Title : An exploration of factors influencing the decision regarding choice of maternal health care facility among pregnant tribal women in Tamil Nadu
Abstract:
The WHO vision of quality of care highlights both clinical safety and women’s experience of care as essential components of maternal healthcare. In many low-resource settings, maternal healthcare is delivered through a mix of public, private, and community-based providers. Although Tamil Nadu has high institutional delivery coverage, gaps persist in the experience and quality of maternal healthcare among marginalised communities, including tribal women. This study shifts the focus from asking what is wrong with the community to examining how the health system aligns, or fails to align, with women’s needs, expectations, and lived realities. This qualitative study was conducted among tribal communities in Sittilingi Valley, Tamil Nadu, India, where women have access to government, private, and NGO-based healthcare facilities. Villages were selected to capture variation in geographic access, and participants were selected to reflect different place-of-delivery experiences. Data collection included 20 in-depth interviews, 8 key informant interviews, and 3 focus group discussions. Data were analysed thematically and interpreted using Levesque’s access framework and a realist-inspired ICAMO lens. The findings showed that women’s maternal care pathways were fragmented and multi-institutional. Government facilities were commonly used for registration and routine compliance, private facilities for diagnostics, and NGO-based Tribal Hospital services for antenatal follow-up and delivery. Women’s decisions were shaped not only by availability, accessibility, and affordability, but also by dignity, autonomy, emotional safety, communication, and trust. Many women preferred paid NGO-based care for delivery despite the availability of free public services. A realist-inspired interpretation showed that government settings often triggered fear and mistrust, private care generated anxiety and financial burden, while NGO-based care generated trust and reassurance. The study highlights that high institutional delivery coverage alone does not ensure equitable or acceptable maternal healthcare. Women’s choices were shaped not merely by service availability, but by their experience of care. These findings point to the need for a more inclusive, respectful, and patient-centred health system that values dignity, trust, continuity, and responsiveness in maternal healthcare delivery.
