Institutional deliveries in India’s nine low performing states: levels, determinants and accessibility

Figures & data

Figure 1. Map showing geographical location of the study area (LPS) in the country

Figure 2. Selection of study participants, NFHS-4 2015–16

Figure 3. Conceptual framework showing the influence of background and intermediate factors on institutional delivery

Table 1. Descriptive statistics for the study participants, LPS, NFHS-4 2015–16 (n = 112,518)

Characteristics	N (Sample)	% (Percentage)
Place of residence
Urban	22,784	19.3
Rural	89,734	80.8
Caste
SC	21,748	21.1
ST	17,079	11.6
OBC	51,817	50.5
Other	18,616	16.8
Religion
Hindu	92,775	82.5
Muslim	16,941	15.8
Other	2,802	1.6
Age (years)
15–24	38,065	33.1
25–34	62,181	55.5
35–49	12,272	11.4
Age at marriage (years)
Below 18	49,044	45.7
18 and above	61,834	54.3
Education
No education	41,996	39.7
Primary	16,910	14.7
Secondary	43,954	36.9
Higher	9,658	8.7
Wealth index
Poorest	39,165	36.5
Poorer	27,730	24.3
Middle	19,061	16.4
Richer	14,426	12.5
Richest	12,136	10.4
Mass media exposure
No	39,624	37.7
Partial	66,930	56.7
Full	5,964	5.6
Pregnancy complication
No	62,798	54.8
Yes	49,525	45.2
Met with CHW
No	56,314	53.4
Yes	56,167	46.6
Distance to health facility
No problem	31,370	27.5
Small problem	39,249	34.6
Big problem	41,899	37.9

Note: Numbers are un-weighted and percentages are weighted.

Figure 4. Maternal mortality ratio (MMR) in LPS and other India states, SRS 2016–18

Figure 5. Coverage of institutional delivery (%) across LPS, NFHS-4 2015–16

Figure 6. Distribution of institutional delivery (%) by public-private sector across LPS, NFHS-4 2015–16

Table 2. Percentage distribution of institutional deliveries by selected characteristics across LPS, NFHS-4 2015–16

Characteristics	Assam (n = 8,534)	Bihar (n = 16,822)	Chhattisgarh (n = 6,805)	Jharkhand (n = 8,947)	Madhya Pradesh (n = 17,406)	Odisha (n = 9,015)	Rajasthan (n = 11,950)	Uttar Pradesh (n = 28,741)	Uttarakhand (n = 4,298)	All nine LPS (n = 112,518)
Place of residence
Urban	93.4	77.2	84.8	83.6	94.5	90.1	91.7	74.2	81.5	83.1
Rural	70.7	64.9	69.4	59.1	77.7	86.0	84.0	68.8	67.2	71.2
Caste
SC	85.0	60.1	71.4	59.3	85.2	87.2	86.5	66.7	65.9	71.0
ST	81.1	56.6	64.9	50.9	61.6	74.8	78.5	51.6	72.9	65.6
OBC	85.4	67.7	76.3	69.6	88.4	92.6	85.9	69.1	69.1	74.4
Other	66.0	71.9	90.1	82.0	92.2	92.9	91.3	78.9	76.4	80.3
Religion
Hindu	86.2	68.9	72.2	67.1	81.5	87.5	86.4	71.7	73.1	75.7
Muslim	55.6	53.7	91.0	62.6	90.9	74.5	78.4	62.6	65.0	62.6
Other	71.0	59.0	76.9	49.1	94.2	69.4	97.0	89.6	87.6	67.1
Age (years)
15–24	75.7	72.9	76.5	70.4	84.0	89.4	89.1	76.2	73.4	78.7
25–34	74.3	65.3	71.7	61.7	82.4	86.8	85.4	70.1	73.1	73.2
35–49	61.3	52.2	64.8	50.3	73.2	77.3	73.0	56.7	58.5	59.9
Age at marriage (years)
Below 18	65.5	63.7	63.2	59.5	76.7	81.0	82.7	63.9	60.7	68.2
18 and above	80.7	69.3	78.4	69.0	87.5	89.6	89.2	74.9	76.4	78.4
Education
No education	51.6	57.4	56.9	46.3	69.0	68.3	76.5	57.5	53.7	60.4
Primary	62.5	66.4	67.0	58.7	80.9	85.7	86.9	66.9	59.4	71.9
Secondary	82.5	79.2	78.3	76.8	90.0	94.8	92.7	79.2	74.5	83.5
Higher	97.3	92.5	96.5	92.7	98.2	97.8	97.6	91.2	93.2	93.9
Wealth index
Poorest	52.2	57.9	57.9	50.2	65.5	75.3	72.9	58.4	44.5	60.1
Poorer	73.7	71.3	71.8	70.3	83.6	88.9	82.2	68.7	53.6	74.4
Middle	87.3	79.4	77.8	75.4	91.0	95.5	87.5	72.6	64.8	80.8
Richer	93.5	85.3	83.4	87.1	93.2	97.7	91.2	77.2	76.2	85.3
Richest	98.1	92.3	92.8	95.6	97.9	97.7	96.6	88.4	91.5	92.9
Mass media exposure
No	56.0	60.0	53.7	50.5	66.4	72.0	74.0	60.7	51.8	61.4
Partial	83.0	73.4	75.6	74.3	87.3	90.4	89.7	75.1	73.3	80.2
Full	88.9	80.3	86.2	84.0	93.8	97.3	94.9	85.5	84.5	87.4
Pregnancy complication
No	73.2†	65.5	69.7	63.0	81.3	65.3	84.4	69.4	70.1	72.7
Yes	73.3†	67.1	76.7	65.7	83.6	88.1	88.2	70.5	74.6	74.6
Met with CHW
No	64.3	63.7	68.9	60.4	78.4	84.2	82.9	65.5	69.1	68.8
Yes	78.8	71.6	74.0	68.3	85.9	87.4	89.8	76.1	75.6	79.0
Distance to health facility
No problem	84.8	72.8	79.0	77.8	88.9	91.5	89.9	75.2	79.3	80.5
Small problem	75.1	70.6	75.1	67.8	82.5	88.7	86.3	70.5	73.7	75.4
Big problem	62.8	59.7	63.8	56.6	76.4	81.9	80.3	64.8	62.0	66.7

