Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India

The study is located in the state of Odisha, where 22% of the population is ST, as compared to 8.6% of the total population of India. Odisha is also one of the High Focus states for improving maternal health, with an MMR is of 222 deaths per 100,000 births, compared to India’s 167 deaths for India [2]. Tribal women in Odisha are 2.5 times more likely to bear a child by age 19 years, and 2.7 times more likely to have more than four children. Tribal mothers are 1.3 times more likely to be underweight and anemic [15]. While 85% of all women in Odisha deliver in health facilities, only 73% of tribal women deliver in health facilities [16].

Maternal mortality is a high priority issue for the Odisha state government and in addition to JSY, and JSSK, the state government introduced the MAMATA scheme, to “promote health seeking behavior” and provide wage compensation and improved nutrition to pregnant and lactating women. Launched in 2010, MAMATA provides up to Rs 5000 (USD 80) for antenatal care and infant care services, in addition to JSY, which provides an incentive for institutional childbirth. The MAMTA incentive is given in four installments over pregnancy and post-partum (until the child is 9 months old) to ensure that mothers access a range of maternal and child health services.

The results have been quite dramatic. While only 36% of women in Odisha delivered in institutions in 2005–2006, this figure more than doubled to 85% in 2015–16 [16]. Yet, tribal communities are disadvantaged. The tribal dominated districts in the Southern Division record an MMR of 245.

This study was conducted in Kalyansinghpur block of the mineral rich and densely forested district of Rayagada in southern Odisha. STs comprise 56% of the population of Rayagada. [17]. In terms of development indicators, Rayagada district is one of the most deprived districts in Odisha [17]. Only 72% of births take place in institutions, compared to 85% for the state [3]. Kalyansinghpur block has a population of 66,000 of which 65% is tribal, mostly belonging to the Kondha tribe [18]. The block has a literacy rate of 38%, and is one of the poorest blocks in the district. The study was limited to 9 villages situated in one Gram Panchayat (population 4663). Of the nine villages, four were easily accessible and connected by all-weather roads, while five were isolated and located in the hills. Four out of the five isolated villages did not have any all-weather roads; one did, but people had to walk at least 5 km to reach a vehicle. The isolated villages were materially more deprived than the accessible ones. While villages with more accessibility had hand pumps for water, the isolated ones depended on river streams. In two villages, people walked close to 6 km, crossing hills and streams, just in order to get food rations from the nearest distribution center. This provided us an opportunity to explore the differences in birthing customs and utilization of formal maternal health services, based on the relative isolation of the village.

The Kondhs are forest and hill dwelling communities and are culturally, socially and linguistically different from the mainstream Odia population [19]. Anthropological studies describe three kinds of Kondhs – the Dongaria (or hill dwelling), the Desia (or plain dwelling) and the Kuttia Kondh. [20]. This study is situated among the plain Kondhs. There is also a history of conflict between the Dongaria Kondh community, the state and mining corporations in the region [21]. The Niyamgiri hill, where the local Dongaria Kondh tribe has fiercely protested against acquisition by Vedanta, a mining conglomerate [21], is located adjacent to the area where this study was conducted. The hill has spiritual value for the people and they depend on it for produce and herbs.

Kondh society is patrilineal and patrilocal; polygyny is not uncommon [20]. Most women in our study sample reported having 4 to 5 children, with first delivery occurring between 16 and 20 years of age. In addition to multi-parity and low age at first pregnancy, poor nutrition and lack of rest during pregnancy also jeopardizes maternal health outcomes. In our study area, women ate only two meals a day consisting of rice, roasted wheat flour (sattu) or a watery porridge made of millets (ragi), the latter being part of the traditional diet [22].

Despite tribal women having more independence and fewer restrictions than women belonging to caste Hindu communities [23], their status remained low and decision-making regarding issues like seeking health care and large expenditures rested with men. Women tended fields, reared animals, and sold produce in addition to housekeeping, fetching water and firewood, cooking and caring for children. This workload carried into pregnancy. Women explained that strenuous labour could not be avoided as the family’s livelihood depended on it.

The health facilities serving the field area included a sub-centre, a primary health centre, a community health centre and the district hospital. A village health and nutrition day was held each month at the village level, which was conducted by the Auxillary Nurse-Midwife (ANM). The community’s closest contact with the health system were the ASHA community health workers. There were 5 ASHAs in the field area, some of who were responsible for taking care of 3–4 villages. The ASHA belonged to the village, but was not from the tribal community. There was also an Anganwadi Worker (crèche/pre-school worker) (AWW) in the villages who provided nutrition services to mothers and children.

