“Get out of the car.”
Confused, I opened the door and stepped out, only to realize why we stopped. One kilometer from the village, a stream flowed through the road. Surrounded by running water and uneven stones, the only way to reach the village was to get our tires wet and pray we wouldn’t get stuck. As the car struggled over the rocks, my supervisor and I pushed from behind to give it just enough force to pass through. We made it across, mostly dry.
At the time we crossed the stream, I was on my way to conduct focus groups with mothers in a village that the local birth waiting home serves. My work was not urgent, so I was not worried about the consequences of the car getting temporarily stuck. But, imagine an ambulance making this same journey to pick up a mother in active labor. What if the ambulance gets stuck, and the mother doesn’t make it to the health facility in time? Or, what if the ambulance cannot reach the village at all because of the road quality? These are realistic challenges for mothers from remote, hard-to-reach areas who want to deliver institutionally.
Birth waiting homes were created to deal with these issues, among others. Also known as maternity waiting homes, they are centers where mothers can stay for a few days before their expected delivery date and after delivering. The idea is that if mothers are under medical supervision before going into labor and during the delivery process, nurses can deal with any complications that arise, which would not be the case during home deliveries.
In Jharkhand’s Kolhan division, maternal and infant mortality rates are high. However, the numbers are decreasing because of innovative programs like the Maternal and Newborn Survival Initiative (MANSI), a partnership between AIF, Tata Steel Foundation, and the National Health Mission. Between September 2023 and January 2024, MANSI inaugurated three birth waiting homes across the Kolhan division, which heavily consists of rural and tribal communities. Birth waiting homes have the potential to benefit all mothers, but especially those in villages that are hard to reach by road.
Over the past eight months, I have had one priority: increasing birth waiting home utilization as a means to decrease delivery-related complications. In February, I began conducting focus groups with mothers and health workers to learn about barriers to birth waiting home usage, with the goal of gaining new insight and proposing solutions.
After months of initial research on birth waiting homes and beneficiary communities, I analyzed admission rates from each community in the catchment area to decide which villages to target. I was curious, for example, why zero mothers from a nearby, easy-to-reach village delivered at the facility, while eight mothers from a remote, hard-to-reach village chose to deliver there.
As I met mothers and health workers, I nodded my head and bid “johar,” the local variety of “namaste.” My Hindi was juvenile, so I stood no chance of communicating with mothers in the local languages of Ho, Mundari, Santali, and Odia. Having a familiar face in a MANSI worker ask questions in the local languages brought credibility to the focus groups that I alone would not have been able to induce.
Among the brightly ornamented walls of their homes, I sat alongside mothers while they voiced their sentiments toward the birth waiting homes. On patterned carpet, we discussed their delivery experiences at the birth waiting homes, other facilities, and their own homes. Our meetings were sometimes interrupted by buffalo trudging by, pigs scurrying about, or other unexpected, delightful visitors. In the midst of it all, I sought to understand the broader context to the factors influencing their decisions of where to give birth.
In many villages, mothers discussed transportation and cost issues related to reaching the birth waiting homes, as well as their desire for more food to be provided at the facility; issues we already knew about and are looking to address. But, some mothers gave insight into new, nuanced issues. I learned that in one village, there is a faction that does not believe in the government or any services that the government provides, so they only deliver at home. In another village, nine days after birth, there is a purification ceremony for mother and child. The ceremony costs about the same amount as hiring a private vehicle to go from the village to the birth waiting home. Weighing the options, the families often choose to spend money on the ceremony. And, for some people, that cost, around 2,500 rupees or 30 USD, is their entire monthly salary.
After the focus groups were complete, I grouped the barriers to birth waiting home utilization into two categories: accessibility and awareness. The focus groups revealed two key insights: many mothers were unaware of birth waiting homes, and those who knew of them often misunderstood their purpose as a place to stay before delivery. Some needed clarification on what the birth waiting home was, and others said that because they didn’t know anyone who delivered there, they were hesitant to go. Because of this, the focus groups doubled as educational sessions, as we taught mothers about the benefits of birth waiting homes. Afterwards, I asked mothers if they would deliver there in the future. The majority said yes, but I wondered if they would follow through.
I discussed my findings with my supervisor, and we agreed that I should target awareness issues by making educational, promotional videos about the birth waiting homes. The idea of making videos thrilled me. Aside from the excitement of filming, I believed that increasing awareness would solve many of the accessibility issues. Let’s think back to the village blocked by a stream. Most transportation issues can be solved by arriving at the birth waiting home before being in active labor, because even if the drive is more difficult or takes longer, the mother doesn’t have to worry about complications without care. By giving ample time to call the ambulance, mothers won’t have to worry about the vehicle not being available and subsequently having to hire a costly private vehicle.
My focus groups went beyond learning about barriers faced by mothers. They started conversations. They laid the foundation for new projects. And, they induced a call to action. Following one focus group, a sahiya told me, unprompted, that she will take mothers for an exposure visit to the birth waiting home. I felt pride hearing this, as the focus groups made the sahiya conscious of the awareness issues, and from that she felt compelled to take initiative.
It is through communities’ feelings, experiences, and collective stories that we will together build narratives that shape how we approach development work. For me, mothers’ voices will guide improvements to birth waiting homes. I realized that sometimes, the solution isn’t removing the roadblock itself; it is giving people the time, knowledge, and facilities to cross whatever roadblock or stream is in their way.
