Community-led solutions to promote safe institutional deliveries in scattered tribal settlements of Madhya Pradesh, India

Abstract

Background

In Madhya Pradesh, India, the Department of Public Health and Medical Education has undertaken initiatives to promote institutional deliveries in aspirational districts through community engagement and the involvement of frontline health workers. However, in districts with scattered settlements, hilly terrain, and difficult-to-reach hamlets, geographic and infrastructural barriers continue to constrain maternal health outcomes. In the tribal district of Barwani, traditional beliefs and cultural preferences further reinforce the community’s reliance on home-based deliveries, which increase the risk of preventable maternal and neonatal complications and deaths. To address these intersectional inequities in rural India, the Antara Foundation, a public health nonprofit, piloted a community-led Home Delivery Prevention Model in Pati block of Barwani district. The model aimed to quantify and address barriers contributing to home deliveries through the active involvement of the local community. Institutional delivery was used as a proxy indicator for access to institutional maternal care.

Objective

This paper documents the implementation of the model that ensures institutional deliveries among pregnant women in ‘hard-to-reach’ hamlets (faliya) and explores how locally driven, community-led approaches can promote equitable access to public healthcare in remote, indigenous settings.

Methodology

The model, designed in December 2023 with the help of community volunteers, was implemented from January to June 2024. A mixed-methods approach was used, with quantitative analysis of government data to identify pilot areas. Content analysis of the qualitative data, which was collected by the implementation team from pregnant women and their families through FGDs and interviews, informed the community action. A purposive sample of 127 pregnant women was selected across five sub-health centres (SHCs) with the highest number of home deliveries. Data collected was stored, handled and managed ethically throughout the pilot, guided by the Declaration of Helsinki 2024.

Results

The intervention demonstrated preliminary improvements in family and local community support, resulting in institutional delivery for 83% of pregnant women who gave birth during the study period.

Conclusion

This pilot study provides evidence that community-led models, grounded in local participation and integration with public systems, can enhance the uptake of institutional care in regions with high geographic and social inequities.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02849-4.

Plain language summary

In Madhya Pradesh, India, the Department of Public Health and Medical Education has undertaken initiatives to promote institutional deliveries in aspirational districts through community engagement and the involvement of frontline health workers. Despite ongoing government efforts, scattered settlements in hilly terrain and difficult-to-reach hamlets in some districts significantly limit the maternal health outcomes in remote communities. Additionally, in the tribal district of Barwani, due to traditional beliefs and cultural differences, the community prefers that women deliver at home. To address this multi-layered presence of health inequity, the Antara Foundation, a non-profit organisation, piloted a community-led model in one of the district’s administrative blocks, Pati. The intervention quantified the spread of geographical and institutional inequity in the block and, through targeted intervention, identified measures to address them locally. The proxy for institutional care was institutional delivery of pregnant women in areas with the maximum share of home deliveries. The model, designed in December 2023 and implemented from January to June 2024, tracked 127 pregnant women. In the five SHCs with the highest and moderate home delivery caseloads, 98 women delivered during the study period, of whom 81 (83%) delivered in hospitals, following targeted support and follow-ups by empowered community volunteers, tribal field coordinators, and frontline workers. This pilot study provides evidence on how community-led models, grounded in local participation and system integration, can enhance institutional equity in regions with high geographical and social challenges.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02849-4.

Introduction

Over the past decade, India has strengthened maternal and child healthcare through expanded service delivery and a more robust public health infrastructure. However, despite continued public health efforts and global advancements, maternal and newborn deaths remain disproportionately high among Indigenous communities1 in India, particularly in states with remote rural regions like Madhya Pradesh [1]. This is largely attributed to limited access to timely care and treatment, particularly in forested tribal areas [2]. India’s public healthcare system aims to improve maternal, newborn and child health and nutrition (MNCHN) indicators by expanding service reach to the most remote areas. Indian Public Healthcare Standard (IPHS) 20222 guides the availability and quality of primary-level healthcare, with one facility for every 5,000 population and in tribal areas, for every 3,000 population [3]3. This is because tribals live in geographies that are spread out or forested and require closer attention to ensure they receive all services on time. This is also important as there continues to be a stark disparity in health outcomes between the culturally, ethnically, and socially diverse Indigenous communities and their non-Indigenous counterparts, as the Lancet Global Health (2021) highlighted in a recent study [4].