The sub-centre serving the community was usually shut as the ANM, who should have been residing at the centre, spent her time travelling across 15 villages in her duty area to provide outreach services, and was rarely available at the centre. The primary health centre, which should ideally have been conducting normal deliveries as well as providing basic emergency obstetric care, was ill-equipped and poorly staffed, and no delivery services were being conducted. The closest delivery point was a nine-bedded community health centre located about 15 kms from the villages, which conducted only normal deliveries. The community health centre building was run down and there was a dearth of water and electricity. In the warmer months, women had to move out to the verandah to escape the heat. Even though a community health centre is expected to provide comprehensive emergency obstetric care, it did not deliver this care due to the lack of skilled providers and non-availability of life-saving commodities like blood. In case of complications where women were severely anaemic or had obstructed labour or eclampsia, they were referred to the district hospital. The district hospital was able to manage most emergencies, but in case it could not, women were referred to a private missionary hospital about 50 km away.

The study was exploratory, using qualitative methods to understand the culture, practices and perspectives around maternal health in the community. Fieldwork was conducted between December 2014 and April 2015 in collaboration with a local non-profit organization¹ that works on livelihood issues. The NGO had been working in the field for a long period and has a thorough knowledge of the social dynamics within the communities. The local NGO facilitated the fieldwork, helped identify participants, and was able to ensure that women and health workers were willing to be interviewed for the study. An experienced field investigator, familiar with the maternal health programme in the state and who spoke Odia (the state language), was stationed in the field for one and a half months. She was accompanied by a local assistant who spoke Kui² (the tribal language) and provided translation support. The first author is a researcher with a master’s degree in public health. She made three visits to the field during the time of the study – twice for conducting interviews with key informants and once to discuss and validate the emerging findings with local organizations.

All data was collected in Odia, but transcribed in English by the field investigator. Transcripts were reviewed by the first author and gaps/new areas of exploration were identified which warranted further fieldwork. The overall analytical approach was grounded theory. Grounded theory is used to make sense of perceptions of participants about certain events or phenomena, rather than being informed by a pre-existing hypothesis [24]. It is being used in health systems research to explore patients’ perceptions and experiences of services as well as of illness [25]. In the early stages of data collection, the data were first open-coded by the first author. These were then reviewed with the field investigator as the data collection and analysis proceeded, and the lack of congruence between the community’s perceptions around pregnancy and childbirth and the health system’s approach began to emerge as an important finding. Subsequent data collection, especially observations, conducted after the interviews, explored this aspect more deeply. Once data collection was complete, themes were identified by the first author. These were reviewed by the research team and finalized.

In contrast to the government’s promotion of institutional delivery guided by the belief that every childbirth could potentially lead to complications, we found that in this community pregnancy and childbirth is perceived as a natural process, not requiring much external intervention. Traditional practices both in the antenatal and post-natal period are primarily geared towards protecting the mother and child, through conducting prayer ceremonies to ward off evil spirits, and restricting diet. Little importance is given to ‘small problems’ like fever in the post-natal period or swelling of feet in the antenatal period as these are considered a common part of pregnancy. Women go through childbirth without disturbance to their regular life. The woman can go about her daily activities and work until the time of delivery and this is an important consideration for them. The delivery is conducted in the home compound with a close family member as an attendant, in a surrounding familiar to the woman. The process of delivery is said to be ‘impure’ and so delivery takes place outside the house. It takes place in a squatting position and women are allowed to walk around in between contractions. Generally, no herbs are given during pregnancy or labour. After delivery, the placenta is buried in a pit and covered with sticks. The woman bathes on the pit to wash away all the impurity, and then it is filled up. The purpose of this ritual, as reported by women, was to protect the baby. If the placenta is left out in the open it is likely that it would be eaten by animals and this could bring harm to the baby. Along with this understanding of pregnancy and childbirth as a primarily natural process, there is awareness that pregnancy can get complicated. The traditional birth attendant for instance mentioned that in case of prolonged labour, retained placenta or unrestrained bleeding, it is necessary to take the woman to the health facility. This suggests that there is a well-established practice of birthing in the community, which includes some rituals as safety precautions and also recognizes the need for health system interventions in certain cases.

