Table 2 Overview of structural and intermediary factors of maternal health in India
Structural factors | Intermediary factors | ||
|---|---|---|---|
| Â | Â | 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 |