural

Health Mission. Available from:

http://pib.nic.in/newsite/PrintRelease.aspx?relid=108357 (accessed 24

October 2017).

India : International Health Care System Profiles. Available from:

http://international.commonwealthfund.org/countries/india/ (accessed 24

October 2017).

India.pdf.

64

Janani Suraksha Yojana - Guidelines for implementation - Ministry of Health and

Family Welfare (2005). Available from:

ww.ilo.org/dyn/travail/docs/683/JananiSurakshaYojanaGuidelines/Ministryo

fHealthandFamilyWelfare.pdf+&cd=3&hl=en&ct=clnk&gl=in (accessed 24

October 2017).

Janani Suraksha Yojana - Guidelines for implementation - Ministry of Health and

Family Welfare.pdf.

JSY guidelines,2005.

Karkee R, Binns CW and Lee AH (2013) Determinants of facility delivery after

implementation of safer mother programme in Nepal: a prospective cohort

study. BMC Pregnancy and Childbirth 13: 193.

Kesterton AJ, Cleland J, Sloggett A, et al. (2010) Institutional delivery in rural

India: the relative importance of accessibility and economic status. BMC

pregnancy and childbirth 10(1): 30.

Koblinsky M, Moyer CA, Calvert C, et al. (2016) Quality maternity care for every

woman, everywhere: a call to action. The Lancet 388(10057): 2307–2320.

MacDorman MF, Declercq E and Menacker F (2011) Trends and characteristics of

home births in the United States by race and ethnicity, 1990–2006. Birth

38(1): 17–23.

Mensah J, Oppong JR and Schmidt CM (2010) Ghana‟s national health insurance

scheme in the context of the health MDGs: an empirical evaluation using

propensity score matching. Health Economics 19(S1): 95–106.

Modugu HR, Kumar M, Kumar A, et al. (2012a) State and socio-demographic

group variation in out-of-pocket expenditure, borrowings and Janani

Suraksha Yojana (JSY) programme use for birth deliveries in India. BMC

Public Health 12(1): 1048.

Modugu HR, Kumar M, Kumar A, et al. (2012b) State and socio-demographic

group variation in out-of-pocket expenditure, borrowings and Janani

Suraksha Yojana (JSY) programme use for birth deliveries in India. BMC

Public Health 12: 1048.

Nair H and Panda R (2011) Quality of maternal healthcare in India: Has the

National Rural Health Mission made a difference? Journal of Global Health

1(1): 79–86.

National Family Health Survey. Available from:

http://rchiips.org/NFHS/factsheet_NFHS-4.shtml# (accessed 19 October

2017).

65

Navaneetham K and Dharmalingam A (2002) Utilization of maternal health care

services in Southern India. Social science & medicine 55(10): 1849–1869.

Open Government Data Platform India Blog. Trends in Child Delivery at Health

Facilities (Institutional Delivery) across India from 2008-09 to 2012-13.

Available from: https://community.data.gov.in/trends-in-child-delivery-at-

health-facilities-institutional-delivery-across-india-from-2008-09-to-2012-

13/ (accessed 17 October 2017).

Shah P (2016) ORF_Occasional_Paper_103_RMNCH-. Available from:

http://cf.orfonline.org/wp-

content/uploads/2016/12/ORF_Occasional_Paper_103_RMNCH-.pdf


Pande R and Malhotra A (2006) Son Preference and Daughter Neglect in India.

Available from: https://www.unfpa.org/sites/default/files/resource-

pdf/UNFPA_Publication-39764.pdf+&cd=3&hl=en&ct=clnk&gl=in


Rahman A and Anwar I (2013) Behavior Change Communications during Antenatal

Visits Using Pictorial Cards Improves Institutional Delivery Rates: Evidence

from Matlab, Bangladesh. International Journal of Tropical Disease and

Health 3: 242–256.

Randive B, San Sebastian M, De Costa A, et al. (2014) Inequalities in institutional

delivery uptake and maternal mortality reduction in the context of cash

incentive program, Janani Suraksha Yojana: Results from nine states in

India. Social Science & Medicine 123: 1–6.

Reproductive, Maternal, Newborn, Child and Adolescent Health | National Health

Portal Of India. Available from: https://www.nhp.gov.in/reproductive-

maternal-newborn-child-and-adolescent-health_pg (accessed 24 October

2017).