As discussed earlier, the thrust of maternal health policies over the past decade has been on institutionalizing childbirth and this has led to a corresponding increase in the proportion of women giving birth in public health facilities [26]. This was also true in our field area, but despite the increase, 26 out of the 70 deliveries that were recorded in the year preceding the study took place at home (as mentioned in the ANM’s records). It was interesting to note that home deliveries took place both in villages that were well connected by roads as well as those without connectivity. This suggests that geographical isolation is not the only factor that prevents women from utilizing the formal health system for delivery care. Women gave different reasons for delivering at home. Since the burden of both household work and livelihood was borne by women, they were concerned about the number of days that would be lost if they went to the hospital. Birthing at home meant that they could go back to work immediately and tend to their children. One woman who had had four previous normal births at home, felt that no additional advantage was provided by going to the hospital. In fact, it only meant loss of wages and additional expenses. So she was planning to have her fifth birth at home as well.

Government policy stipulates that home deliveries be attended by a skilled birth attendant or a trained birth provider. JSY prescribes cash assistance of 500 rupees [approximately USD 7] for home birth as long as the pregnant women is below the poverty line and above 19 years of age, for up to two births [27]. In case a woman opts for a home birth, the ANM is expected to attend to the birth, and this has been laid out formally in her roles. The role of ANMs in practice however remains restricted to preventive services and providing antenatal care [28]. Significantly, none of the deliveries at home were attended by a skilled birth attendant. The delivery was usually attended to by a close family member, usually the mother in law, or an elderly woman in the household. The delivery was perceived to be complicated if labour went on for more than 12 h, or if there was excessive bleeding following delivery. In this situation, the woman was taken by the family to the community health centre. The traditional midwife or Dai, who used to attend home deliveries, had stopped intervening in cases of delivery for the past 10 years. She mentioned that now the focus was on taking women to health centers, for which ASHAs were motivating women, and so there was no role for her. However she narrated that in the past, she would attend to births and also called on the ANM’s help in some cases when she anticipated complications, such as when twins were expected or when the position of the baby was incorrect. This suggests that even when Dais were assisting births, there was a system by which they identified complications and sought help from skilled providers. There was no hesitation in sending women to the hospital when necessary. However this collaborative way of functioning does not exist anymore. As of today, there is no Dai to help women during birth, nor does the ANM assist home births. As a result, women who deliver at home are left with no skilled support.

It was evident that health care providers, especially ASHAs and ANMs, were very concerned with ensuring that all women delivered in institutions. We noted that not all deliveries that were recorded as ‘institutional delivery’ were necessarily conducted in a public health facility. Several women who actually delivered at home were later taken to the health facility and recorded as institutional deliveries so that they could avail of the JSY incentive. The outreach workers acknowledged that it was difficult to get women to come for institutional deliveries. They genuinely believed that they were working for the benefit of the laboring woman by encouraging her go to the health facility but, according to them, women were resistant. The following case study narrated by an Anganwadi worker illustrates this impression of the health workers. It is also an example of how women who deliver at home eventually end up being recorded as institutional deliveries:

She was not interested in going to the hospital for delivery. They say, “We are Adivasi people, we don't want to go outside and other male member shouldn't touch us.” I told her, “We are all present for your benefit why shouldn't you listen to us? Both mother and baby will be safe in the health facility.” When she was not convinced I spoke to her husband, “If anything happens the family will suffer.” I thought I had convinced them and was feeling very happy. But then she ended up delivering at home. Her labour pains began in the morning but without informing anybody she went to the field for work. Only after she came back home she called me and asked me to contact the ASHA for the vehicle. In the meantime she delivered the baby before the vehicle reached the village. Thankfully her family agreed to visit the hospital and the cord was cut there. She received the Rs.1400/- for institutional delivery. However, many a times, if the vehicle reaches after they delivered, they refuse to visit the hospital. What's wrong with it, they can get treatment, child immunization and the cash benefit. (Interview with AWW)

While there was a reliance on incentives and disincentives to increase coverage of services, there appeared to be a gap between the intended purpose of services and women’s understanding of it. During ANC check-ups, which were conducted at the VHND once a month, almost all women reported receiving iron folic acid (IFA) tablets, having an abdominal check-up, haemoglobin tested and blood pressure recorded. However, during observation of the VHND we observed that none of the women were explained what was being done and with what purpose. Women therefore did not understand why the tests were being done during antenatal check-ups and often they would not follow advice given. Although IFA tablets were provided to almost every woman, not a single woman had taken the full course. One reason for this could be that traditionally no medicinal herbs were taken during pregnancy for fear of harming the fetus and so women did not consider it proper to take any other form of medicines. One woman reported that she had experienced nausea and vomiting after taking the IFA tablet and so she discontinued it. Both, “cultural beliefs against consumption of medications during pregnancy” and “negative side effects” have been reported as barriers in IFA tablet consumption in previous research [29].