Note: All percentage differentials are significant at p < 0.05 (derived from Pearson’s chi-square test) otherwise indicated by †.

Table 3. Multivariate logistic regression models assessing socio-demographic and intermediate factors influencing institutional deliveries across LPS, NFHS-4 2015–16

Variables	Assam OR (95% CI)	Bihar OR (95% CI)	Chhattisgarh OR (95% CI)	Jharkhand OR (95% CI)	Madhya Pradesh OR (95% CI)	Odisha OR (95% CI)	Rajasthan OR (95% CI)	Uttar Pradesh OR (95% CI)	Uttarakhand OR (95% CI)	Overall OR (95% CI)
Socio-demographic factors
Place of residence
Urban (Ref.)
Rural	0.52 (0.36–0.75)**	0.92 (0.81–1.06)	0.99 (0.83–1.18)	0.72 (0.61–0.85)**	0.58 (0.49–0.69)**	0.99 (0.77–1.28)	0.97 (0.82–1.16)	1.31 (1.21–1.42)**	0.66 (0.54–0.81)**	0.94 (0.89–0.98)**
Caste
SC	0.83 (0.62–1.12)	0.61 (0.53–0.69)**	0.53 (0.36–0.78)**	0.58 (0.45–0.75)**	1.03 (0.84–1.27)	0.70 (0.50–0.97)*	1.28 (1.04–1.57)*	0.73 (0.67–0.80)**	0.83 (0.69–0.99)*	0.85 (0.81–0.90)**
ST	0.72 (0.55–0.93)*	0.56 (0.45–0.69)**	0.54 (0.38–0.77)**	0.50 (0.39–0.64)**	0.42 (0.34–0.51)**	0.54 (0.39–0.74)**	1.13 (0.92–1.40)	0.50 (0.41–0.62)**	1.24 (0.82–1.89)	0.58 (0.54–0.61)**
OBC	1.07 (0.83–1.37)	0.79 (0.71–0.89)**	0.55 (0.39–0.79)**	0.80 (0.64–1.00)	1.11 (0.92–1.34)	0.86 (0.62–1.19)	1.16 (0.97–1.39)	0.80 (0.74–0.87)**	1.04 (0.84–1.28)	0.99 (0.94–1.04)
Other (Ref.)
Religion
Hindu (Ref.)
Muslim	0.23 (0.18–0.29)**	0.49 (0.44–0.54)**	1.69 (0.96–2.95)	0.67 (0.58–0.77)**	0.89 (0.71–1.11)	0.45 (0.24–0.84)*	0.61 (0.52–0.73)**	0.68 (0.63–0.73)**	0.75 (0.58–0.97)*	0.57 (0.55–0.60)**
Others	0.66 (0.50–0.87)**	0.54 (0.19–1.57)	1.26 (0.83–1.93)	0.91 (0.78–1.07)	1.26 (0.57–2.81)	0.52 (0.41–0.65)**	2.37 (1.04–5.44)*	1.72 (0.81–3.66)	0.80 (0.39–1.65)	0.86 (0.78–0.95)**
Age (years)
15–24 (Ref.)
25–34	0.64 (0.55–0.76)**	0.75 (0.69–0.81)**	0.78 (0.69–0.89)**	0.75 (0.68–0.84)**	0.81 (0.73–0.89)**	0.68 (0.58–0.80)**	0.71 (0.62–0.80)**	0.81 (0.76–0.86)**	0.74 (0.62–0.87)**	0.79 (0.76–0.81)**
35–49	0.42 (0.34–0.53)**	0.55 (0.49–0.61)**	0.64 (0.51–0.79)**	0.63 (0.53–0.75)**	0.62 (0.53–0.73)**	0.54 (0.43–0.68)**	0.52 (0.43–0.62)**	0.66 (0.60–0.72)**	0.58 (0.43–0.78)**	0.63 (0.59–0.66)**
Age at marriage (years)
Below 18	0.68 (0.59–0.80)**	0.84 (0.78–0.91)**	0.66 (0.59–0.75)**	0.78 (0.71–0.87)**	0.75 (0.69–0.82)**	0.64 (0.56–0.74)**	0.73 (0.65–0.81)**	0.82 (0.78–0.87)**	0.78 (0.66–0.92)**	0.78 (0.76–0.80)**
18 and above (Ref.)
Education
No education (Ref.)
Primary	1.17 (0.95–1.43)	1.21 (1.08–1.35)**	1.13 (0.96–1.32)	1.33 (1.15–1.54)**	1.24 (1.10–1.39)**	1.75 (1.44–2.12)**	1.34 (1.15–1.57)**	1.18 (1.09–1.27)**	1.28 (0.99–1.64)	1.24 (1.18–1.29)**
Secondary	2.34 (1.96–2.81)**	1.71 (1.54–1.90)**	1.46 (1.24–1.71)**	2.07 (1.82–2.34)**	1.57 (1.40–1.77)**	2.84 (2.36–3.42)**	2.03 (1.71–2.40)**	1.73 (1.61–1.86)**	1.70 (1.36–2.12)**	1.83 (1.75–1.90)**
