By: Vijayetta Sharma and Anandajit Goswami
One of India’s greatest strengths in community outreach in healthcare is the vast network of Accredited Social Health Activists (ASHA), which stands at 1.03 million as of September 2024, and contributes to the largest volunteer health workforce in the world. As a trusted community health worker selected from within the community, ASHA is vital in enhancing healthcare utilization and coverage under the National Health Mission (NHM). A nationally representative study finds that there has been an increase of 17% in women receiving at least one ANC visit, 5% in four ANC visits, 26% in deliveries attended by skilled birth attendants, and 28% in facility-based deliveries with the intervention of ASHA in India.
A well-equipped and well-supported ASHA is bound to the improve maternal health, nutrition, immunisation and other community health outcomes through strategic interventions in different regions. The community outreach activities by ASHA, coupled with other provident health provision measures, have contributed significantly to a 61.8% reduction in the Maternal Mortality Ratio (MMR) (254 to 97) from National Family Health Survey (NFHS-3, 2005-06) to National Family Health Survey (NFHS-5,2019-21).
Although ₹24,994.45 million was expended for ASHA workers in India and ₹414.791 million in Haryana for FY 2024-25, the overall spending as per the National Health Mission (NHM) budget has declined by 20.69% and 28.38% respectively since 2019-20, reflecting reduced focus. The shift in priorities, overlapping responsibilities and role sharing in other schemes has posed limits to consistency of postnatal care at home. Ironically, postnatal care has also not received much focus in national and International statistics by the WHO, UNICEF, NFHS, and DHS, etc., ignoring the data capturing on 4 prescribed postnatal visits.
Despite the consistent efforts by ASHA by visiting door to door in the field, the postnatal service utilization by women lags behind the other indicators in maternal and child health services. Much to our dismay, world over, around 30 percent women and their newborns do not receive the postnatal care, as per the World Health Organization. As noted by the authors in district Faridabad, Haryana, 84.3% of Janani Suraksha Yojana (JSY) beneficiaries received a visit from ASHA within seven days of childbirth, and 66.8% reported receiving postnatal counselling. However, only one-fifth (21.3%) of JSY beneficiaries were accompanied by ASHA to the health centre for all four recommended postnatal check-ups.
An ASHA from the district Faridabad highlighted the logistical and emotional strain of accompanying mothers for postnatal care. She exclaimed,
“When we go for postnatal check-ups for new mothers and their newborns, many mothers resist weighing their babies. They feel the traditional hanging weighing scales are unsafe, as there have been instances of infants slipping or falling down. The soft neck of a newborn needs full support, and placing them in a bag-like sling feels not only unsafe but also unethical and disrespectful to the dignity of the child. Such experiences greatly influence the perception of quality of care provided by the health centre, and often discourage mothers from seeking immediate next postnatal check-ups.
In rural areas of the country, deep-rooted cultural traditions discourage taking newborns outside for at least a month after the birth. This belief was echoed by many Janani Suraksha Yojana (JSY) beneficiaries. The culturally ingrained child care practices in rural areas, aimed at protecting infants from threats such as the “evil eye” or illness, often hinder timely postnatal interventions despite the efforts of policymakers. An Auxiliary Nurse Midwife (ANM) reported that, in several cases, women were found carrying knives during delivery, a symbolic act rooted in defensive customs proposed to ward off negative energies. As a result, postnatal care visits to health centres suffer significantly due to stark prevalence of these primitive cultural beliefs, which unfortunately transform into anti-care practices.
The scarcity of basic postnatal supplements, especially calcium tablets, at public health centres further demotivates women and they refrain from visiting the health centre. Some JSY beneficiaries acclaimed, “Why should we walk all the way to the health centre with a small baby, troubling our ASHA didi, if the medicines we need aren't even available there? After such a long and tiring walk, getting something as basic as calcium should at least feel rewarding.” Many times, mothers-in-law, who are often both culturally informed and systemically aware, discourage visits to health centres for postnatal check-ups, not out of tradition, but due to practical concerns. They understand the limitations of the public health system and see little value in a visit when no complications are apparent. An ASHA shared her experience;
“When I arrived to accompany a woman for her postnatal check-up, her mother-in-law gently remarked, ‘She’s doing fine. We know there won’t be any medicines there- just consultation. You have so many other homes to visit; don’t waste your time here.’”
