The stakes in Barwani are unusually high. Government health data from 2019 to 2020 show that although the district holds only 1.5 percent of Madhya Pradesh’s population, it accounts for 18.5 percent of the state’s home deliveries, the highest share of any district. Madhya Pradesh itself lags behind national averages, with an infant mortality rate of 40 per 1,000 live births compared with 26 nationally, and a maternal mortality ratio of 159 per 100,000 live births against a national figure of 88. Within Barwani, the burden is concentrated in a single administrative block: in 2022-23, Pati block recorded 13 of the district’s 65 neonatal deaths and 15 of its 22 maternal deaths.

The pilot, designed in December 2023 and implemented from January to June 2024 by the nonprofit Antara Foundation in partnership with the state’s Department of Public Health and Medical Education, targeted the root of the problem with a mixed-methods approach. Researchers first mined the government’s Health Management Information System to rank sub-health centres by their share of home deliveries, then purposively selected five of the highest-burden centres in consultation with the district collector. From the line lists of those centres, 127 pregnant women in their third trimester were enrolled for interviews and focus group discussions conducted in their homes, in the local Bhil or Barela languages, with informed verbal consent and no audio or video recording.

What the team found was a dense web of overlapping barriers, which they sorted into eight categories and graded as high, medium, or low severity based on how severely each restricted institutional delivery, how much it influenced the decision of where to give birth, and whether alternatives existed. Emergency unpreparedness featured in 95 percent of tracked cases, meaning families lacked basics such as clean clothes, saved money, a identified blood donor, or contact numbers for the nearest facility. The influence of the Dai, the traditional midwife, appeared in 96 percent of cases, and traditional healers known locally as Baba shaped decisions in 70 percent of them. Some families reported that a healer had advised against calling an ambulance, or had tied a protective thread around the woman and insisted on his care alone; in some hamlets, families said they trusted the healer more than the auxiliary nurse midwife because, in their words, not a single case handled by Baba had gone wrong.

Physical isolation compounded these cultural forces. Seventy percent of tracked cases lay in the least accessible hamlets, called faliyas, which are scattered across hills 1 to 5 kilometres from the nearest facility; 86 percent of Pati block lacks internal roads connecting its hamlets, and roughly 70 percent of villages have no mobile network coverage at all. More than 65 percent of cases could not access the free ambulance service, and 66 percent sat in connectivity dead zones. Social norms weighed heavily too: about 91 percent of cases reflected family-level beliefs that home birth was normal and preferred, with women citing purification rituals required if outsiders touched the newborn, prayer rituals that could not be performed for the first three days in a hospital, and the objection of mothers- and fathers-in-law.

The intervention’s answer was not to parachute in outside experts but to build a three-tiered team drawn from the community itself. Field coordinators, local tribal people fluent in the local language, conducted the interviews and worked with villages to design solutions. Faliya volunteers, recruited from the very hamlets where the women lived, connected pregnant women to frontline health workers and mobilised neighbours to arrange transport to the point where an ambulance could reach. Tribal community counsellors, trained to engage sensitively, visited every enrolled woman alongside frontline workers to counsel on maternal health practices and address fears about institutional care. Village leaders, including the elected Sarpanch, were briefed on the barriers and enlisted in resolving them.

The results were measurable. Of the 98 women from the highest-risk areas who gave birth during the study period, 81, or 83 percent, delivered in a hospital. Among 26 families who initially insisted on home delivery during focus group discussions, 20, or 77 percent, ultimately chose institutional birth after regular counselling. The team validated every reported delivery by cross-checking enrolment records under the Janani Suraksha Yojana, the national safe-motherhood cash incentive scheme, and reviewing discharge papers, a step designed to guard against over-reporting in a program where the outcome indicator was also the intervention’s target.

The study’s authors illustrate the mechanism with the anonymised case of a young mother of two in a remote forested village, whose family trusted only the traditional healer and had no road to the hospital. She was also a high-risk pregnancy, with a height below 145 centimetres. Field representatives made repeated visits with frontline workers, counselling the family on the importance of institutional delivery and on the government’s financial incentives for formal care. The family was convinced, and the woman delivered safely at the nearest government hospital. The authors also note positive spillovers: some husbands took a firm stand for facility birth, frontline workers reported feeling supported rather than alone, and trust in the public health system visibly strengthened as communities worked alongside government staff.

The findings sit within a broader global evidence base. Research cited in the study links maternal mortality to health system capacity, socioeconomic disparity, and governance, and documents how distance, education, and economic status shape where marginalised women give birth. Comparable approaches have worked elsewhere in South Asia: Bangladesh invested in community-based skilled birth attendants and emergency transport, Nepal expanded birthing centres and incentive programs, and Sri Lanka strengthened primary care and midwifery. The Barwani model’s distinctive claim is its integration with existing government machinery, using HMIS data, existing frontline workers, and established protocols rather than building parallel systems, an alignment the authors argue makes it well suited for embedding in programs like the National Health Mission.

The authors are candid about the limits of the evidence. The pilot covered a single high-priority block chosen for logistical feasibility, so generalisation to other tribal settings with different social contexts is untested, and the work was an implementation documentation exercise rather than a controlled evaluation, lacking randomisation, control groups, and long-term follow-up. They call for rigorous studies across diverse tribal regions before scaling up. Still, the direction of travel is clear: in a district where terrain, tradition, and distrust had made home birth the default, mapping barriers case by case and handing the tools to trusted local volunteers shifted the default toward the hospital. The Barwani district administration has begun integrating the model into its own efforts, suggesting that the cheapest and most durable infrastructure for maternal health in remote India may be social rather than physical.

Subject of Research: Community-led interventions to increase institutional deliveries among tribal pregnant women in remote Madhya Pradesh, India

Article Title: Community-led solutions to promote safe institutional deliveries in scattered tribal settlements of Madhya Pradesh, India

Article References: Bhatt, P., & Awasthi, A. (2026). Community-led solutions to promote safe institutional deliveries in scattered tribal settlements of Madhya Pradesh, India. International Journal for Equity in Health, 25(1), Article 231. https://doi.org/10.1186/s12939-026-02849-4

Image Credits: AI Generated

DOI: 10.1186/s12939-026-02849-4

Keywords: institutional delivery, maternal health, tribal communities, Madhya Pradesh, community health workers, health equity, India, home deliveries, traditional healers, rural healthcare, Antara Foundation, Barwani