A mixed method approach was adopted in order to understand the health system competency for maternal health services in the study area. Primary data were collected by Focus Group Discussions (FGDs) and Key Informant (KI) interview techniques. Secondary data from various government documents were analysed to understand the Government policy implications. The Health Management Information System (HMIS) data were analysed for the comparison of Odisha and Balasore district in terms of registered pregnancy, ANC, and institutional delivery. The study has been carried out during the year 2012-13.

This section delineates the major findings of health system competency at two different levels. The first section delineates the district level competency of Balasore district followed by block level competency of Jaleswar block of the same district.

Balasore District Profile

Balasore is one of the most populous districts of the state having 5.50% of total population in only 2.44% of the land area. High population density (532 sq/km), huge rural population (89.11%) and poverty (about 73%) status of the district demand immediate intervention in livelihood and infrastructure development. The district is located in deltaic region, criss-crossed by a good number of rivers and rivulets. These water bodies act as physical barriers and demand huge number of bridges, culverts to make all corners of the district accessible. Natural calamities play a destructive role in the district by damaging road network almost every year. Agriculture is the backbone of the district’s economy. It provides both direct and indirect employment to 67% of the workforce [11].

Lack of Basic Civic Amenities

There is shortage of pucca road, electricity connection and piped water in the health care centers including anganwadi centers in the district. Lacks of these amenities affect inter-sectoral coordination for National Rural Health Mission (NRHM), particularly improvement of the maternal health services in the district [11]. The lack of basic amenities acts an impediment for the rolling out of public health programs.

Gaps in Health Care Infrastructure

Analysis of existing health infrastructure revealed that against required strength of 483 Sub-centers, there are 275, of which only 87 sub-centers have dedicated pucca buildings. There are 66 PHCs in the district against the required strength of 81. Even existing PHCs lack ECG and X-Ray machines for proper diagnostic services. CHCs also lack basic diagnostic and ambulance services making the tribal pockets inaccessible. [Table/Fig-1] summarizes the infrastructural gaps in the district [11].

Besides the infrastructural problems the district has widespread inaccessibility which has adverse impact on the provision of health care services. This is evident from the number of difficult areas identified by the NHSRC. There is one sub-divisional hospital at Nilagiri; one CHC at Baliapal; two PHCs at Pratappur and Berhampur; and nine PHC (N) at Ghantua, Langaleswar, Srirampur road, Jamakunda, Kalakad, Kansa, Betakata, Sajanagada and Ayodhya classified as difficult areas according to the NHSRC.

ANC Registration Increases but Early Registration is a Distance Dream

A comparison between registered pregnancy between the year 2010-11 and 2011-12 shows an increasing trend of total registered pregnant women for ANC, but a decreasing trend of registration within the first trimester for both state of Odisha and Balasore district. This may be due to low level of awareness in the community regarding the ANC services. The percentage increase in first trimester compared to total ANC registrations, but the percentage increase is marginal in case of Balasore district (56.3% to 57.1%) compared to the state (35.9% to 40.3%). This shows sluggish maternal health program in the district and the state as well which is far behind the national average and MDG 5. The [Table/Fig-2] enumerates the ANC registration during the year 2010-11 and 2011-2012 [12].

Increased number of Non-Skilled Birth Attendants (Non-SBA)

Number of home deliveries attended by non SBA trained birth attendants (TBA/Dai) is very high compared to number of home deliveries attended by SBA trained birth attendants (Doctor/Nurse/ANM) in both the case of the state and Balasore district as well. However the percentage of SBA attended home deliveries to total reported home deliveries are much low in Balasore (6.3% and 3.3% for the year 2010-11 and 2011-12 respectively) compared to the state average (23.2% and 14.8% for the year 2010-11 and 2011-12 respectively). In both the cases the percentage of SBA attended home deliveries to total reported home deliveries are glaringly low. This shows less penetration of the practice of skilled birth attendance in the rural area. The [Table/Fig-3] shows the number of home deliveries attended by SBA and non-SBA [12].

Non-payment of Incentives to Mothers for Home Delivery

The percentage of mothers paid of JSY incentive for home deliveries to total reported home deliveries is very low in the case of both Balasore and Odisha. Though there is provision for JSY incentives for the home delivery, there is lack of proper mechanism for payment of JSY incentive for those deliveries. This further jeopardizes the health of both mother and child especially in tribal districts. The condition is much serious in Balasore (0.7% and 0.6% for the year 2010-11 and 2011-12 respectively) in comparison to State average (7.5% and 5.4% for the year 2010-11 and 2011-12 respectively) [12] [Table/Fig-4].

[Table/Fig-4]:

Mothers paid JSY incentives for home delivery

*Source: HMIS Portal (2013)

Decrease in Home Deliveries

Percentage of home deliveries to total reported deliveries is low in case of Balasore district (9% and 6.3% for the year 2010-11 and 2011-12 respectively) in comparison to State average (17.8% and 15.2% for the year 2010-11 and 2011-12 respectively). The percentage of home deliveries over the years has been decreasing showing more emphasis on institutional deliveries but the desired improvement in total institutional delivery is still a distant dream [12] [Table/Fig-5].