Higher	5.17 (2.59–10.31)**	3.29 (2.45–4.42)**	4.94 (3.05–8.00)**	4.08 (2.88–5.77)**	3.21 (2.09–4.94)**	3.19 (1.70–6.02)**	4.33 (2.87–6.53)**	3.70 (3.21–4.27)**	3.72 (2.62–5.28)**	3.77 (3.42–4.16)**
Wealth index
Poorest (Ref.)
Poorer	1.78 (1.51–2.09)**	1.49 (1.36–1.63)**	1.56 (1.33–1.83)**	1.44 (1.26–1.64)**	1.71 (1.53–1.91)**	1.50 (1.26–1.78)**	1.34 (1.15–1.56)**	1.21 (1.12–1.30)**	1.19 (0.86–1.64)	1.45 (1.39–1.51)**
Middle	2.57 (2.02–3.28)**	1.85 (1.62–2.13)**	1.68 (1.38–2.05)**	1.52 (1.28–1.82)**	2.40 (2.03–2.82)**	3.13 (2.35–4.17)**	1.51 (1.26–1.82)**	1.25 (1.15–1.37)**	1.47 (1.05–2.05)**	1.69 (1.60–1.78)**
Richer	3.94 (2.66–5.83)**	2.30 (1.88–2.82)**	1.92 (1.50–2.45)**	2.68 (2.04–3.53)**	2.69 (2.18–3.31)**	3.93 (2.46–6.29)**	1.77 (1.42–2.21)**	1.55 (1.39–1.73)**	2.11 (1.47–3.02)**	2.07 (1.94–2.21)**
Richest	13.61 (4.16–44.48)**	3.14 (2.09–4.72)**	3.35 (2.38–4.70)**	4.49 (2.88–7.01)**	6.37 (4.48–9.06)**	2.96 (1.55–5.65)**	3.12 (2.29–4.24)**	2.50 (2.18–2.86)**	5.18 (3.37–7.95)**	3.45 (3.15–3.78)**
Mass media exposure
No (Ref.)
Partial	1.15 (0.98–1.35)	1.02 (0.93–1.11)	1.19 (1.02–1.40)*	1.14 (1.01–1.28)*	1.32 (1.19–1.46)**	1.27 (1.09–1.48)**	1.28 (1.11–1.46)**	1.05 (0.98–1.12)	1.11 (0.88–1.41)	1.15 (1.11–1.19)**
Full	0.92 (0.63–1.36)	1.08 (0.89–1.30)	1.16 (0.81–1.64)	1.29 (0.94–1.77)	1.51 (1.16–1.96)**	2.18 (1.04–4.56)*	1.51 (0.96–2.37)	1.24 (1.04–1.48)*	1.30 (0.87–1.95)	1.31 (1.19–1.44)**
Intermediate factors
Pregnancy complication
No (Ref.)
Yes	1.01 (0.87–1.18)	1.09 (1.02–1.17)*	1.36 (1.21–1.53)**	1.04 (0.94–1.15)	1.10 (1.01–1.20)*	1.33 (1.16–1.52)**	1.28 (1.14–1.44)**	1.09 (1.03–1.15)**	1.34 (1.15–1.56)**	1.13 (1.10–1.17)**
Met with CHW
No (Ref.)
Yes	1.81 1.57–2.08)**	1.65 (1.53–1.78)**	1.41 (1.23–1.61)**	1.59 (1.44–1.75)**	1.65 (1.51–1.80)**	1.45 (1.23–1.70)**	1.80 (1.60–2.03)**	1.59 (1.51–1.68)**	1.50 (1.29–1.74)**	1.63 (1.58–1.68)**
Distance to health facility
No problem (Ref.)
Small problem	0.87 (0.71–1.07)	1.03 (0.93–1.15)	1.07 (0.92–1.24)	0.96 (0.82–1.13)	0.89 (0.79–1.01)	0.91 (0.73–1.13)	1.01 (0.88–1.17)	0.96 (0.90–1.03)	1.19 (0.97–1.46)	1.00 (0.95–1.04)
Big problem	0.56 (0.46–0.69)**	0.70 (0.63–0.77)**	0.77 (0.66–0.89)**	0.77 (0.66–0.91)**	0.89 (0.79–1.00)	0.62 (0.51–0.77)**	0.83 (0.72–0.96)*	0.88 (0.82–0.94)**	0.81 (0.67–0.98)*	0.79 (0.76–0.82)**
States
Assam										2.47 (2.24–2.73)**
Bihar										2.42 (2.22–2.63)**
Chhattisgarh										1.78 (1.62–1.97)**
Jharkhand										1.81 (1.65–1.98)**
Madhya Pradesh										3.50 (3.21–3.82)**
Odisha										4.62 (4.18–5.11)**
Rajasthan										4.87 (4.43–5.34)**
Uttar Pradesh										1.78 (1.65–1.93)**
Uttarakhad (Ref.)