Roseman MJ and Reichenbach L (2010) International Conference on Population

and Development at 15 Years: Achieving Sexual and Reproductive Health

and Rights for All? American Journal of Public Health 100(3): 403–406.

Roy S and Sahu B (2013) Can ASHA be the ray of hope for providing MCH

services in Odisha, India? Exploring through a qualitative study. The

Journal of Global Health Care Systems 3(2).

RSBY. Available from: http://www.rsby.gov.in/about_rsby.aspx (accessed 24

October 2017).

66

Sahoo J, Singh SV and Gupta VK, et al. (2015) Do socio-demographic factors still

predict the choice of place of delivery: A cross-sectional study in rural North

India. Journal of Epidemiology and Global Health 5(4): S27–S34.

Salve HR, Charlette L, Kankaria A, et al. (2017) Improving Access to Institutional

Delivery through Janani Shishu Suraksha Karyakram: Evidence from Rural

Haryana, North India. Indian Journal of Community Medicine : Official

Publication of Indian Association of Preventive & Social Medicine 42(2):

73–76.

Sibley L and Ann Sipe T (2004) What can a meta-analysis tell us about traditional

birth attendant training and pregnancy outcomes? Midwifery 20(1): 51–60.

Sidney K, Diwan V, El-Khatib Z, et al. (2012) India‟s JSY cash transfer program

for maternal health: Who participates and who doesn‟t - a report from Ujjain

district. Reproductive Health 9: 2.

Sidney K, Ryan K, Diwan V, et al. (2014) Utilization of a State Run Public Private

Emergency Transportation Service Exclusively for Childbirth: The Janani

(Maternal) Express Program in Madhya Pradesh, India. PLOS ONE 9(5):

e96287.

Sunil TS, Rajaram S and Zottarelli LK (2006) Do individual and program factors

matter in the utilization of maternal care services in rural India? A

theoretical approach. Social Science & Medicine 62(8): 1943–1957.

Suryanarayana R, Santhuram A, Chandrappa M, et al. (2016) Prevalence of anemia

among pregnant women in rural population of Kolar district. International

Journal of Medical Science and Public Health 5(3): 454.

Sustainable Development Goals Fund (2014) From MDGs to SDGs. Available

from: http://www.sdgfund.org/mdgs-sdgs (accessed 17 October 2017).

unstats | Millennium Indicators. Available from:

https://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.ht

m (accessed 8 October 2017).

Vega J (2013) Universal health coverage: the post-2015 development agenda. The

Lancet 381(9862): 179–180.

Vellakkal S, Reddy H and Gupta A, et al. (2017) A qualitative study of factors

impacting accessing of institutional delivery care in the context of India‟s

cash incentive program. Social Science & Medicine.

WHO | Maternal mortality. Available from:

http://www.who.int/mediacentre/factsheets/fs348/en/ (accessed 8 October

2017a).

67

WHO | SDG 3: Ensure healthy lives and promote wellbeing for all at all ages.

Available from: http://www.who.int/sdg/targets/en/ (accessed 17 October

2017b).

WHO | Universal health coverage and universal access. Available from:

http://www.who.int/bulletin/volumes/91/8/13-125450/en/ (accessed 24

October 2017c).

WHO | Trends in maternal mortality: 1990 to 2015 (2015). Available from:

http://www.who.int/reproductivehealth/publications/monitoring/maternal-

mortality-2015/en/ (accessed 8 October 2017).

Checklist

Block name :

Village name :

Serial number

of the

household

Address of the

household

Number of

women in the

household in the

ages 15-39 years

How many of

them

delivered

between May

2016 – May

2017

Name of the

respondent who

delivered

between May

2016 - May

2017

Consent to

participate:

Yes

No

Participant

serial number:

Reason for

refusal to

participate

1. 1.

2.

3.

y y m m d d

Annexure II

Research information sheet for the interview schedule

Place of delivery and its correlates in Janjgir-Champa district, CG: a cross-

sectional study

Introduction

I am Divya Florence G, studying Master of Public Health (MPH) in Achutha

Menon Centre for Health Science Studies (AMCHSS), Sree Chitra Tirunal Institute

for Medical Science and Technology, Trivandum. This study titled “Place of

delivery and its correlates in Janjgir-Champa district, CG : a cross- sectional study”

is being done as a part of the course requirement for that I am currently undertaking.

Purpose of the study

The purpose of this study is to find the factors that contribute at various levels to the

place of delivery and the reasons for unplanned home delivery.