Tribal communities in the state of Odisha typically reside in forest and hilly areas, which are geographically challenging to reach. In light of this, the Odisha Government has made available a free and dedicated ambulance service. However, women in the more isolated villages reported that access to a vehicle was a problem. In these areas, women had to be brought quite a distance to the motorable road in order to reach the ambulance.

A is an isolated village with no government services at all. There is no ASHA or AWW situated in the village, nor do they visit. All deliveries occur at home. The reason for this is quite obvious, considering the long and difficult journey that a woman would have to undertake to get from the village to the CHC. A woman from A would first have to climb down for about 6 kms in a rough hilly terrain crossing four streams, to village B. From here she would need to walk downhill about 5 kms to village C and then another 1.5-2 km to D, after crossing two streams. For this entire journey there is no road. From D to E there is a dirt road of about 2.5-3 km. Only once the woman reaches E does she have access to an all-weather motorable road where an ambulance can be reached to get to the CHC which is located about 12 km away. The entire journey takes around 6 hours. (Researcher’s field notes)

Almost everyone – respondents, families and services providers – reported that there were problems in reaching the ambulance. To begin with, most villages had very poor cellular phone connectivity. When cellular phone connectivity was available, the emergency helpline for ambulances was perpetually busy. Even when the ambulance was contacted, it could take as long as 4 h for it to reach the village. In case of isolated villages, ambulances refused outright. Of the 12 women who we observed at the community health centre, 4 had come from far-off distances and had not been able to come by ambulance.

Recognizing that geographic isolation is a challenge, maternity waiting homes have been set up by the Government of Odisha since 2012, where women can stay for approximately one month before delivery. Women who are identified as high risk in the antenatal period are referred to a waiting home and transport is also provided. However, our field observations indicate that tribal women were not using the waiting homes and most people in the community were unaware of their existence. Women who had been referred to a waiting home were not aware of its purpose and were concerned about out-of-pocket expenses as well as neglect of domestic responsibilities, and therefore refused to stay there.

S, a 16 year old first time mother, was sent to the District Hospital in Rayagada for delivery. S was very young, weak and severely anaemic, hence the ANM had recommended that she be taken to the institution before she went into labour. On reaching Singhpur CHC, she was referred to the District Hospital as a complicated case. S had to stay in the District hospital for 10 days before she delivered her child. The ASHA who had accompanied her could not stay for this entire period. She was required to stay alone (without her family, who waited outside) and did not understand the language that was being spoken. S says that she will never go back to the institution for delivery. (paraphrased interview with recently delivered woman).

The health care providers had also become accustomed to this situation and did not even attempt to communicate with the women. In one instance, a woman’s prescription carried the ASHA’s name rather than the woman’s. In another instance, a woman with fever during pregnancy was turned away from the CHC and asked to return with the ASHA (researcher’s fieldnotes).

Apart from language, there were other things about the health facility that did not agree with women, such as the food. Women were provided food that was insufficient as well as unfamiliar for them – sooji (semolina) in the morning, one slice of bread, a glass of milk and an egg in the afternoon, and one slice of bread and milk at night. The food, though commonplace, was unfamiliar and not in keeping with the dietary habits of the Kondh community. For example the Kondhs do not consume milk and so it was either discarded or returned.

The surroundings and birth practices were also unfamiliar to the woman. Delivery took place in the lying position as opposed to the squatting position that women were accustomed to. As one woman remarked in a group discussion:

[at the hospital]… all women lay in bed. In my case I didn’t want to lie in bed. They told me not to worry. If they allowed me to sit it would have been better. But they don’t allow that. I know their problem. If we sit how could they check? And it is not possible for the nurse to sit with every woman when the time comes for delivery. (Recently delivered woman in a group discussion).