Madhya Pradesh (MP) is the second-largest state in India by area, with the fifth-largest population (nearly 88 million, comparable to that of Turkey). With an infant mortality rate of 40 per 1,000 live births4, exceeding the national average of 26 and a maternal mortality ratio of 159 per 100,000 live births, higher than the national average of 885, Madhya Pradesh presents a critical opportunity for improvement [5]. Enhancing maternal and child health outcomes in the state could yield substantial gains in national health statistics, making it a strategic focus area for collaborative efforts between government and private partnerships. The Antara Foundation (TAF), a non-profit organization, implements its Akshita program across rural regions of MP. The overall program aims to improve maternal and child health outcomes by supporting the public healthcare system to deliver solutions at scale. TAF partners with the government and communities to improve the quality of services, prioritising high-risk beneficiaries for timely services, and creating a strong referral mechanism. This paper presents a reflective documentation of one pilot conducted by TAF in the Barwani district. This tribal district in Madhya Pradesh has a population of 1.38 million, with the Bhil and Bhilala tribes accounting for 69% of it.

The Health Management Information System (HMIS) report for 2019–2020 reveals that despite accounting for only 1.5% of Madhya Pradesh’s population, Barwani district contributes a significant 18.5% to the state’s total home deliveries, the highest among all districts. This is followed by Sheopur and Khargone districts, which account for 13.8% and 13.3% of the share, respectively.6 For tribal communities in Barwani, difficult terrain and traditional beliefs are major obstacles to accessing hospital deliveries.

In 2018, Barwani was selected as an aspirational district under the government’s Aspirational Districts Programme, which aims to effectively transform 112 of the most underdeveloped districts across the country, with the support of the state-level administration. To understand the health burden in Barwani, across its nine administrative blocks7, TAF analysed health administration data, such as the Health Management Information System (HMIS). In the year 2022-23, a total of 65 Neonatal Deaths were reported in Barwani. Out of these, 13 deaths (20%) were in Pati Block, while 15 out of 22 (68%) Maternal Deaths reported for the district were also from Pati Block. This revealed a disproportionate burden of health inequity on Pati, which has a projected population of 205,766 and requires at least 10 delivery points as per the IPHS guideline8. It currently has eight delivery points, including one non-functional facility, resulting in 70% coverage only. Due to its institutional gaps and particularly difficult terrain, Pati was recognised as an Aspirational Block in 2023.

In Pati, villages are scattered over a 3–5 km radius, forming hamlets separated by hills. This poses logistical hurdles for health workers to deliver timely services to all beneficiaries. Furthermore, the presence of traditional healers and midwives, who are often trusted by local communities for safer delivery practices, challenges the uptake of institutional services. This highlighted the need for collaborative efforts to strengthen the public healthcare system to deliver better care to the indigenous community.

Background

India’s public healthcare system comprises a network of government-run facilities and services designed to provide affordable and accessible healthcare to everyone, particularly in rural and underserved areas. It operates at three levels:

1. Primary Healthcare: The foundation of India’s public health system, primary healthcare focuses on preventive, promotive, curative, and basic rehabilitative services. It includes treatment for common illnesses, maternal and child healthcare, immunization, and disease prevention. These services are primarily delivered through Sub Health Centres (SHCs)9 and Primary Health Centres (PHCs), with outreach support at the village level.

2. Secondary Healthcare: Secondary care provides medical services beyond primary care but not necessarily with highly advanced technology. It includes treatment for moderate to complex conditions, such as surgeries, skilled childbirth care, and advanced diagnostics. Delivered at district hospitals and Community Health Centres (CHCs), it serves as a referral link to tertiary care.

3. Tertiary Healthcare: Tertiary care represents the highest level of medical care, involving advanced and specialized diagnostic, therapeutic, and rehabilitative services. Tertiary Care Institutions serve as a centre for referral, medical education, and research.

Primary Healthcare caters to the last mile, and its outreach is extended in India with the support of programs like the National Health Mission, where Accredited Social Health Activists (ASHAs) in every village promote health care and mobilize communities to access healthcare services. The Antara Foundation (TAF) has partnered with the Madhya Pradesh government for the past five years to address the challenges that public health institutions face in delivering services. The TAF intervention package aims to strengthen the healthcare system and expand its outreach to ensure that every mother and child receives timely services.

During TAF’s ongoing health system strengthening efforts in Barwani, initiated in January 2022, the TAF team conducted qualitative interviews with frontline healthcare workers (most of them belonging to the indigenous community) and engaged with pregnant women and their families to elucidate the barriers influencing their decisions regarding institutional care and hospital deliveries. Institutional barriers were vividly apparent, contrary to IPHS norms, where one SHC is designated to serve a population of approximately 3,000, typically covering 3–5 villages; most facilities cater to more than that. In Pati block, each village comprises an average of three hamlets, with nearly 30% having more than six hamlets situated 1–5 km away from the nearest village health facility and farther away from the SHC. Moreover, 86% of Pati lack internal roads connecting faliyas (hamlets) within villages, and approximately 70% of villages do not have mobile network coverage, further limiting healthcare access and communication. Additional barriers included women’s limited mobility outside their faliya and a lack of trust in the public healthcare system, which remained geographically distant and socially unfamiliar to the community. Consequently, Pati was prioritized for further investigation to understand these barriers and inform targeted interventions.

