Determinants of underutilisation of free delivery services in an area with high institutional delivery rate: a qualitative study

There has been an increase in institutional delivery rates in India in the recent years. However, in areas with high institutional delivery rates, most deliveries (>50%) occur in private institutions rather than in government facilities where zero expense delivery services are being provided. This study aimed to understand, from the community health volunteers' viewpoint, the reasons for underutilization of zero expense delivery services provided in government health facilities. Five Focused Group Discussions (FGD) were conducted among Accredited Social Health Activist (ASHAs) of a Primary Health Centre (PHC) in Dayalpur village, Haryana in December 2012. Participants were asked to articulate the possible reasons that they thought were responsible for expectant mothers not choosing to deliver in government health facilities. Verbal informed consent was obtained from all participants. The commonly stated reasons for underutilization of government health facilities for delivery services were lack of quality care, abominable behaviour of hospital staff, poor transportation facilities, and frequent referrals to higher centres. This study reflected the necessity for new policies to make government health facilities friendlier and more easily accessible to clients and to make all government hospitals follow a minimum set of standards for providing quality care.