Procedure

The interview will take approximately 30 to 45 minutes of your time. I will be

asking you a few questions regarding your last pregnancy and the place of delivery

in detail. All the information you share will be documented. I would like to contact

you again if there is a need for further clarification regarding the information that

you have shared at your convenience.

Benefits

This study will not directly benefit you. The information that you provide will help

in the future planning and policy making for the society. There will be no incentive

provided to participate in the study.

Discomfort

A few questions may be personal in nature for example asking you about your

previous pregnancy history in detail and if you feel uncomfortable, please feel free

to skip the question asked. You do not have to answer any question that makes you

feel uncomfortable or if you need to time to answer any question please feel free to

do so. You are not obligated to sit through the whole interview.

Confidentiality

Your privacy is priority. All the information that you have provided will be kept

strictly confidential. The personal information will not be shared with anyone. The

information other than your personal information will only be used for the analysis

of the study. My guide will also have access to the information you have shared but

only after, i have removed any information that could identify you.

Voluntary

Your participation in the study is voluntary. At anytime during the interview should

you feel uncomfortable or change your mind, you are free to withdraw from the

study. There will be no loss of benefit or penalty should you refuse to participate.

Thank you.

Signature of the researcher:

Is there any doubts that you would like to clarify? Yes / no

Are you willing to consent for the interview? Yes / no

Contact details of the researcher Member Secretary of the IEC

Contact details of the guide

Prof (Dr) Mala Ramanathan

Professor

AMCHSS, SCTIMST

Contact number: 0471-2524234

e-mail id: [email protected]

Divya Florence G

MPH student

AMCHSS, SCTIMST

Contact number: 7896714887


Guide

Dr Mala Ramanathan



Annexure III

Research information sheet for the in-depth interview

Place of delivery and its correlates in Janjgir-Champa district, CG: a cross-

sectional study

Introduction

I am Divya Florence G, studying Master of Public Health (MPH) in Achutha

Menon Centre for Health Science Studies (AMCHSS), SreeChitra Tirunal Institute

for Medical Science and Technology, Trivandum. This study titled “Place of

delivery and its correlates in Janjgir-Champa district, CG: a cross-sectional” is

being done as a part of the course requirement for the Masters of Public Health

course that I am currently undertaking.

Purpose of the in-depth interview

The place of delivery is usually determined well before the day of delivery. Some

women prefer to deliver in the health facility while some at home. Your experience

is unique because you had planned to deliver in the health facility which due to

unforeseen circumstances you could not. I want to find out the reasons for those

unforeseen circumstances.

About the in-depth interview

Procedure of the in-depth interview

This process will involve a conversation that will take about 45 minutes of your

valuable time. There are no correct answers to any question that I ask. I will be

taking notes about your response and since it is difficult to note everything that you

say, I request your permission to record your response. I may contact you again in

case of clarification of anything from your response that I do not understand.

Benefits

There is no direct benefit for you from the study. The information that you provide

will help in the future planning of research and in policymaking.

Discomfort

A few questions may be personal in nature and if you feel uncomfortable please feel

free to skip, the question asked. You do not have to answer any question that makes

you feel uncomfortable or if you need to time to answer any question please feel

free to do so. You are not obligated to sit through the whole interview against your

willingness.

Confidentiality

Your privacy is priority. All the information that you have provided will be kept

strictly confidential. The personal information will not be shared with anyone. All

the recordings will be kept password locked. The information other than your

personal information will be used for the analysis of the study.

Voluntary

Your participation on the study is voluntary. At any time during the interview

should you feel uncomfortable or change your mind, you are free to withdraw from

the study. There will be no loss of benefit or penalty should you refuse to

participate.

Thank you.

Signature of the researcher:

Is there any doubts that you would like to clarify? Yes / no

Are you willing to consent for the interview? Yes / no

Contact details of the researcher Member Secretary of the IEC

Divya Florence G

MPH student

AMCHSS, SCTIMST



Contact details of guide

Prof (Dr) Mala Ramanathan

Professor

AMCHSS, SCTIMST



Divya Florence G

MPH student

AMCHSS, SCTIMST



Guide

Dr Mala Ramanathan



Annexure IV

Informed consent for the interview schedule

Place of delivery and its correlates in Janjgir-Champa District, CG: a cross- sectional

study

Participant serial number

I have read/been read and understood the details provided in the information sheet. All my

doubts and questions regarding the study have been clarified to my satisfaction. By signing/

providing thumb impression I confirm my voluntary participation in this study and also

understand my role as a participant. I agree to be contacted again should any information

needs further clarification. I understand I can withdraw from the study any time without any

obligation. I have been assured confidentiality regarding my personal details.

