Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Print this page Email this page Users Online: 505

 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 8-12

Determinants of institutional delivery in three North Indian states: Evidence from DLHS 4

Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Date of Web Publication22-Mar-2018

Correspondence Address:
Dr. Manas P Roy
Department of Pediatrics, Safdarjung Hospital, New Delhi - 400 029
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and Permissions

Background and Objective: Institutional delivery (ID) is considered pivotal for ensuring maternal and neonatal health. Emphasis has been put on the same in India repeatedly with aim to reduce mortality in this vulnerable group. The aim of the study is to find out the determinants of ID in north India.
Materials and Methods: Data for the ecological study were retrieved from District Level Household and Facility Survey 4 (2012-13) for 53 districts in three north Indian states, viz. Punjab, Haryana, and Himachal Pradesh. District wise proportion for ID and different demographic factors were considered along with Antenatal care service components. Regression was used to find out the determinants for higher rate of ID.
Results: Overall, 80% ID has been documented in the present survey in district level. Among different variables, consumption of 100 iron folic acid (IFA) tablets and higher parity were negatively associated with higher rate of ID (coefficient = - 0.692 and - 0.573, respectively), whereas uptake of three or more ANC visits was seen to be associated with it positively (coefficient = 0.422).
Conclusions: ANC visits, parity and consumption of IFA tablets are associated with higher rates of ID at district level in North India.

Keywords: ANC, DLHS 4, India, institutional delivery, maternal health

How to cite this article:
Roy MP. Determinants of institutional delivery in three North Indian states: Evidence from DLHS 4. J NTR Univ Health Sci 2018;7:8-12

How to cite this URL:
Roy MP. Determinants of institutional delivery in three North Indian states: Evidence from DLHS 4. J NTR Univ Health Sci [serial online] 2018 [cited 2022 Jan 22];7:8-12. Available from: https://www.jdrntruhs.org/text.asp?2018/7/1/8/228156

  Introduction Top

India, with 47,000 maternal deaths per year, contributes to highest fraction of maternal mortality in the world. Despite a drop of 59% in maternal mortality ratio (MMR) since 1990, the country is unlikely to achieve the target set for Millennium Development Goals (MDG) by 2015. With a MMR of 178/100,000, India suffers from its populous nature, inequity in socioeconomic status, poor healthcare services in government sector, and high out-of-pocket expenditure in private facilities.[1] Lack of access to and utilization of healthcare services for delivery are among the main reasons for the high maternal and neonatal mortality rates in the country.[2]

As evident from different part of the world, institutional delivery (ID) is a key factor in reducing maternal deaths.[3] In India, too, for averting maternal death, ID has been recognized as a strong pillar. Several mechanisms have been adopted for increasing ID including conditional cash transfer, free transport, zero expense delivery, and performance based incentives. Fact, over past few years, there has been remarkable increase in ID (39% in National Family Health Survey 3–73% in Coverage Evaluation Survey 2009).[4],[5] But, with 1 year to go for MDG timeline, it seems impossible to achieve the target on maternal death without improving ID further, coupled with challenges like state-level inequalities and decision making at district level.[6]

In India, women's religion, caste, education, parity, socioeconomic status, and type of family have earlier been correlated with health seeking behavior, including ID. In addition, profile of antenatal care (ANC) visits has also been implicated as the determinants of ID.[7],[8],[9],[10],[11] But most of the researches are community based and limited to particular block or district. There is dearth of analysis on a large scale. In this perspective, the present paper, ecological in nature, examined demographic factors and ANC service components related to ID in three north Indian states, based on data available from District Level Household Survey 4 (DLHS-4) (2012-13), a nationwide sample based household survey. A better understanding of these factors will help in achieving increase in utilization of healthcare services, thus reducing maternal deaths.

  Materials and Methods Top

The data used in this article were obtained through publicly available online resources. The datasets are available for public use with anonymity on the survey participants.

DLHS 4, conducted in 2012–13, covered 69335 women aged between 15 years and 45 years in these three states. They were asked about their socioeconomic background and care taken during ante, intra, and postnatal period. The present article considered only antenatal issues.