Irregularity in Post-Partum Care

Postpartum care in both Balasore District and Odisha has increased during the year 2010-11 and 2011-12. Balasore district is performing well in terms of women getting post-partum checkup between 48 hours to 14 days (71.1% in 2010-11 to 81.7% in 2011-12). However, the percentage of women receiving post-partum check-up within 48 hours of delivery to total reported deliveries have decreased (72.4% in 2010-11 to 66.7% in 2011-12) [12] [Table/Fig-6].

Basic Facts of Jaleswar Block

Jaleswar (384.11 Sq km) is a thickly populated block (population 1,13,329) of Balasore District having 256 villages and 34,138 households and has high concentration of SC (22.7%) and ST (27.9%) population. The block is also plagued by low literacy rate of 66.21% [11].

Inequitable Distribution of Health Infrastructure

Geographically, the Subarnarekha River divides the Block into 2 parts, i.e. Jaleswar and Hatigarh. In comparison to Hatigarh, the Jaleswar region is better placed in terms of infrastructure (14 out of 26 Sub-centres), manpower (99 out of 177 Ashas). The only First Referral Unit (FRU) (Gopi Kissan Bhattar) of the block is also situated in Jaleswar.

Lack of Awareness

A preliminary analysis of Block statistics for the month of August 2013 shows its low performance in ANC service. Although 309 women had registered for JSY, only 163 women registered within first trimester which shows lack of awareness. The number of pregnant women having hypertension and anaemia was 25 and 103 respectively. These predisposing factors for high risk pregnancy are widely prevalent in this block. Although JSY popularizes deliveries at home by trained birth attendants in remote area but there were no such cases for the month under consideration. Eight deliveries took place at home by traditional birth attendants (TBA). Although the block has witnessed a high emphasis on institutional deliveries, there has been no single case of caesarian delivery, in the FRU, which shows high referral rate to higher centers due to lack of functional manpower and technology (NRHM, 2012) [9].

Reluctance to Adhere to the Norms of 4 Mandatory ANC Checkups

The low level of availability of health care facilities is evident from poor OPD and IPD services. While OPD facilities are available at all health centers, IPD facility is only available at one CHC located at Hatigarh. The ANC services of Jaleswar Block need better improvement. The [Table/Fig-7,8] shows poor performance of Jaleswar block in terms of total ANCs (only 77%) of expectant mothers. There is a gradual decrease of ANC percentage from first to fourth (86% to 84% to 79% to 77%) [12].

[Table/Fig-8]:

Declining trend of ANC checkups and delivery in Jaleswar block

*Adapted from HMIS Portal (2013).

There is constant drop out of the cases in subsequent ANC visits due to lack of infrastructural and institutional problems in health care system.

Poor transportation facility is a major barrier for women beneficiaries to avail institutional care. This is evident from low turnout in OPD and IPD services. Women fallout from regular ANC visits due to several reasons. Compliance with IPHS standards needs serious attention to ensure safe delivery. The IPHS standards provide enough scope for availability of quality services in public health institutions. The study recommends continuous tracking and follow-up of ANC at individual level. Similar findings are also found in Odisha by Mahapatra and Kumar and Shi et al., [13,14]. Further, they suggest improvement of basic infrastructure and referral network that could help in achieving better health of the vulnerable population. Hence, improving access of tribal communities to the health centers by strengthening communication facilities could improve the health status.

Additional efforts are required for capacity building of front line workers (ASHAs, ANMs, health workers, etc.) to track ANC progress by the help of HMIS. This will make home visits regular, effective and meaningful particularly in remote tribal communities. There is a need of flexible cash transfer schemes, particularly for tribes, understanding their difficulties in maintaining all records and documents.

Similar studies are consistent with our current findings reported by Joshi & George and Bhatia regarding the operational challenges in Maharashtra [15,16]. In addition to sufficient incentive, they suggest provision of regular training to grass root level workers to minimize attrition. Further, there is requirement of simplifying the procedures of reporting and monitoring of pregnant mothers. The ASHAs need to be given with sufficient drugs in ASHA kit to provide prompt care in the community.

Innovative methods may be adopted to empower tribal communities to identify important parameter of maternal morbidity: preventive measures, danger signs, referrals. This would ensure health seeking behaviours in the tribal communities. Social determinants of health in tribal area, especially improvement of living conditions, women leadership, education, money and other resources should be taken into consideration while rolling out JSY program in more inclusive manner. Besides focusing exclusively on increasing JSY coverage, a deeper insight is required to understand how the cash is spent at family level to reap the targeted benefit. Mahapatra & Kumar reported similar findings in tribes of Odisha [13]. They recommend improvement of living conditions by various government programs which ultimately promote the health of the tribal communities.

Rath and Acharya confirmed the importance of social determinants of health in tribal communities to gain health [17]. Further, their arguments are directed toward creating awareness about different tribal beliefs and practices that affect health in reproductive age. Emphasis on social determinants of health is a focus area for the improvement of health in the vulnerable community.

In addition, the findings of some of the similar studies have been evaluated regarding the maternal health situation and the utilization of services in different part of India in [Table/Fig-9].

The assessment at both the district level and block level in Balasore district showed a gloomy picture and provides ample room for improvement of the health system for the delivery of maternal health services in the region. The six health system building blocks depicted by the World Health Organization undoubtedly do not match the requisite standards of maternal health service delivery at both levels. All these six building blocks need to be strengthened in order to improve the maternal health services of the district. Considering the unusual physiography and socio-cultural context of the region specific strategies need to be devised for the delivery of desired maternal health services.