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Priyanka Dixit and Laxmi Kant Dwivedi

conceptions and fears of medical institutions, have led women to continue to rely on home births in
India (Stephenson, Baschieri, Clements et al., 2006). As a result, rural women may continue to un-
der-utilize health care facilities relative to urban women despite the introduction of free maternal
care schemes.
The effect of religion and caste were found to vary in relation to all three births. Muslim and
scheduled caste women were less likely to deliver their three most recent births in an institution. For
the other two recent births, religion was not a significant predictor — a finding that is consistent with
earlier studies (Mekonnen and Mekonnen, 2002; Saroha, Altarac, and Sibley, 2008). The observation
that Muslim women sought less assistance from medical settings is likely to be attributed to their
religious beliefs, cultural norms, and traditional practices (Ganle, 2015). Our finding that sche-
duled caste women had lower odds of institutional delivery even after adjusting for other covariates,
suggests that there may be additional social and/or cultural reasons for the low uptake of delivery
services among these groups.
Findings again conform to the positive correlation between level of education and the consistent
utilization of institutional delivery. Women with some level of education were more likely to deliver
all births at health facilities than those who were unable to read and write. However, for the third to
the last birth, there was no significant difference between illiterate women and literate women with
below primary level education. Studies conducted in different parts of India (Govindasamy and Ra-
mesh, 1997; Kesterton, Cleland, Slogett et al., 2010; Navaneetham and Dharmalingam, 2000; Varma,
Khan, and Hazra, 2010; Vora, Koblinsky, and Koblinsky, 2015), and in other countries such as Ban-
gladesh, Nepal, Nigeria, Malawi, and Afghanistan also found a similar association (see Palamuleni,
2011). These may be due to the fact that educated women had better awareness about the benefits of
preventive health care services, have familiarity with modern medical culture, and have higher re-
ceptivity to health-related information. We also speculate that literate women are more likely to
overcome some old stereotypes, norms, and beliefs, and know themselves better in terms of the phy-
siological condition of pregnancy. They know that each and every birth needs medical attention and
consequently they would deliver in an institution. Moreover, highly educated women are likely to be
more confident about asking questions related to the health care needs of themselves and their child-
ren; and are more willing to be listened to by their health care providers, who may encourage institu-
tional delivery (Bloom, Lippeveld, and Wypij, 1999). Partner’s education showed a significant posi-
tive relation with institutional delivery for the most recent birth; however, the same was not signific-
ant in relation to older births. The possible reason may be that in the recent time period educated
partners had become more aware about the health care of mothers and children, which has changed
their attitudes and beliefs, and played a key role in overcoming the barriers to accessing maternal
health care services. This argument is consistent with some recent studies conducted in Gujarat, In-
dia, and other developing countries (Daniel and Desalegn, 2014; Vora, Koblinsky, and Koblinsky, 2015).
Previous studies have shown a linear increase in institutional delivery with an increase in wealth
quintiles (Chakraborty, Islam, Chowdhury et al., 2003; Gabrysch and Campbell 2009; Goel, Roy,
Rasania et al., 2015; Kesterton, Cleland, Slogett et al., 2010; Titaley, Dibley, and Roberts, 2010; Vora,
Mavalankar, Ramani et al., 2009), the present study also showed a similar finding in the case of con-
sistent utilization of institutional delivery. Despite different government incentive programs, the high
cost of delivery care is often blamed for the low rate of delivery service utilization, especially for
poorer women. This finding may be explained by the fact that transportation costs and the loss of
daily wages may be high; as a result, women from poorer households prefer to deliver every birth at
home. A large inequality in the use of skilled birth attendants are found in developing countries, with
the poor being at a stark disadvantage (Houweling, Ronsmans, Campbell et al., 2007; Mayhew, Han-
sen, Peters et al., 2008).
Our finding also shows that women who never had a terminated pregnancy or loss of a child in
her lifetime were more likely to deliver at home. The possible reason for the inconsistent use of in-
stitutional delivery could be that these women have developed self-confidence and have become less

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