Keeping rate of ID as the dependent variable, six demographic factors available from DLHS 4 were considered.[12] DLHS is a periodic survey, conducted by International Institute of Population Science, Mumbai. Among independent variables, apart from client characteristics (mean age of girls at marriage, literacy, birth order), utilization of other health services like three ANC check-up, consumption of 100 IFA tablets and blood test for hemoglobin (Hb) were also taken into account. Linear regression was used to find out the factors related with ID at the district level. A total of 53 districts belonging to three north Indian states viz. Punjab, Haryana, and Himachal Pradesh were examined. During data collection, most recent births to ever married women (which took place after 1 January, 2008) were considered.


District was the unit for analysis. Statistical analysis was performed using PASW for Windows software (Version 19.0; SPSS Inc, Chicago). The confidence level was set at 95%. Bivariable analyses were conducted to assess the association between ID and sociodemographic variables. All independent variables were entered into multiple linear regression analysis and the final model was selected by a forward stepwise strategy.

  Results Top

[Table 1] shows the summary of ID and socioeconomic variables. ID in three states was 80%, with minimum at Mewat (51.2%) and maximum at Panchkula (94.1%). Mean literacy was 80.8%, with lowest at Mewat (68.5%) and highest at Hamirpur (90.4%). Mean age for girls at marriage ranged from 19.7 years at Mewat to 23.8 years at Shahid Bhagat Singh Nagar, with a mean of 21.6 years for the region under study. Birth order three or more was seen in 18.8% of women, with highest at Mewat (43.3%) and lowest at Mandi (4.4%). At least three ANC was taken by 77% pregnant women, highest at Fategarh (92.6%) and lowest at Mewat (55.9%). Total 100 IFA tablets were consumed by 39% of women during pregnancy. Highest consumption was seen at Lahul and Spiti (90%) and lowest at Mewat (6%). Hemoglobin test was availed by 51.6% of pregnant ladies, maximum at Solan (91.5%) and minimum at Mewat (10.3%). The worst case scenario was found in Mewat in all aspects.
Table 1: Overview of district level indicators from district level household survey-4 (DLHS-4) for three North Indian states

Click here to view

[Table 2] shows the result of simple linear regression, considering all 53 districts belonging to these three states of north India. ID was strongly and negatively associated with higher birth order and consumption of 100 IFA tablets. Three ANC visits were positively associated with ID. Rest variables were not significant at bivariate level. In forward regression analysis, these three independent variables were significantly related to ID [Table 3].
Table 2: Factors associated with institutional deliveries in districts of three north indian states

Click here to view
Table 3: Factors associated with institutional delivery (ID) by the mothers on linear regression

Click here to view

  Discussion Top

Overall, moderate ID (80%) was reported from these three states under consideration, though regional variation is evident. For example, Mewat is considered one of the most vulnerable districts in the country, as evident from previous studies. Higher proportion of rural population, illiteracy, high fertility, and low utilization of health services make this a common back bencher in all health parameters.[13],[14] This adds to lack of researches in this particular area. It is possible to identify several hypotheses that may explain the worse health at Mewat. A multilevel study involving individual, family, village, and district in this region is warranted in future.

A better coverage of ID has been reflected in the present analysis than national figure during CES 2009. A major credit for this goes to Janani Suraksha Yojana (JSY). In fact, state wise analysis proved that there is an upward trend at the latest survey. Haryana has documented modest rise to 77% from 63% while for HP (50.3% to 77.8%) and Punjab (60.3% to 82.7%), the difference is quite striking. No doubt, appointment of ASHA at community level has changed the trend of delivery in favor of hospitals. However, the success story is patchy as there is reduction in uptake of three or more ANC visits in all three states under discussion. (Haryana: from 68.6% to 44.8%, Punjab: from 73.4% to 57.7%, and HP: from 67.4% to 58.3%).

Compelling evidence was found that three or more ANC is related to higher proportion of ID. Pregnancy is often considered as a window of opportunity for healthcare providers to address upcoming delivery related issues. It is the time to win confidence of the clients. Use of ANC has been a known predictor for ID.[7],[8],[15],[16],[17],[18],[19] In other way, clients coming to regular ANC visits do already have faith in healthcare delivery system. Through more ANC visits, clients get more explanation to their queries and therefore, enhance possibility for ID. The healthcare provider should utilize this opportunity to build the rapport further.[20] Under JSY, conditional cash transfer has been introduced in the country to enhance number of such visits as well as ID. The finding suggests that it might be prudent to put more emphasize on ANC visits. The practice of not attending ID could be reversed through effective antenatal counseling during ANC visits.