Signature/thumb impression of the

participant:

Name of the participant: ________________________

Date:

Time:

If the participant is unwilling to sign the consent form but is ready to participate

Signature/ thumb impression of the witness:

Name of the witness: ______________________

Date:

Time:

Annexure V

Informed consent for the in-depth interview


study


I have read/been read and understood the details provided in the information sheet.

All my doubts and questions regarding the study have been clarified to my

satisfaction. By signing/ providing thumb impression I confirm my voluntary

participation in this study and what my role as a participant. I agree to be contacted

again should any information needs further clarification. I understand I can

withdraw from the study any time without any obligation. I have been assured

confidentiality regarding my personal details.

Signature/thumb impression of the

participant:

Name of the participant: ________________________

Date:

Time:

If the participant is unwilling to sign the consent form but is ready to participate

Signature/ thumb impression of the witness:

Name of the witness: ____________________

Date:

Time:

Annexure VI

Assent form for the interview schedule


study




satisfaction. All my doubts and queries have been clarified to my satisfaction. I

understand my role as a participant. I agree to be contacted should any information

needs clarification. I also understand that I am free to withdraw from the study at

any time. I have been assured confidentiality regarding my personal details. I

confirm to participate in the study.

I have identified ____________ as a person that I trust to consent on my behalf.

Signature/thumb impression on the minor:

Name of the minor : ______________________

Date:

Time:

Signature/thumb impression of the guardian:

Name of the guardian: _________________________

Relationship with the minor: _____________________

Date:

Time:

Annexure VII

Assent form for the in-depth interview


study




satisfaction. All my doubts and queries have been clarified to my satisfaction. I

understand my role as a participant. I agree to be contacted should any information

needs clarification. I also understand that I am free to withdraw from the study at

anytime. I have been assured confidentiality regarding my personal details. I

confirm to participate in the study.

I have identified ____________ as a person that I trust to consent on my behalf.

Signature/thumb impression on the minor:

Name of the minor : _________________

Date:

Time:

Signature/thumb impression of the guardian:

Name of the guardian: ________________

Relationship with the minor: _____________

Date:

Time:

Annexure VIII

Place of delivery and its correlates in Janjgir-Champa district, CG – a cross

sectional study

Participant serial number (verify with the screening sheet information before

entering)

Section A: General information

Sl

no

Questions Responses Instructions

A1 Respondent’s name

A2 Date of the interview

A3 Number of visits made to complete

the interview

Section B: Background characteristics

I would like to ask you a few questions about yourself

B1 How old are you?

(By this I mean, how old were you

on your last birthday)

……………..years

B2 Have you ever been enrolled in

school?

1 Yes If option 2

go to B4 2 No

B3 What is the highest level of

educational qualification that you

have attained?

1 No formal education

2 Primary level (class I

to V)

3 Secondary level (class

VI to X)

4 High school (class XI

to XII)

5 Undergraduate

6 Post graduate and

above

7 Others

(specify)………….

99 Don’t know/refused to

answer/no response

B4 Do you work doing things not 1 Yes If option

related to household

responsibilities?

2 No 2, go to B6

B5 What work do you do that

provides you with money as

wages/salary?

(primary occupation)

1 Daily wages

2 Private

3 Government

4 Student

5 Others

(specify)………


answer/no response

B6 Which community do you belong

to?

1 Scheduled caste

2 Scheduled tribe

3 Other backward class

4 Others

(specify)………..


answer/no response

B7 What religion do you practice? 1 Hindu

2 Muslim

3 Christianity

4 Others

(specify)…………..


answer/no response

B8 How old were you when you got

married?

(age in completed years)

……………years

B9 What is your current marital

status?

1 Married

2 Widowed

3 Divorced

4 Separated


answer/no response

Section C: Household characteristics

In this section, I will be asking you details about your family and the place of

residence. Please answer the questions to the best of your knowledge. There is no

right or wrong answer. If you are unsure of anything, please feel free to clarify with

any member in the household. If you do not wish to answer a question, please feel

free to do so.

C1 How would you best describe

your family?

1 Nuclear 2 Joint

3 Extended

C2 Who is the head of the family?

…………………

C3 In general, when a family

member falls ill who decides

which place to go for

treatment?