The experiences of women emphasize that birthing in institutions is very different from women’s experiences of delivery at home. Accommodating women’s concerns requires structural adjustments be made in health facilities, however no efforts were being made to do so.

Community members consult a range of traditional healers and informal (untrained) providers for various health issues, including during pregnancy. For routine illness, two local informal (untrained) providers in the area were consulted, but respondents insisted that informal providers play no role in handling childbirth. Despite this denial, in one case of post-natal complications, the family reported that they called the informal provider to give the mother an injection. This silence around the informal providers could be attributed to a circular from the district collector (a powerful local government administrator) forbidding informal providers from providing any services to pregnant women. While this circular may have been issued to avert harm, it appears that the practice has merely gone underground.

Among traditional healers, two important figures, the Bejini (or sorcerer) and the Dai, have significant roles to play. The Bejini is usually a single woman considered to have black magic powers. The Bejini is consulted in the antenatal period to predict the doomba (spirit) of the baby and such a prediction is said to be indicative of whether a complication is likely to occur. She usually accepts an animal sacrifice (often a hen) and conducts a ceremony to heal or avert a possible complication. The Dai is the most important traditional health care provider, however, her role has been made irrelevant. When the NRHM was introduced, the Dai mentioned that she had been considered for the post of ASHA and had also undergone training. However the role required her to travel to a number of hamlets, which are located far apart. This was something she found difficult and she therefore refused to become an ASHA. The frontline providers considered traditional providers to be negative influencers of women’s health. They recounted incidents where villagers had refused to accept formal health services on the advice of the traditional provider. However, despite the apparently important roles that informal and traditional providers have, the formal health system had no way of engaging them.

A significant factor that affected women’s decision whether to choose institutional care was that of others’ or their own adverse experiences. A few months before we began fieldwork, two maternal deaths had taken place in neighbouring villages. Whenever we asked women about institutional deliveries they cited these cases. In one of these cases, the woman had “run away” from the hospital and refused to return in the post-partum period when she was extremely ill.

B, a 24 year old pregnant woman with two previous institutional deliveries, was taken to the PHC at around 8 months because she developed blurred vision and severe headaches. The doctor told her husband that she had malaria and referred her to the CHC and from there to the District Hospital. For three days B stayed in the district hospital and got no relief. B’s husband was not allowed to stay by her side. Because B did not know the language, she could not communicate with any of the hospital staff. After three days of being ill, B and her husband left the hospital without informing anyone as she was not getting any better and they were getting no information. B felt that if she was going to die, she would prefer to die at home, in the presence of her family and children. They took a private vehicle and came back to B’s mother’s house where she delivered. The child did not survive. After the delivery, B was very weak and continued to have blurred vision. Her husband tried to convince her to go back to hospital, but she refused. Two days after the delivery, she died. A maternal death investigation was conducted which concluded that B had died because she had not adhered to medical treatment and left the hospital against medical advice. No effort was made to explore why B had left the hospital. (Interview with woman’s husband).

Such experiences of women with facilities easily spread to the entire community and they played a role in shaping women’s decisions about whether to go to the facility or not. For instance, in one case, a woman who delivered at the CHC but had a ‘weak child’ was asked to take the child to the district hospital, but she refused. Her neighbour’s child had been referred to the district hospital, they spent 20,000 rupees and eventually the baby died. Thus the family had no faith in the district hospital and felt that it would only lead to a loss of money and no relief. Moreover, there were women who had themselves faced bad experiences at the health facility and did not want to go back. One of the respondents had had a previous delivery in the CHC where she lost her child. In the next delivery she delayed informing the ASHA about her labour pains because she did not want to go to the institution. She did not want to take a risk a second time and found a way to deliver at home. This time the delivery was normal and the child was well.

Why should we go to hospitals when they do not care for us? If my wife had delivered at home she may have still died, but she would at least have received some food or water to drink. At the hospital she got nothing. If she had died at home, we would regret it, but at least she would be around us and we could have done something. We would not have to spend money to take her dead body back to village. What is the benefit for us in taking our women to hospital for delivery? (Interview with woman’s husband).

Perhaps because the woman belonged to the priest’s family, S’s story spread to other villages. No explanation was offered for her death by the system and in fact, the disappearance of the doctor deepened the sense of mistrust that people have in the system. In one informal interaction with women in a well-connected village, one of the older women remarked, “Why should they (our women) deliver in hospital? To die? If you have to die it should be with near and dear ones, where the person can have some food or water.”