Significance level: **p < 0.01; *p < 0.05.

Abbreviations: Ref: Reference category; OR: Odds ratio; CI: Confidence interval

Table 4. Percentage distribution of reasons for not delivering in a health facility across LPS, NFHS-4 2015–16

Reasons for not delivering in a health facility	Assam	Bihar	Chhattisgarh	Jharkhand	Madhya Pradesh	Odisha	Rajasthan	Uttar Pradesh	Uttarakhad	Overall
Costs too much	23.9	15.5	7.5	17.5	12.8	22.7	9.4	15.9	15.8	15.5
Facility not open	12.1	11.4	6.7	8.2	12.0	14.3	9.1	8.4	13.2	10.0
Too far/no transportation	25.5	15.3	27.5	24.4	30.5	24.2	20.2	10.8	15.8	17.3
Don’t trust facility/poor service	3.1	6.5	4.0	5.7	5.6	4.5	3.8	7.4	8.7	6.2
No female provider	2.3	4.5	1.9	3.3	3.7	2.2	4.3	3.1	4.1	3.5
Husband/Family did not allow	17.7	24.7	16.0	14.9	16.6	9.3	16.7	18.0	12.3	18.9
Not necessary	36.5	37.6	47.4	43.0	24.5	34.0	42.0	39.6	39.8	38.2
Not customary	8.5	3.6	4.6	4.1	2.9	3.3	4.2	4.2	4.5	4.1
Other	0.9	6.1	4.8	7.9	12.0	3.6	10.0	14.1	8.1	9.4