1 Father / father-in-law 2 Mother /mother-in-law

3 Partner

4 Others (specify)………


answer/no response

C4 In case of any maternity related

issue who decides which place

to go for treatment?

1 Father / father-in-law 2 Mother /mother-in-law

3 Partner

4 Others

(specify)…………


answer/no response

C5 What is the type of your

partner’s occupation?

1 Daily wages 2 Private

3 Government

4 Student

5 Others

(specify)………..


answer/no response

C6.1 What is the type of your

house?

(record observation)

1 Pucca 2 Semi-pucca

3 Kachha

C6.2 What is the nature of

ownership of the house?

1 Own house 2 Rented house

3 Living in relatives

house

4 Others(specify)…..

C6.3 What is the main source of

drinking water?

1 Piped 2 Hand pump

3 Well

4 Surface water

5 Others(specify)……..

C6.4 What is the distance from your

house to the source of drinking

water?

1 In the dwelling/ yard 2 Less than 1 km away

3 1 -2 km away

4 More than 2 km away

C6.5 What kind of toilet facility do

the embers of your family use?

1 Own flush / pour flush 2 Public / shared flush

3 Public / shared pit

4 No facility (open space)

5 Others (specify)……..

C6.6 What is the source of lighting

in the house?

1 Electricity 2 Kerosene

3 Oil

4 Others (specify)…….

C6.7 What is the main fuel used for

cooking?

1 Electricity 2 Liquid petroleum gas

3 Coal / lignite

4 Kerosene

5 Firewood

6 Others (specify)………

C7 Does the household own any

vehicle?

1 Yes If option

2, go to

C8 2 No

C7.1 Which vehicle does the

household own?

1 Four wheeler

2 Motorbike / scooter

3 Bicycle

4 Animal cart


C8 Does the household own a

ration card?

1 Yes If option

2, go to

C9 2 No

C8.1 Which ration card does the

household own?

1 APL

2 BPL

C9 Whose house did you stay at

during your last pregnancy?

1 Mother’s house 2 Own house

3 Others(specify)

Section D: Village characteristics

I would like to know about the health facility, maternity care services available in

your village. Please answer the following to the best of your knowledge. As I

mentioned before, if you do not wish to answer any question please feel free to say

so.

D1 Which health facility is the

nearest to your house?

1 Sub centre

2 Primary health centre

3 Community health

centre

4 Taluk hospital

5 Private hospital /

private clinic

6 Vaidya (traditional

healer)



answer/no response

D2 How far is the health

facility from your house?

1 Less than 1 km

2 1-2 km away

3 3- 4 km away

4 5-9 km away

5 More than 10 km

away


answer/no response

D3 Does the identified health

facility provide any

maternity care services?

1 Yes If option

2/99, go

to D6 2 No


answer/no response

D4 Which services does the

health facility provide?

1 Antenatal

2 Delivery and postnatal

D5 Does the mentioned health

facility provide 24 hours

delivery services?

1 Yes

2 No


answer/no response

D6 Which health facility does

the family prefer to go to

for any maternity related

health need?

1 Sub centre


3 Community health

centre

4 Taluk hospital

5 Private hospital

/private clinic

6 Vaidya / local healer


answer/no response

D7 Is there a trained birth

attendant who resides in

the village?

(By trained birth attendant

I mean, a person who has

undergone a course

through the modern health

care sector to upgrade her

skills in conducting

delivery)

1 Yes

2 No


answer/no response

D8 Is the trained birth

attendant available 24

hours in the village?

(by this I mean, does the

trained birth attendant

attend to any delivery

related calls anytime

during the day and night)

1 Yes

2 No


answer/no response

D9 Do you have any

diagnosed illness that you

continue to have now?

1 Yes

2 No


answer/no response

D10 What are diagnosed to

have?

1 Heart condition

2 breathing related

condition

3 Reproductive

conditions

4 Psychiatry condition

5 Others (specify)


answer/no response

Section E: Previous obstetric history

I would like to know about your history of the pregnancy and its outcomes. If the

questions make you uncomfortable in any way, we could stop for a while and if you

wish, we can continue with the interview. As I mentioned before you are free to quit

the interview at any time.

E1 What was your age at first

pregnancy?

(in completed years)

…………….years

E2 How many pregnancies did you

have until date?

1 1

2 2

3 3

4 More than 4

E3 How many of them are live

births?

………..

E4 Which place did you deliver

before the recent delivery?