An actionable insight from the intervention area was to work closely with the community to understand each barrier and explore how they could help solve it. In the district of Barwani, with its hilly terrain, scattered households, and language barriers, a mechanism was developed to engage the community in identifying and addressing these challenges.

Literature review

Maternal health outcomes are shaped by a complex interplay of structural, systemic, and socio-cultural determinants. Souza et al. (2023) highlight global trends in maternal mortality, emphasizing the role of health system capacity, socioeconomic disparities, and governance in shaping maternal health transitions. Their analysis underscores that while improvements in skilled birth attendance and facility-based deliveries contribute to reductions in maternal mortality, persistent inequities, particularly in low-resource settings, continue to hinder progress (Dehury, 2022) [6]. Thind et al. (2008) reinforce these findings in the Indian context, illustrating how factors such as education, economic status, and distance to health facilities influence the choice of delivery location, with home births remaining prevalent among marginalized populations due to socio-cultural and infrastructural barriers (Ussatayeva, 2021) [7]. Research indicates that harmful social norms frequently contribute to poor health outcomes. Social norms can perpetuate harmful health practices and hinder positive behavioural changes, underscoring the importance of addressing these norms in health interventions (WHO, 2008) [8].

The challenges faced by indigenous and disadvantaged groups10 are further emphasized by The Lancet Global Health (2021) [4], which argues for the continued recognition of indigenous rights in health policies. This aligns with the broader discourse on health inequities, particularly in maternal care, where indigenous and marginalized women face systemic barriers to accessing quality healthcare. Studies exploring the intersection of social determinants and maternal health highlight the ethical and policy implications of inequitable access to maternal health services (Sri, 2012) [9]. These works emphasise the need for rights-based approaches that prioritize community engagement and culturally sensitive interventions to ensure timely care for pregnant women. Timely care and referral are important, as delays in reaching healthcare facilities have also been widely observed to contribute to preventable maternal and child mortality (Carvalho, 2020) [10]. Furthermore, secondary sources highlight the role of community empowerment and building governance structures in shaping maternal health policies, which necessitate the involvement of local governance in all health interventions. (World Health Organization, 2008, pp. 2, 192, 199) [8].

The International Journal for Equity in Health (2020) published a paper that demonstrates why indigenous communities often refrain from using public healthcare services, even when they are accessible (George et al., 2020) [11]. Most of the behavioural observations in this study among the indigenous communities of Kerala were found to be true for the Bhil community in Barwani, Madhya Pradesh. Hence, this pilot not only offers solutions to improve access but also provides examples to meaningfully engage tribal communities in government efforts to sustain the improved uptake of maternal and child healthcare services. Addressing infrastructural deficits, fostering trust in health institutions, and integrating community-led approaches are critical for sustainable improvements. A study focusing specifically on TAF’s intervention area, Barwani, reported a list of social determinants that contribute to tribal health challenges across Madhya Pradesh (MP) and highlighted the need for a targeted tribal plan (AIGGPA, 2019) [12]. TAF’s study builds on this report to delve deeper into some of these social determinants that directly affect the targeted indicator of Institutional Deliveries in Barwani.

Objectives of the study

Barwani is one of the intervention districts where the overall program has been running since 2022. The objective of this pilot was to identify and address barriers that limit pregnant women’s access to institutional delivery through community support. This study presents the process of achieving positive results in the targeted maternal health indicator of institutional deliveries through dedicated community engagement.

Methods and materials

This is a mixed-methods study that involves both quantitative and qualitative data. The government’s Health Management Information System (HMIS) database, which includes monthly health administration reports, was used to study the status of maternal and child health indicators. Qualitative data were collected during the project through interviews and focus group discussions (FGDs).

To achieve the objective of improving institutional delivery, a pilot study was conducted from January 2024 to June 2024 in the Pati block of Barwani District, involving 127 pregnant women. Based on preliminary observations from the field, the study plan incorporated two arrangements:

• Targeting Sub-Health Centres (SHCs): The area of intervention was selected by prioritizing some maternal and child health indicators. Due to logistical and resource limitations, the project was tested in the most concerning areas as per prioritized indicators.

• Engaging Local Representatives: A team from the local tribal community, who speak the local language of Bhil or Barela, were recruited. They were familiarised with the public healthcare system that is accountable for providing improved outreach and counselling to all pregnant women, lactating mothers, and children, and were trained to engage with the participants sensitively.

Scope of study

This study focuses on documenting actionable findings from pilot intervention, particularly in understanding and addressing barriers to institutional deliveries through community engagement. While improved maternal and child health outcomes are an expected long-term impact of this intervention, their assessment/ evaluation falls beyond the scope of this study and requires further longitudinal research.

Sample selection

Using administrative data from HMIS, April 2023 – January 2024, all SHCs in the total home deliveries of Pati Block were categorized as High, Medium and Low based on their share of home delivery in Table 1:

Table 1.