Table 5. Perceived distance to the health facility across LPS, NFHS-4 2015–16

States	No problem	Small problem	Big problem
Assam	23.2	42.7	34.1
Bihar	18.9	36.7	44.4
Chhattisgarh	33.4	34.5	32.1
Jharkhand	17.1	34.0	48.9
Madhya Pradesh	32.3	31.3	36.4
Odisha	21.7	38.0	40.2
Rajasthan	34.8	35.3	29.8
Uttar Pradesh	31.4	32.4	36.2
Uttarakhad	38.2	28.9	32.9
Overall	27.5	34.6	37.9

Table 6. Interaction models (bivariate and multivariate) assessment to determine the impact of place of residence and distance to the health facility on institutional delivery utilization in LPS, NFHS-4 2015–16

Place of residence × Distance to the health facility	Crude OR (95% CI)	Adjusted OR (95% CI)
Urban × no problem (Ref.)
Urban × a small problem	0.80 (0.74–0.87)**	1.03 (0.95–1.13)
Urban × a big problem	0.56 (0.51–0.62)**	0.89 (0.81–0.99)*
Rural × no problem	0.59 (0.55–0.63)**	1.00 (0.93–1.07)
Rural × a small problem	0.46 (0.43–0.49)**	0.98 (0.92–1.05)
Rural × a big problem	0.30 (0.29–0.32)**	0.75 (0.70–0.81)**

Significance level: **p < 0.01; *p < 0.05.

Note: Adjusted model was controlled for caste, religion, age, age at marriage, education, wealth status, exposure to mass media, pregnancy complication, and met with CHW.

Abbreviations: OR: Odds ratio; CI: Confidence interval

Table 7. The percentage distribution (%) and multivariate logistic analysis assessing the likelihood of JSY scheme utilization by socio-demographic characteristics of women in LPS, NFHS-4 2015–16

Characteristics	Total N	JSY (%)	OR (95% CI)
Place of residence†
Urban	19,137	39.3	1.00
Rural	64,511	60.2	1.32 (1.26–1.37)**
Caste†
SC	15,757	62.4	1.31 (1.25–1.38)**
ST	11,172	66.4	1.51 (1.43–1.60)**
OBC	39,612	55.1	1.14 (1.09–1.19)**
Other	14,915	43.1	1.00
Religion†
Hindu	70,928	56.9	1.00
Muslim	10,897	48.3	0.75 (0.72–0.79)**
Other	1823	49.7	0.77 (0.69–0.85)**
Age†
15–24	30,092	54.3	1.00
25–34	46,010	56.3	1.24 (1.20–1.28)**
35–49	7546	57.1	1.19 (1.13–1.26)**
Age at marriage†
Below 18	33,837	60.8	1.07 (1.04–1.10)**
18 and above	48,863	51.8	1.00
Education†
No education	25,584	62.4	1.64 (1.54–1.75)**
Primary	12,200	61.6	1.73 (1.62–1.84)**
Secondary	36,779	54.6	1.65 (1.56–1.74)**
Higher	9085	32.0	1.00
Wealth index†
Poorest	23,711	65.5	3.41 (3.19–3.65)**
Poorer	20,822	63.6	3.22 (3.03–3.42)**
Middle	15,464	56.6	2.58 (2.43–2.74)**
Richer	12,386	46.0	1.87 (1.76–1.98)**
Richest	11,265	27.7	1.00
Mass media exposure†
No	24,392	62.6	1.00
Partial	53,988	53.4	1.19 (1.14–1.24)**
Full	5268	44.0	1.08 (1.00–1.16)*

Note: †Differences were significant at p < 0.01 (derived from Pearson’s chi-square test).

Significance level for multivariate analysis: **p < 0.01; *p < 0.05.

Abbreviations: OR: Odds ratio; CI: Confidence interval

Figure 7. Coverage of JSY scheme (%) across LPS, NFHS-4 2015–16