(by this I mean, the delivery

before May 2016 . for primi-

mothers this question will not be

asked)

1 Sub centre


3 Community health

centre

4 Taluk hospital


private clinic

6 Home


The following questions are regarding your last pregnancy you had after May 2016

in the district. Please answer them to the best of your knowledge and if you have

documents regarding the pregnancy and delivery, you are free to use them to answer

the questions.

E5 When did you have your last

delivery?

……….month

……….year

E6 Did you ever have an antenatal

check-up done?

1 Yes If option

2, go to

E13 2 No

E7 How many antenatal check-ups

did you have in total?

1 1

2 2

3 3

4 4

E8 How many doses of injection 1 None

Tetanus toxoid did you receive? 2 1

3 2

E9 Were you prescribed iron and

folic acid tablets from the health

facility?

1 Yes

2 No

E10 How many months did you

consume the iron and folic acid

tablets that was prescribed to

you?

1 Daily for more than 3

months

2 2-3 months

3 Less than 2 months

4 Never


answer/no response

E11 Were you diagnosed to have any

of the following during the

course of the last pregnancy?

1 Anaemia

2 Gestational diabetes

3 Pregnancy induced

hypertension

4 Eclampsia


answer/no response

E12 Were you on any medication for

the illness that you were

diagnosed to have during the

course of the last pregnancy?

1 Yes

2 No

E13.

1

Did you intend to deliver in a

health facility?

1 Yes

2 No

E13.

2

Which place/health facility did

you/your family decide upon?

1 Sub centre


3 Community health

centre

4 Taluk hospital


private clinic

6 Home

7 Others

(specify)………


answer/no response

E13.

3

What was the reason for

choosing the place / health

facililty?

E13.

4

Whom did you intend to take as

your birth companion for the last

1 Mother / mother-in-

law

delivery? 2 sister/ sister-in-law

3 Partner

4 Friend / neighbour

5 Local dai

6 ASHA/mitanin

7 No one

E13.

5

Did the family make prior

transport arrangements to reach

the health facility before the

delivery?

1 Yes

2 No


answer/no response

E13.

6

Did you keep aside a set of clean

clothes to wear after the

delivery?

1 Yes

2 No

E13.

7

Did you keep a set of clean

clothes to use for the baby soon

after delivery?

1 Yes

2 No

E13.

8

What financial arrangements did

the family make to cover the

expenses for the delivery?

1 Savings from the

family

2 Borrowings from the

family

3 Loan from the bank

4 Mortgaging property

to the money lenders

5 Others (specify)


answer/no response

E14 Where did you have your last

delivery?

1 Home

2 Health facility

3 On route to the facility

4 On route from the

facility

E15 When did you leave from your

house to go to the health

facility?

1 Early morning (4am –

9am)

2 Late morning (9am –

12n)

3 Afternoon (12n –

4pm)

4 Evening (4pm – 7pm)

5 Night (7pm – 4am)

6 Never left the house

E16 When did your labour pains

begin?

1 Early morning (4am –

9am)

2 Late morning (9am –

12n)

3 Afternoon (12n –

4pm)

4 Evening (4pm – 7pm)

5 Night (7pm – 4am)


answer/no response

E17 Did you reach the health facility

before the delivery occurred?

1 Yes

2 No

E18 Was the birth companion the

same as you had planned?

1 Yes

2 No

E19 Who was the birth companion? 1 Mother / mother-in-

law

2 Sister/ sister-in-law

3 Friend /neighbour

4 Partner

5 Local dai

6 ASHA /mitanin

E20

What transportation did you use

to reach the health facility?

1 Own

2 Borrowed

3 Public


E21 How long did you actually have

to wait for the transportation to

be ready?

1 Less than 1 hour

2 1-2 hours

3 3-4 hours

4 More than 4 hours

E22 Are you a beneficiary of JSY? 1 Yes

2 No

E23 Was there any expenses incurred

by the family for delivery?

1 Yes

2 No

E24 How did you meet all the

expenses for the delivery?

1 Yes

2 No

E25 Were you allowed admission at

the health facility?

1 Yes

2 No

E26 How many health facilities did

you approach in total before you

had your delivery?

……………

E27 From the first health facility the

you were refused admission,

where did you go to for delivery.

1 Home

2 Another health facility

E28 Eventually, who conducted the

delivery?