Categorization of the share of Sub-Health Centres in Home Delivery

SHCs and their Contribution to Home Deliveries
No of SHC	Contributor/Case load	No of HD	% Contribution
12	High	386	54%
16	Medium	245	34%
21	Low	83	12%
49*		714	100%

Out of the 12 SHCs with the highest contribution and 16 with a medium contribution to home delivery, a total of 5 SHCs were purposefully selected in consultation with the district collector11 of Barwani. All of the 49 SHCs were within TAF’s intervention area; however, only five were prioritized due to their challenging terrain, availability of staff and resources at health facilities, and the organization’s logistical feasibility. All the registered pregnant women in their last trimester of pregnancy (gestational age above 7 months) were selected for the interviews from the line-list database of these SHCs. The study only excludes pregnant women who were not present at home at the time of the visit.

Data collection

Community Conversations across Pati block, conducted in December 2023, informed the team of the common barriers that influence pregnant women’s decisions to deliver at home. These barriers were shortlisted, and a semi-structured open-ended interview was designed around them. A total of 127 pregnant women in the selected SHCs were in their third trimester of pregnancy, as reported by the frontline workers at these centres.

After obtaining informed verbal consent from these women, a semi‑structured questionnaire was used to interview all of them through house‑to‑house visits and FGDs with their family members from January 2024 to June 2024. The frontline workers in the SHC were asked to communicate the purpose of these home visits to the families in advance. The team was clearly instructed to speak in the local language, which was translated into Hindi for the record later. It is important to build rapport on the first visit, and hence, rather than documenting the entire conversation during the interview and FGDs, only the information that provided an inference on the barriers was documented.

Each interview and FGD was conducted in the home setting. Only those trusted by the family were part of the discussion. Key decision makers in the family were intentionally included in the discussions. The influential people, like traditional healers (Baba) and midwives (Dai) were not included in the FGDs to ensure the responses are unbiased and capture independent perspectives. In some cases, where facilitators required trusted traditional healers and midwives to convince the families to talk to them, only then were they initially allowed to sit during discussions. However, even in these cases, an exclusive interview with pregnant women was ensured through frontline health workers.

These FGDs and interviews focused on understanding the key barriers preventing pregnant women and their families from opting for institutional deliveries and their possible resolutions. Furthermore, both in the interview and during the FGDs, it was emphasised that the participation was completely voluntary and that participants’ answers would only be used within the government’s health system for their institutional care; otherwise, they would be treated confidentially and anonymously. Participants and their families were also informed that they can refuse to engage with the team at any point, and their information will be omitted from the study if they choose to. When barriers linked to Baba and Dai were largely reported in particular cases or areas, they were followed through separate discussions with the two constituencies to understand their influence and perspectives.

Following the first interviews with the pregnant women, the team visited them for follow-ups during which regular data on their access to available public health services was collected.

Team for data collection and action

As discussed in the literature review, research has shown that introducing institutional care to Indigenous communities requires trust building, as healthcare decisions are deeply influenced by social norms and traditional beliefs. To address this, the study recruited and engaged local community members to guide implementation, ensuring that any case-related intervention was culturally appropriate and accepted. The team was composed of individuals from the same community, each cadre playing a distinct role:

1. Field Coordinators (FC) – Local tribal people who were part of the extended TAF team, responsible for conducting interviews and FGDs with pregnant women, their families, and community influencers12 to document barriers and perceptions related to institutional deliveries. They also actively collaborated with village communities to design strategies to resolve barriers.

2. Faliya Volunteers (FV) – Local volunteers who assisted frontline workers in providing continued follow-up and immediate support to pregnant women at the household level. As households are scattered across the village in hamlets, these faliya-level volunteers were responsible for connecting pregnant women in faliya to village services.

3. Tribal Community Counsellors (TCC) – Trained counsellors from the tribal community who provided targeted counselling to pregnant women hesitant about institutional care, addressing their fears and concerns through culturally sensitive engagement.

FCs and TCCs were trained in conducting sensitive and informed conversations on maternal health, supported by a concise two-page guidance document. FVs were from the same hamlet, so they were introduced to the services available for mothers and children under the public healthcare system, and their importance. This community team ensured that barrier resolution strategies were contextually relevant, leveraging existing social structures to promote institutional deliveries.

Data recording and privacy management

Due to data sensitivity, no audio or video recordings were made. Some photos were taken after verbal permission and written consent from participants and their families. The team’s handwritten field notes from the FGDs and interviews were used to update the barrier information in a Microsoft Excel sheet called Barrier Assessment Format [attached as a supplementary file 1]. Data collected was stored, handled and managed in this sheet ethically throughout the pilot, guided by the ‘Free and Informed Consent’, ‘Privacy and Confidentiality’, ‘Individual, Group, and Community Vulnerability’ sections of the Helsinki Declaration of 2024. The study does not include real names or any other identifiable information about participants to ensure anonymity.