This brings forth a growing perception among the rural women that unless there’s a visible problem, the routine postnatal care will not offer any tangible benefits, particularly when service delivery gaps persist. There is also a notable disparity in postnatal care-seeking behavior based on the place of delivery. Women who deliver in private clinics often continue with postnatal care at the same facilities, guided by the recommendations from private nursing staff, and show a success rate in visit proportion to public health centres. In contrast, those delivering in public facilities show irregular follow-up patterns along with low referral support. This study showed that while 97.9% of women delivering in public institutions had home visits by ASHA, only 18.7% were accompanied to health centre, 51.8% received counselling, and 51.8% received referral services; compared to 56.7% who received home visit by ASHA and 66.7% receiving referral services in private institutions. This reflects systemic trust gaps and service inconsistencies in the healthcare delivery systems for postnatal women.
Beyond cultural norms and place of delivery, the behavior and perceived indifference of paramedical staff at health centers also deter women from seeking postnatal care. Among ASHA who described paramedical behavior as cordial, 52% reported satisfaction with PNC visits ( Postnatal Care). In contrast, among those describing the behavior as merely normal, only 20% were satisfied with the PNC services at health centres. Many women expressed that they feel more confident recovering at home. A strong perception of home-based care overruled the access to institutional care, many beneficiaries remarked that the traditional remedies and nourishing recovery preparations made by their mothers-in-law or other relatives are believed to offer better healing than institutional care. A JSY beneficiary remarked in this respect;
“Why should we visit the health center when the ANMs are impolite, the equipment doesn’t work, and there’s no proper sanitation or toilet facility for emergencies? Our mother-in-lawsoffer better nutritional support.”
These sentiments of the rural women reflect a deeper mistrust in the system, where the absence of essential supplies and lower empathetic engagement contribute to low utilization of postnatal services to improve which, strengthening the ASHA infrastructure through regular capacity-building, supportive supervision and better incentivization can help them address cultural resistance, improve PNC follow-ups, and boost community trust. If the ASHAs are supported institutionally and socially, outcomes may improve dramatically. But these workers cannot continue to fill the shortcomings of the distorted systemic arrangements of the public health system.
If the ASHA, elderly women, and local influencers are trained in Localized IEC (Information, Education and Communication) campaigns addressing harmful cultural practices, it could help in reducing cultural resistance, such as isolation of newborns or the use of knives during delivery. An improvement in facility-based post-natal care, especially sanitation, respectful treatment, privacy, and functionality of equipment, would improve the care environment at public health centres, thereby encouraging women to seek institutional PNC. Further, in order to instill belief in the effectiveness of institutional care, ensuring the availability of essential postnatal supplements can increase motivation for mothers to access services. The introduction of safer and mother-friendly newborn weighing equipment that reduces discomfort and fear would reduce the dissatisfaction among mothers.
Further, there is a need to build public-private referral gaps by creating structured referral linkages and counselling protocols in public facilities to match the continuity of care often seen in private institutions.
Well-strategized and targeted orientation sessions for influential family members like mothers-in-law can help convert cynics into allies for improving institutional postnatal care. If India is truly committed to maternal and child health, it must equally invest in the well-being of its frontline workers through institutional support, dignified work environment, timely payments, and modern tools. ASHAs are the foot soldiers of India's public health system, yet too often they are asked to march without proper equipment and provide services to the rural populace. For real reform, India must devise re-engineered field-to-institution strategies to confront systemic blockages and postnatal service inconsistencies, ensuring that the burden of failure does not fall unfairly on the shoulders of ASHA workers.
It is also worth mentioning that this article is an output from the seed money project, “An Assessment of Post-Natal Maternal Healthcare Under Janani Suraksha Yojana (JSY) in Faridabad, Haryana”, sanctioned by Manav Rachna International Institute of Research and Studies.
(Dr. Vijayetta Sharma is Associate Professor of Public Policy at Manav Rachna International Institute of Research and Studies.)(Dr Anandajit Goswami is Professor and Research Director at Manav Rachna International Institute of Research and Studies, Faridabad, Visiting Research Fellow, Ashoka Centre for a People-centric Energy Transition and Honorary Visiting Professor, Impact and Policy Research Institute.)
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