1 Doctor

2 Nurse

3 Local dai

4 Family member



answer/no response

E29 How did the delivery happen? 1 Normal vaginal

delivery

2 Vaginal delivery with

the

instruments/episiotom

y

3 Caesarean section

E30 Within how many days did you

go to the health facility after the

home/out of facility delivery?

1 Did not go at all

2 1 day

3 2 days

4 More than 2 days

Guidelines for in-depth interview

Objective of the in-depth interview: to determine the reasons for unplanned delivery

I am going to ask you a few questions about your last delivery in more detail. From

the interview, I understand that you had planned to go to the health facility for your

last delivery. I am trying to find out why some women choose to deliver at home

and some in the health facility. I will be taking about 45 minutes of your valuable

time. There is no right or wrong answers here. I will be taking notes of what you

say which will be used for the study. Since it might be difficult to write everything

you say, can I record your responses so that I will not miss any details. I assure you

that your responses will be kept strictly confidential and password locked. If you do

not wish to continue with the interview, you are free to terminate the conversation

at any minute. Can you tell me about your plans regarding where and how to deliver

when you realised you were pregnant? By this I mean , Where did you intend to go

for delivery? Who was going to assist / help you? Why did you want to deliver at

the health facility / home? What are the benefits of delivering at health facility /

home? What are the advantages of delivering in the health facility / home? Did you

deliver where you intend to deliver? Who were all the people who were involved in

the deciding where to go for delivery? What all did they tell you about it? How did

the local ASHA/ mitanin / dai do with regard to your decision? Would you say she

was helpful or not? Why would you say that? What was the reason for choosing a

health facility? How did you arrive at the decision? Did you leave your house soon

as your labour pains started? Was there any delay? What was the reason for the

delay? Did you face any difficulties reaching the health facility? What were the

difficulties? How did you manage them? Were you sent away from a health

facility? What was the reason given to you? What did you do then? Where did you

go from there? Was the local health worker with you the whole time?

35

At home, what were all the preparations done by the family / local dai/ health

worker for the delivery? If the delivery happened on route, what was done there?

Where did you go afer that? Did you go to the health facility/ home? Why? Who

was with you? Did you face any complications like too much bleeding? Were you

given any medications at home for the delivery? What was the outcome of the

delivery? What would you recommend for someone you know – to deliver at home

or at a hospital? Why?

:

:

घर र

र

घर 15-39

र र

ई 2016 - ई

2017

र

ई 2016 - ई 2017

:

र

र:

र र

1. 1.

2.

3.

Annexure X

- औ , : -

. ( ), , ( ) " - औ , : "

औ

30 45 औ I ई औ

ई औ ई

, औ , I

I

I ई ई ई , ई I

, ई

:

ई ? /

? /

Annexure XI

- औ , : -

. ( ), ,

( ) " - औ

, : "

घ ई , I

45 ई औ ,

ई

औ ई

,

औ , I

I

ई ई

,

ई

:

ई ? /

? /

Annexure XII

- औ , : -

/

औ / औ औ

/ :

: ________________

:

:

/ :

: ______________________

:

:

Annexure XIII

ई

- औ , : -

/

औ / औ औ

/ :

: ________________

:

:

/ :

: ______________________

:

:

Annexure XIV

- औ , : -

/

औ औ

____________ ओ

/ :

: __________________

:

:

/ :

: _________________________

: _____________________

:

:

Annexure XV

ई

- औ , : -

/

औ औ

____________ ओ

/ :

: __________________

:

:

/ :

: _________________________

: _____________________

:

:

Annexure XVI

- औ - ए

(

)

:

A1

A2

A3

: ओ

B1 ?

( , )

……………..

B2 ?

1

2

B4

2

B3

?

1 औ

2 ( I to

V)

3 ( VI

to X)

4 ई ( XI

&XII)

5

6 औ

7 (

)………….

99 /

/ ई

B4 घ

?

1

2, B 6

2

B5 / ?

( )

1

2 3

4

5 (

)………….

99 /

/ ई

B6

?

1

2

3 4 (

)………….

99 /

/ ई

B7

?

1

2

3 ई ई 4 (

)………….

99 /

/ ई

B8

?

( )

……………

B9

?

1

2 3 4

99 /

/ ई

C: घ ओ

, औ ई

, घ

,

C1

?

1

2

3

C2 ?

…………………

C3 , ई 1 /

?

2 /

3 4 (

)………….

99 /

/ ई

C4

?

1 /

2 /

3 4 (

)………….

99 /

/ ई

C5

?