Data validation

To ensure the accuracy and reliability of institutional delivery data, multiple validation steps were incorporated into the study design. The status of each delivery was confirmed by cross verifying the Janani Suraksha Yojana (JSY)13 enrolment records and reviewing discharge papers for all reported cases. FCs maintained an MS Excel sheet with data validation details and all relevant documents used for it. [validation sheet attached as supplementary file 2] FCs received specialised training to accurately capture relevant variables, identify barriers to institutional delivery, and assess their magnitude using a structured Excel-based data collection tool. This combination of documentation review, systematic data entry, and culturally sensitive field engagement enhanced the validity of the findings, ensuring that both quantitative and qualitative data accurately reflected the true context of institutional deliveries in the intervention area.

Data analysis

A descriptive content analysis was conducted by listing all barriers under the eight most frequently observed categories.

Barrier 1- Ambulance not available: This code included any mention of free ambulance service not available, including ambulance not reaching the village, unavailability or delay in ambulance and ambulance driver asking for money.

Barrier 2- Access Issue/Difficult Terrain: This barrier included internal road connectivity, accessibility to the main road, access limitations due to hilly terrain to facilities within the village, and the availability of drivable roads between the village and healthcare facilities.

Barrier 3- Dai is a preferred choice: Traditionally, communities were dependent on locally available midwives/birth attendants for home deliveries and therefore still trusted them. This barrier reflected the family’s preference to have their daughter or daughter-in-law delivered at home, in the presence of the local midwife, whom they locally call ‘Dai’.

Barrier 4- Family and Social norms: Women’s mobility is limited due to a patriarchal society in Madhya Pradesh. If participants provided references to instances where they were unable to access the nearest facility due to their family’s intervention, this barrier was highlighted. Other restricting norms followed by the family were also tagged with this barrier.

Barrier 5- No mobile network: This barrier consisted of cases where villages had no area with mobile connectivity, or some areas with limited connectivity.

Barrier 6- Lack of emergency preparedness: Some basic preparations are required before a delivery, like clean clothes, some money, finding a blood donor for emergency, understanding risks from antenatal checkups, sonography, and contact numbers of the nearest facility. Lack of any of these was noted under this barrier.

Barrier 7- Baba advised for home delivery: During home visits, many families choose to deliver at home because they fear going against Baba’s (local traditional healer) advice. It was observed that many traditional healers asked families not to go outside the village to deliver, as it may turn fatal. Such reasons were considered under this barrier.

Barrier 8- Migration: Many families or family members migrate outside the village in search of a livelihood. This category of barrier covered the extent to which this migration was affecting the family’s decision to deliver at health care institutions.

The cumulative frequency of each barrier was recorded, and the most observed barriers in the SHCs were prioritized to ensure safe institutional delivery of pregnant women there. During the FGDs with families of the pregnant woman, possible resolutions were identified, and collective action was taken with the support of the field team. Initially, HMIS data were analyzed to record institutional delivery of registered pregnant women; the same data were observed month-on-month during the pilot.

Data interpretation and action

To synthesize qualitative insights from interviews, a grading matrix was developed to categorize barriers encountered in the field [as shown in Table 2]. While responses varied across interviews, a standardized classification system was applied to ensure comparability. Barriers were graded as High, Medium, or Low based on three key factors:

Table 2.

Snippet of columns that record barriers from the MS Excel

Case No.	Barrier 1 Ambulance not available	Barrier 2 Access Issue/ Difficult terrain	Barrier 3 Dai is a preferred choice	Barrier 4 Family and Social norms	Barrier 5 No mobile network	Barrier 6 Lack of emergency preparedness	Barrier 7 Baba advised for home delivery	Barrier 8 Migration
1	Medium	Medium	High	Low	Low	High	Low	Low
2	Medium	Medium	Medium	Low	Medium	Medium	Low	Low
3	Low	Low	High	Low	Medium	High	Medium	Low
4	High	High	High	High	Medium	High	Medium	High
5	High	High	Medium	Medium	Medium	Medium	Medium	Low
6	High	High	High	Medium	Medium	High	Medium	Low
7	Low	Low	Medium	Medium	Low	High	Medium	Low

Extent of the Challenge – The severity and persistence of the barrier as described by respondents.

Impact on Institutional Deliveries – The degree to which the barrier influenced decision-making regarding delivery location.

Alternative Solutions Available – The availability of mitigating factors, such as access to private transport, network availability, or social support.

Each grade was explained as:

• High: Barriers that severely restricted institutional deliveries with no immediate solutions.

• Medium: Barriers that posed challenges but could be mitigated with some effort.

• Low: Barriers that existed but had minimal impact due to the availability of alternatives.

The process that followed the interpretation is shared below and demonstrated in Fig. 1:

Fig. 1.