A key finding of this study is effect of parity. Birth order was a strong predictor for ID in the present study, consistent with previous ones.[8],[9],[10],[16],[21] A primi woman is more likely to seek maternal healthcare services than multipara as there is perceived uncertainty and apprehension associated with first pregnancy.[22] But afterwards, the mother perceived pregnancy as a normal phenomenon and get confident about delivery at home.[16] Time and resource constrain in case of larger family might be another explanation.[11] A separate strategy could be designed to target multipara women for bringing them to hospital and motivate them for sterilization.

Surprisingly, that consumption of 100 IFA tablets was negatively associated with proportion of ID. It could be due to ecological fallacy. On the other hand, it could happen that those clients are already compliant to medical advices, thus being confident and reluctant towards ID. This finding has programmatic implication. Women consuming 100 IFA tablets should not be taken for granted for ID. Throughout the pregnancy, it gets clearer which clients are more prone for ID. On one hand, there is need to consolidate the success and to focus on the rest of the women for making them convinced for the same, on the other. Strengthening capacity of local health personnel, in terms of influencing clients for complete ANC package and ID, is pivotal in this regard.

Mother's education imparts strong influence on utilization of healthcare, as suggested by different studies.[7],[9],[10],[11],[12],[16] The finding is not replicated in present analysis. One reason for that could be the fact that overall literacy rate of the district was considered, not only mothers' one. It was hoped that an improved literacy of a district will also reflect that of mothers. Similarly, age at marriage, although important for ID in previous research, is not reflected here probably because of ecological nature of study.[23] Further research is warranted in this regard.

There is considerable diversity in the output after implementation of same program design throughout the country. This is influenced by availability, accessibility, cost, and quality of the services. Still, the findings call for stressing on complete ANC visits in the concerned states. For example, even after providing cash benefits and free amenities including transport, we are yet to reach the bench mark of 100% ID. In the long run, we need to see ANC as a cornerstone of ID, not a distinct target set for being achieved separately. Given the perceived idea of parallel mechanisms for different units of the same spectrum of ANC, we may need to revise the system where providing ANC is the responsibility of the sub-centre but conducting delivery falls to Primary Health Centre (PHC) and Community Health Centre (CHC), in terms of responsibility. A synchronized effort of streamlining the services would possibly see better outcomes in future.


The study was limited to three states of north India. So, the findings may not be generalized for the whole country, considering its variety of context in different parts. Being an ecological one, the study lacks temporal relationship between variables. Many a factors like standard of living, mother's age, religion/caste, place of residence, distance to hospital were not taken into account. Better designed cross-sectional study would indicate the associations for ID more precisely.

Association between ANC and ID arises not because of a causal effect of ANC on the likelihood of ID. Pregnancy complication, as confounding factor, influences both the likelihood of ANC and the likelihood of ID.[9] Due consideration of this would have made the study better suited to the complex equation of ID.

On the other hand, evaluation of ID and its determinants with the latest available data is one of the strength of this study. Consequently, the results and interpretations presented in this article can provide support to the need for better antenatal coverage.

