1

FACTORS INFLUENCING
MOTHER’S DECISION TO
DELIVER AT GOVERNMENT OR
PRIVATE HOSPITALS – A
COMMUNITY BASED
COMPARATIVE STUDY

DEPARTMENT OF COMMUNITY MEDICINE

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GOVT MEDICAL COLLEGE, MANJERI

CERTIFICATE

This is to certify that the project entitled 'FACTORS INFLUENCING MOTHERS

DECISION TO DELIVER AT GOVERNMENT OR PRIVATE HOSPITALS – A
COMMUNITY BASED COMPARATIVE STUDY’ is a bonafide record of work submitted
by the following students of 2021 MBBS batch to the Department of Community Medicine,
Government Medical College, Manjeri as a part of Phase III MBBS curriculum as stipulated
by National Medical Commission and was done during the academic year 2024-2025.

Guided By :
 Dr. Jayakrishnan Thavody
 Dr. Rameeza Rayikkal Answar

Professor & HOD

Dr. Priya Chandran
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ACKNOWLEDGEMENT
We would like to express our sincere and profound gratitude to all the faculty and staff
members of Community Medicine department, Government Medical College, Manjeri
especially to the Head of the Department, Dr. Priya Chandran, our research guides Dr.
Jayakrishnan Thavody and Dr. Rameeza Rayikkal Answar, who had always been supporting
and motivating us throughout for the successful completion of this project.

We also thank our friends and colleagues who helped us in accomplishing this task with
ease. We would also like to extend our heartfelt thanks to the study subjects whose whole
hearted cooperation ultimately transformed this study into a reality.
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TEAM MEMBERS

ROLL NO. NAME

01 Abdul Basith T

02 Abhijith Das

03 Abhinav Manoj

04 Ahammed Irfan

05 Akhil K K

06 Akshaya Babu

07 Akshwanth C Lakshman

08 Alakananda K

09 Albert Andrews

10 Aleema V K

11 Aleena Lakshmi B

12 Amal Francis

13 Amnisha C P
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CONTENTS

SL.NO TITLE PAGE NO

1 Objective 3

2 Abstract 4

3 Introduction 5

4 Literature review 7
Materials and
5 10
methodology
6 Result 12

7 Discussion 24

8 Conclusion 26

9 Reference 27

10 Annexure 29
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OBJECTIVE
To determine the factors influencing mother’s decision to choose private or
public institution.
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ABSTRACT

Background: Mother and child health is of significant importance in the community and a lot
of it depends on the prenatal, natal and postnatal care of the mother and child. Institutional
deliveries are known to have a positive impact on their health and it is important to understand
the factors that lead to the choice of place of delivery

Objective: Comparative analysis of Factors Influencing mothers decision to choose private or

public institution

Method: A cross sectional study was conducted on the population of mothers with child less
than 5 years from Malappuram district with a number of variables such as education,
occupation of mother, distance to place of delivery, medical expense, environmental hygiene,
type of delivery, length of stay before and after delivery, consultations apart from regular
check-ups. Data was collected using a semi-structured questionnaire. The collected data was
analyzed using SPSS version28. Informed consent was taken from participants prior to data
collection and further procedures.

Result: 51% of the population prefer public hospitals while 49% prefer the private sector.

Conclusion: The study indicates how the decision has reached one of the choices of private
and public hospitals. Briefly, the lower income population and those having lower education
prefer the public sector owing to reduced expenses. Private hospitals are chosen by the higher
educated higher income population owing to more facilities and medical interventions such as
cesarean sections, although at higher cost.
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INTRODUCTION

In the context of childbirth, births can take place either at home or at healthcare
facilities, whether they are private or public. Institutional birth (IB) pertains to delivering
babies in healthcare establishments, such as hospitals or birthing centers, under the watchful
care and supervision of proficient healthcare practitioners and skilled health workers.

Increasing the IB is one of the main strategies adopted in India for decreasing the maternal
mortality ratio. According to NFHS-5 (National Family Health Survey 2019-21) 88.6 percent
of deliveries took place in a health facility. Among urban areas, this share was higher – 93.8
births took place in a health facility, while in rural areas only 86.7 percent of all births were
institutional.[1]

In Kerala as reported in HMIS 2019-20, around 99.9% of the deliveries took place in
institutions, out of which 31.8% took place in public health facilities while 68.2% took place in
private facilities.[2][3]

Public IBs in India carry immense significance due to their potential to address healthcare
disparities and improve the health outcomes of the socialized and marginalized population.
Initiatives like Janani Suraksha Yojna and Janani Suraksha Karyakram provide financial and
medical support to women [4] further in resource-constrained settings, where access to quality
healthcare remains a challenge, public healthcare institutions serve as lifeline for pregnant
women, especially from semi-urban and rural areas, by providing them access to the optimal
continuum of care required during a delivery episode. Public facilities offer affordable or free
services to ensure that a larger chunk of the population can access necessary maternal
healthcare, reducing disparities and improving overall healthcare equity.