A 3-step process of identifying village, assessing barriers and finding community-led solutions

Step 1: Identify villages in the SHCs with the highest home deliveries and provide handholding to frontline workers to strengthen the public healthcare system’s service delivery, wherever necessary.

Step 2: Pregnant women who were due for delivery within the next 3 months were visited and interviewed to understand their barriers to seeking institutional care. The barriers were discussed with the families through FGDs and organized under the 8 barrier categories.

Step 3: A well-wisher of each pregnant woman or an active fellow resident in the cluster (faliya) was identified as a medium of communication between the frontline worker and the pregnant woman’s family. Each visit by these volunteers was aimed at understanding why families chose home-based deliveries, assessing the quality of the MNCHN service available to them, and encouraging safe institutional deliveries. Influential community members, including the Sarpanch, the elected leader of the village’s local governance system, were informed of the existing barriers and involved in resolving them. Through this process, each pregnant woman was supported in resolving the most prominent barrier in her case.

The necessary permissions to work with the community were obtained from the district administration and block-level officials in the health department.

Results

While the TAF team prioritized and tracked the 98 pregnant women from the areas with a high likelihood of home delivery, most of them (83%) resulted in institutional deliveries. Content analysis of interviews with pregnant women and FGDs with their families in selected SHCs revealed that these barriers played a role in their earlier preference for home deliveries, which shifted after barriers were resolved through community-led efforts.

The broader analysis of these barriers showed that the influence of Dai, lack of emergency preparedness, limited presence of internal roads, and the family’s social norms are major contributors to home deliveries. Refer to Fig. 2.

Fig. 2.

Categorization of Barriers based on severity

Strategies to resolve the barriers

Faliya-level volunteers (FVs) were trained by TAF to connect the families with the frontline workers. Tribal Community Counsellors (FCCs) visited every pregnant woman, along with frontline workers, to counsel them on good maternal health practices, understand their barriers, and advocate for institutional delivery. With the support of FCs, FVs mobilized community members to ensure institutional delivery for the pregnant women of their village. The community listed possible solutions in each case, which are broadly explained below in Table 3:

Table 3.

Mitigation strategy followed by community for each barrier

S.No.	Theme	Mitigation Strategy
Barrier 1	Ambulance not available	The ambulance service was given the address of the nearest point it can reach. Family or influential members were proactively mobilized by the team to arrange for a private vehicle to transport them to the ambulance.
Barrier 2	Access Issue/ Difficult terrain	In some cases, Faliya volunteers arranged for makeshift methods to help pregnant women cross hills and rivers to reach the ambulance. Relatives who lived closer to the facility or where ambulances could reach, volunteered to give shelter to the pregnant woman and her family till the delivery date.
Barrier 3	Dai is a preferred choice	The volunteer team met Dai in selected villages. Especially in cases of high-risk pregnancy, Dai was informed of possible risks to the health of the mother and child, after which Dai motivated women to deliver at the hospital, and accompanied them as a birth companion.
Barrier 4	Family and Social norms	During FGDs, the hesitation of families in delivering at the hospital was addressed. They were informed of basic facilities that must be available for a safe delivery, which could not be arranged at home. Baba and Dai volunteered to guide families in avoiding any dangerous rituals or practices during pregnancy.
Barrier 5	No mobile network	When the government was informed of this challenge, they requested that the pregnant woman reach the hospital by ambulance prior to her estimated delivery date. In the event of an unexpected labour, Faliya Volunteers coordinated among themselves to inform frontline workers and TAF’s Field coordinators.
Barrier 6	Lack of emergency preparedness	The team assisted pregnant women in organizing birth preparation kits. Frontline workers actively focused on pregnant women and families that lacked emergency preparedness, and female faliya volunteers followed up regularly on all preparation-related updates.
Barrier 7	Baba advised for home delivery	The TAF team met Baba (traditional healer) and informed them of all possible risks associated with home delivery. In many instances, Baba encouraged pregnant women’s families to seek institutional care after these efforts.
Barrier 8	Migration	The public healthcare system provides a ‘mother and child protection’ card, which was duly filled out with all necessary details before the woman migrated. This made it easier for the pregnant woman to access services at a new place.

Along with supporting community-led mitigation strategies in each case, TAF presented the report of these barriers to district administration to provide support and further address institutional gaps.

• 95% of cases tracked lack emergency preparedness, indicating that last-minute planning or lack of awareness contributes to home deliveries. A major reason behind this was the influential presence of Dai (96%), and in 70% of cases, the influence of traditional healers (Baba) in decision-making. During the focus group discussions, families shared that a traditional healer had advised them against calling an ambulance, instead instructing them to consult the healer directly in case of complications. In one instance, a family mentioned that the healer had tied a protective thread around the pregnant woman and emphasized reliance on his care alone. In some hamlets, families report that they trust the local healer more than ANMs because they have never seen any cases fail under their care - “Not a single case handled by Baba has gone wrong.”