1

2 3

4

5 (

)………..

99 /

/ ई

C6.1 घ ?

( ) 1

2 - 3

C6.2 घ ?

1

2 घ

3 घ 4 ( )…..

C6.3 1

? 2

3

4

5 ( )……..

C6.4 घ ?

1 /

2 1

3 1 -2

4 2

C6.5 ?

1 /

2 /

3 / 4 ई (

)

5 ( )……..

C6.6 घ ? 1

2

3

4 ( )……

C6.7

?

1

2

3 /

4

5

6 ( )………

C7 घ ई ? 1

2, C8

2

C7.1 घ ? 1

2 /

3

4

5 ( )……..

C8 घ ? 1

2, C9

2

C8.1 घ ?

1

2 C9

घ ?

1 घ

2

3 ( )……..

D: ओ

, ओ ,

D1 घ ?

1

2

3

4

5 /

6 /

7 ( )……..

99 /

/ ई

D2 घ

?

1 1

2 1-2

3 3-4

4 5-9

5 10

99 /

/ ई

D3 ई

?

1

2/99, D6

2 99 /

/ ई

D4

?

1

2 औ

D5 24

घ

?

1

2

99 /

/ ई

D6

?

1

2

3

4

5 /

6 /

99 /

/ ई

D7

?

( ,

)

1

2

99 /

/ ई

D8 24 घ

?

( , औ

)

1

2

99 /

/ ई

D9 ई

?

1

2 99 /

/ ई

D10 ? 1

2

3 4

5 ( )

99 /

/ ई

E:

औ

, औ

,

E1 ?

( )

…………….

E2 ?

1 1

2 2

3 3

4 4

E3 ?

………..

E4

?

( , ई 2016

-

ओ )

1

2

3

4

5 /

6 घ

7 (

)……..

, ई 2016 औ औ

,

E5

?

………. ……….

E6 ?

1

2,

E13

2

E7 - - ?

1 1

2 2

3 3

4 4

E8 ?

1 ई

2 1

3 2

E9 औ ?

1

2

E10 औ

,

1 3

2 2-3 3 2

4 99 /

/ ई

E11

?

1

2

3

4 99 /

/ ई

E12

?

1

2

E13.

1 ?

1

2 E13.

2 /

/ ?

1

2

3

4

5 /

6 घ

7 (

)………

99 /

/ ई

E13.

3 / ?

E13.

4

?

1 /

2 / 3 4 / 5 ई

6 /

7 ई

E13.

5

?

1

2

99 /

/ ई

E13.

6

?

1

2

E13.

7

??

1

2

E13.

8

?

1

2 ऋ

3 ऋ

4 ओ

5 (

)………)

99 /

/ ई

E14

?

1 घ

2 3

4

E15

घ ?

1 (4am – 9am)

2 (9am – 12n)

3 (12n – 4pm)

4 (4pm – 7pm)

5 (7pm – 4am)

6 घ E16 ? 1 (4am – 9am)

2 (9am – 12n)

3 (12n – 4pm)

4 (4pm – 7pm)

5 (7pm – 4am)

99 /

/ ई

E17

?

1

2 E18

ई ?

1

2

E19 1 /

2 / 3 / 4 5 ई

6 /

E20

?

1

2

3 4 (

)……..

E21 ?

1 1 घ

2 1-2 घ 3 3-4 घ 4 4 घ

E22 ई ?

1

2

E23 ई ?

1

2 E24

?

1

2 E25

?

1

2 E26

??

……………

E27 ,

1 घ

2

E28 , ?

1

2 3 ई

4

5 (

)………

99 /

/ ई

E29 ? 1

2 / ओ

3

E30 घ /

?

1

2 1

3

4 2

ह ए

ह ए ह

औ

,

ई

ओ घ औ

45 I ई

,

ई

ई औ

,

1. ओ

औ ? ,

?

?

/ घ ?

/ घ ?

/ घ ?

?

2. ?

?

3. / / ई ?

? ?

4. ? ?

5. घ ?

ई ? ?

6. ई

? ? ?

7. ?

? ?

8. ?

?

9. घ , / ई /

?

10. , ? afer?

/ घ ? ? ?

11. ई ओ ?

घ ई ? ?

12. घ -

? ?

Scanned by CamScanner

PLACE OF DELIVERY AND ITS CORRELATES IN JANJGIR...

Documents

Transcript of PLACE OF DELIVERY AND ITS CORRELATES IN JANJGIR...