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Table 2 Overview of structural and intermediary factors of maternal health in India

From: Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India

Structural factors Intermediary factors
   Health systems
▪ Economic status
▪ Caste/ethnicity
▪ Gender
- Women’s autonomy
- Son preference
- Exposure to violence
▪ Religion
▪ Culture
- Early marriage
▪ Maternal education
▪ Women’s employment
▪ Husband’s education
▪ Husband’s occupation
▪ Power
▪ Policy gaps
- Health worker not seeing pregnant women in parental homes
- Citizenship issues for migrants
- Two-child norm and policies promoting sterilizations
Community context
▪ Place of residence
▪ Distance
▪ Transportation
Family/household context
▪ Family type and size
▪ Quality of relationships
Individual
Biological or demographic
- Age at marriage
- Age at childbirth
- parity
Health need
- Anemia
- History of complications (previous pregnancies)
- History of adverse pregnancy outcomes (previous pregnancies)
Knowledge/awareness
- Awareness of danger signs and maternity entitlements
- Exposure to mass media and maternal health messages
Behavioral
- Use of antenatal care, institutional delivery
Psychosocial
- Fear of caesarean section and surgery
- Perception of benefits
- Perception of care
- Desired or wanted pregnancy
- Permitting birth companion
Availability of services/facilities
- Infrastructure, equipment, blood, and health specialist
- Lacking or no proper antenatal care
- Care for anemia
- Postnatal care at communities and health facilities
- Abortion services at public facilities
- Lacking or poor provider’s skill and competence: doctor, nurse, auxiliary nurse-midwife (ANM), Accredited Social Health Activist (ASHA)
- Lack of fuel for ambulance
Quality of care
Staff attitude and behavior
- Poor adherence to standards and protocols
- Negligence or lack of care by health worker, including ASHA/ANM not visiting villages
- Non-responsive and disrespectful behavior
- Discrimination by health workers based on social status
- Physical and verbal abuse by health workers
- Lack of priority for maternal healthcare
- Tendency of transfer of blame in hierarchy
- Low motivation
Referral
- Unnecessary or irrational referral
- Multiple referrals
- No appropriate care before referral
- Unassisted referrals
Other
- Longer waiting time at government hospitals
- Illegal demand for money: ambulance
- Lack of proper care in private hospitals
Accessibility
- Cost associated with healthcare
- Lack of ambulance or transport after referral
- Cost associated with referral
- Organization of services (Basic & Comprehensive Emergency Obstetric Care): challenge for referral
- Illegal demand for money
Administrative,managerial,governance
- Ambulance not authorized to drive to another village/hospital
- Organization and supervision of ambulance services
- Lengthy administrative procedures
- Lack of proper monitoring and supervision, including no proper maternal death reviews
- Lack of accountability mechanisms
- Non-issuance of Below Poverty Line cards
- Documentary proof of poverty
Working environment
- Understaffed and over-pressured staff
- Lack of supportive infrastructure for health workers, e.g., road/transport