• 70% of cases tracked are in the least accessible areas (faliyas), hence more than 65% of cases were unable to avail themselves of ambulance service. In such cases, faliya-level volunteers connected the pregnant woman with the frontline workers in the main village and mobilized the village to arrange for transport till the point where an ambulance can reach.

• About 91% of the cases reported a strong influence of family-level social norms that considered home delivery a normal and preferred practice. During in-depth interviews, pregnant women shared various reasons supporting this preference, such as: “After delivering the baby in the hospital, if someone else touches the baby, purification ritual has to be done for the family deity.” Others mentioned, “The prayer rituals cannot be performed for the first three days if the baby is in the hospital,” or that “In the hospital, they do not bathe the baby. When the mother delivers at home, we can easily give baby a warm bath.” Some also stated, “In our house, my mother-in-law/father-in-law does not allow delivering at the hospital.”

• As 66% of cases tracked were in a no mobile network zone, one of the factors for migration, which is observed in 23% of cases. FCs made special visits to these zones and actively coordinated with FVs and frontline workers to make timely calls for ambulances.

Through various strategies adopted by the community, these barriers were resolved for the pregnant women to result in institutional deliveries. Out of 98 pregnant women who were interviewed and delivered during the period, 81 (83%) delivered at the hospital. The mechanisms discussed earlier were crucial in addressing barriers that made institutional delivery possible for these mothers. The highlighted barriers were resolved by the community. Among 26 families from the FGDs who initially insisted on home-based deliveries, 20 (77%) eventually chose institutional deliveries after regular counselling.

Responses observed among families and frontline workers:

1. Positive Behaviour Change in Husbands: In some cases, the husband took a strong stand to ensure his wife delivers in a safe, clean and well-resourced facility.

2. Frontline workers felt encouraged: Frontline workers mentioned that they felt supported after the active involvement of the community in supporting safe deliveries for women. Experiences with frontline workers and supervisors also suggest that this community-led approach has the potential to support the uptake of any public health service.

3. Trust building in the public healthcare system: An important externality of this approach was strengthened trust in the public healthcare system. This was observed as a result of the community’s close collaboration with government representatives, e.g., frontline workers involving communities in identifying and addressing barriers. These findings reinforce the importance of culturally sensitive, community-led strategies, especially counselling, in addressing persistent barriers to institutional delivery.

Case Study: Towards better health care decisions

Devi* was a young mother of 2 girls living in a remote, deeply forested village in Barwani. Her delivery was due on the 25th of January 2024. Everyone in her family believed in ‘baba’ (traditional healer), who made it very clear that delivering at home was the only way to keep Devi and the baby safe during childbirth. The family was also in continuous consultation with ‘Dai’ for all the pregnancy-related concerns. The frontline workers (FLWs) wanted to ensure that Devi, who has a High-Risk Pregnancy (height < 145 cm), delivers in the safety of a hospital and sought support from the TAF field coordinators. When the TAF team visited on January 24, they found that Devi faced several barriers to institutional delivery, including absence of roads to the hospital and her family’s undisputable trust in traditional healers. Further, the family was not prepared for an institutional birth. Taking note, the field representatives supported FLW with multiple visits to Devi’s house, consistently counselling them on the importance of institutional delivery and on government’s financial benefits that the family would receive as an incentive for opting for formal healthcare. The family was convinced, and Devi was eventually delivered at the nearest government hospital in early March. Both the mother and the baby are safe. This process informed the FLW on how to identify preventable home deliveries and create targeted plans to help families make better health decisions. (*name changed)

Discussion

The findings indicate that while supply-side barriers, such as ambulance unavailability and limited road access, are being addressed through government intervention, community-led solutions have been crucial for addressing socio-cultural and physical barriers to promote emergency preparedness for safe deliveries. Birth preparedness by frontline workers must also include addressing the barriers pregnant women face in taking charge of their health.

Institutional deliveries in Barwani remain a crucial indicator for maternal and newborn survival. Despite global progress in maternal, newborn, and child health and nutrition (MNCHN), preventable deaths persist, disproportionately affecting marginalized communities. The Indian public healthcare system seeks to address this challenge by expanding service delivery to the last mile through a tiered network of community-level and primary health facilities (MoHFW, 2022) [13]. However, Indigenous communities in India continue to face significant disparities in healthcare access due to geographical, social, and systemic barriers. Resolving these barriers is not possible without dedicated community support. This intervention leveraged tribal representatives and frontline workers to engage families and shift preferences toward institutional deliveries. Community awareness of the challenges of institutional delivery and their active support for pregnant women are at the core of improving MNCHN status.