  Conclusion Top

From an ecological point of view, relationship of ID rate of districts was considered with some sociodemographic factors in this study. Higher birth order was seen to be associated with low ID rate indicating group of people who are yet to be convinced by healthcare delivery mechanism. Positive relation of three ANC with ID stresses again on emphasizing process of ANC instead of ID. Although key factors have been described here, how these findings could be used to reduce maternal and neonatal mortality would be matter of future research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing health care for all: Challenges and opportunities. Lancet 2011;377:668-79.  Back to cited text no. 1
Govindasamy P, Ramesh BM. Maternal education and the utilization of maternal and child health services in India. National Family Health Survey Subject Reports no. 5, International Institute for Population Sciences, Mumbai, India, 1997.  Back to cited text no. 2
Abou-Zahr CL, Wardlaw TM. Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels and Differentials, 1990-2001. Geneva: WHO and United Nations Children's Fund (UNICEF). 2003.  Back to cited text no. 3
International Institute for Population Sciences, India and Ministry of Health and Family Welfare. National family health survey (NFHS-3) 2005–06, India. Mumbai: International Institute for Population Sciences; 2007.  Back to cited text no. 4
Government of India & UNICEF. Coverage Evaluation Survey, 2009: National Fact Sheet. Available from: http://www.unicef.org/india/National_Fact_Sheet_CES_2009.pdf. [Last accessed on 2015 Jan 29].  Back to cited text no. 5
Nguyen KH, Jimenez-Soto E, Dayal P, Hodge A. Disparities in child mortality trends: What is the evidence from disadvantaged states in India? The case of Orissa and Madhya Pradesh. Int J Equity Health 2013;12:45.  Back to cited text no. 6
Anita P, Jain RB, Punia MS, Vidya R, Kalhan M. Pattern of deliveries in rural areas of a district in Haryana, India. Internet J Epidemiol 2010; 9.  Back to cited text no. 7
Thind A, Mohani A, Banerjee K, Hagigi F. Where to deliver? Analysis of choice of delivery location from a national survey in India. BMC Public Health 2008;8:29.  Back to cited text no. 8
Sugathan KS, Mishra V, Retherford RD. Promoting institutional deliveries in rural India: The role of antenatal-care services. National Family Health Survey Subject Reports 2001;2. Available from: https://www.eastwestcenter.org/sites/all/modules/filemanager/files/Research_Program/NFHS_Subject_Reports/subj-20.pdf. [Last accessed on 2015 Jan 29].  Back to cited text no. 9
Navaneetham K, Dharmalingam A. Utilization of maternal health care services in southern India. Soc Sci Med 2002;55:1849-69.  Back to cited text no. 10
Bhatia JC, Cleland J. Determinants of maternal care in a region of South India. Health Transit Rev 1995;5:127-42.  Back to cited text no. 11
Government of India & International Institute for Population Science. District Level Household and Facility Survey (DLHS 4), 2012-13. Mumbai: Ministry of Health and Family Welfare, Government of India. Available from: https://nrhm mis.nic.in/SitePages/DLHS 4. aspx. [Last accessed on 2014 Sep 05].  Back to cited text no. 12
Kumar A, Goel PK, Vashisht BM, Mittal K. Psychosocial management of diabetes: Applicability of national guidelines to Mewat, an underserved region of Haryana. J Soc Health Diabetes 2014;2:14-7.  Back to cited text no. 13
  [Full text]  
Gaur DR, Goel MK, Goel M. Contraceptive practices and related factors among females in predominantly rural Muslim area of North India. Internet J World Health Societal Politics 2008;5:1.  Back to cited text no. 14
International Institute for Population Sciences. District Level Household and Facility Survey (DLHS-3), 2007-08: India. Mumbai: International Institute for Population Sciences; 2010.  Back to cited text no. 15
Feyissa TR, Genemo GA. Determinants of institutional delivery among childbearing age women in Western Ethiopia, 2013: Unmatched case control study. PLoS ONE 2014;9:e97194.  Back to cited text no. 16
Tarekegn SM, Lieberman LS, Giedraitis V. Determinants of maternal health service utilization in Ethiopia: Analysis of the 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy Childbirth 2014;14:161.  Back to cited text no. 17
Kawakatsu Y, Sugishita T, Oruenzo K, Wakhule S, Kibosia K, Were E, et al. Determinants of health facility utilization for childbirth in rural western Kenya: Cross-sectional study. BMC Pregnancy Childbirth 2014;14:265.  Back to cited text no. 18
Nketiah-Amponsah E, Sagoe-Moses I. Expectant mothers and the demand for institutional delivery: Do household income and access to health information matter?-Some Insight from Ghana. Eur J Soc Sci 2009;8:469-82.  Back to cited text no. 19
Hagos S, Shaweno D, Assegid M, Mekonnen A, Afework MF, Ahmed S. Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia. BMC Pregnancy Childbirth 2014;14:178.  Back to cited text no. 20
Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011;10:31.  Back to cited text no. 21
Chakraborty N, Islam MA, Chowdhury RI, Bari W, Akhter HH. Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int 2003;18:327-37.  Back to cited text no. 22
Abeje G, Azage M, Setegn T. Factors associated with Institutional delivery service utilization among mothers in Bahir Dar City administration, Amhara region: A community based cross sectional study. Reprod Health 2014;11:22.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Factors determining institutional delivery in eastern part of India
Madhumita Mukherjee,ManasPratim Roy
Tzu Chi Medical Journal. 2020; 32(2): 171
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded289    
    Comments [Add]    
    Cited by others 1    

Recommend this journal