The study’s findings align with global evidence highlighting cultural and infrastructural challenges in institutionalizing maternal care among Indigenous communities. (Kildea et al., 2018; Dehury, 2022) [6, 14]. Global research that cites similar challenges includes various methods of involving the community in overcoming possible barriers. Several South Asian countries have adopted innovative approaches to reduce home deliveries. For instance, Bangladesh has invested in community-based skilled birth attendants and improved transportation for emergencies. Nepal has focused on increasing institutional deliveries through incentive programs and building more birthing centres in rural areas. Sri Lanka has strengthened its primary healthcare system and trained midwives to offer better maternal care. These efforts have significantly reduced home deliveries in these countries (Khatri, 2024) [15].

Our study also highlights the need for government intervention to enhance last-mile connectivity, strengthen referral systems, and address trust deficits in institutional healthcare within the community.

Limitations of the study

This article is subject to certain limitations, stemming from both its design as an implementation model and its restricted geographic scope. First, it was conducted exclusively in a high-priority block of Barwani district, which may limit the generalizability of the findings to other tribal areas with different socio-cultural and health system contexts. The focus on Barwani and its blocks was determined by the need to design and pilot solutions within The Antara Foundation’s current intervention area, rather than to represent the wider tribal population of Madhya Pradesh or India.

Second, the primary aim of this work was to document an intervention pilot, rather than to conduct a rigorously controlled scientific evaluation. As a result, the study may lack certain methodological features, such as randomization, control groups, or longer-term follow-up, that are characteristic of more robust research designs.

The study contributes to the discussion on equity in healthcare access with an evidence-backed community engagement strategy. However, future research should seek to validate these findings across diverse tribal settings and employ more rigorous study designs to strengthen the evidence base for scaling up community-led models for institutional delivery.

Conclusion

In cases where families which were initially reluctant to visit the hospital became readily available to do so, due to the trust built by the team of local coordinators. Community led the mobilization of required resources that were within their reach and connected with the health system to address the prioritized barriers effectively.

Providing safe institutional delivery remains a challenge in many developing countries, hindered by deeply rooted cultural, logistical, and systemic barriers. However, community-led interventions, strategic engagement of traditional birth attendants, and government-supported infrastructural improvements can collectively enhance institutional delivery uptake. Additional observations from this pilot suggest that institutional deliveries may help prevent maternal and neonatal deaths by enabling timely management of complications; however, further research is needed to substantiate this inference or provide any comments. Experiences with frontline workers and supervisors also indicate that this community-led approach has the potential to support broader public health objectives beyond maternal health.

Since this intervention was carried out in close collaboration with government health staff and utilised existing government data platforms, such as the HMIS, the model is inherently well-suited for integration into ongoing public health initiatives. Embedding community-led strategies within frameworks like the National Health Mission or similar government programs could facilitate broader adoption without creating parallel systems or duplicating resources. Furthermore, the recommended administrative practices (such as enhanced supervisory involvement, mandatory case reviews, and structured Health and Wellness Centre meetings) are already consistent with established government protocols. This alignment further strengthens the feasibility of scaling up and institutionalizing the model within the existing health system infrastructure. In Barwani, the government has recognised the contribution of this model and has started integrating it into the government’s efforts, underscoring its practical relevance.

Overall, the community-led model implemented in Barwani demonstrated potential in improving institutional delivery outcomes in high-risk tribal populations. Addressing socio-cultural barriers through trusted local actors and leveraging existing health infrastructure allowed for significant uptake. Such a community-led effort could catalyse long-term improvements in the uptake of any public service in underserved geographies.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Piyush Bhatt conceptualised, designed and led the implementation of the pilot study. He also provided datasets for preparing this manuscript. Anviti Awasthi wrote the main manuscript text and prepared figures from the shared datasets.

Funding

This study did not receive dedicated research funding. Data were generated as part of a donor-supported implementation project; however, no funds were exclusively allocated for study design, analysis, or publication.

Data availability

The format used for the analysis of barriers and the de-identified data validation sheet are included as supplementary files. However, the entire dataset used by community health workers during the pilot and the Health Management Information System (HMIS) report cannot be shared because it contains sensitive information about pregnant women that may harm the privacy of participants. The de-identified dataset and case studies from the pilot with anonymised information are available on a reasonable request to the corresponding author.

Declarations

Ethics approval and consent to participate

Authors declare that a formal ethical approval was not applicable as the study was conducted as part of routine program implementation. However, the pilot adhered to the ethical standards outlined in the Indian Council of Medical Research’s National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017) and Informed Consent and Privacy sections of the Helsinki Declaration of 2024. Participation was voluntary, and informed verbal consent was obtained from all individuals involved. In cases where pictures were clicked, written consent was collected. Participants retained the right to refuse or discontinue participation at any time. The data was used solely to support frontline workers within the public healthcare system, and only generalised analysis is presented in this study to ensure the anonymity of participants and the village.

Consent for publication

The authors declare that all participants photographed or video-recorded during the pilot provided written informed consent for the use of their images and videos for external purposes. Consent was obtained in participants’ local language. A copy of the consent form is available for review by the editor of this journal.

Competing interests

The authors declare no competing interests.