Private IBs offer a wide range of options and amenities catering to various needs and
preferences of expectant mothers. These services often include personalized prenatal care,
delivery facilities, and comprehensive postnatal care. Private hospitals typically offer a choice
of delivery options, such as natural birth, cesarean section, or water birth, depending on the
patient's preferences and medical needs. Many private hospitals also provide amenities like
private rooms, in-room birthing pools, and access to specialized medical equipment.

Several factors play a role in choosing the place for safe delivery. Factors influencing choice
of institution for delivery operate at multiple levels - individual, household, community, and
state and may vary from region to region within the country.
 9

The challenges such as exorbitant expenses in private facilities, absence of health insurance
coverage, scarcity of healthcare personnel and infrastructure in public facilities,
socioeconomic disparities, cultural influences, geographical obstacles, and concerns about the
quality of public healthcare services can hinder pregnant women from accessing healthcare
institutions during childbirth.[5]

In Our study we investigate the factors Influenced mothers to choose private or public
institution for delivery, taking account of each individual factors that lead to their decision.
Each patient admitted has different viewpoints towards each factor, so it will be not authentic
not to consider that aspect. The research which includes the individuality aspect makes this
complex. Still the objective of this research remains decoding and loosening this complexity
to an extend such that it will be possible to make available the best technologies and facilities
to every patient irrespective of socioeconomic or any other gradient. The sole aim of this
research is a comparative study of private and public hospitals serving their purpose in
deliveries and mother and child caring.

We organize the study in the following manner. The literature review comes next, followed by
the method, results, and discussion sections. We conclude by providing future research areas
and discussing the limitations of the present study.
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LITERATURE REVIEW
1. A cross sectional study was done about ‘Factors Influencing the Choice of a Public or
Private Health Institutions For Childbirth in Chandigarh’ by Trusty Khumukcham Senior
Resident, Tarundeep Singh Assistant Professor Community Medicine, Manmeet Kaur
Associate Professor of Health Promotion, Madhu Gupta Associate Professor Community
medicine, Rajesh Kumar Professor and Head School of Public Health, of Post Graduate
Institute of Medical Education and Research, Chandigarh. The study was conducted in
selected communities of Chandigarh city in India during 2010-11. A consecutive sample of 300
women (150 in public and 150 in private institutions) who had delivered a baby in previous
three months were interviewed using a pretested interview schedule. Chi square test was used
to find association of socio-demographic, maternal, and institutional factors with the type of
institution selected for delivery. It was found that Women from lower socio-economic status
delivered more frequently in public sector institutions (47.3%) than in private institutions
(16.7%) (p<0.01). In private institutions 30% of the women were delivered through Cesarean
Section compared to 17.3% in public institutions (p<0.05). Physical infrastructure was better in
private institutions. Cost was lower in public (Rs.4,630) than in private institutions (Rs 21,676).
Most women were satisfied with the quality of care received in public and private institutions.
However, some reported that public institution staff need to be more polite. Quality of
infrastructure in health facilities, quality of care, and socio-economic status were associated
with the choice of institution for delivery. Public sector health institutions are a major source
of maternity care in Chandigarh , hence, care providers should be trained in handling clients
gently. Regulations for adherence to protocols, e.g., indications for Cesarean Section and fee
structure etc. need to be implemented in private institutions. [6]

2. ‘High Prevalence of Cesarean Section Births in Private Sector Health Facilities in India’
according to DLHS 4 study conducted by Priyanka Singh, Gulfam Hashmi & Prafulla Kumar
swain on behalf of increasing rate of cesarean section (CS) births worldwide, including India,
is a significant public health concern. This study, based on the District Level Household
Survey 4 (DLHS-4) data, aimed to quantify the prevalence of CS births in public and private
health facilities in India and to identify associated factors where the prevalence of CS births
was significantly higher in private sector health facilities (37.9%) compared to public sector
facilities (13.7%).Women delivering in private facilities were nearly four times more likely to
have a CS. Factors include Urban residence, maternal age (>35),Hypertension in pregnancy,
Breech presentation etc. The findings of this study highlight several important implications
like unnecessary risks; The higher rate of CS births in private sector facilities, especially when
there are no medical indications may pose unnecessary risks to women. Increased costs; CS
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births are generally more expensive than vaginal births, leading to higher healthcare costs for
women. Need for policy interventions; The government of India needs to implement measures
to strengthen public health facilities and ensure that CS procedures are performed only when
medically necessary in both public and private sectors. This study aligns with previous
research on CS rates in India and other countries. Several studies have reported higher CS
rates in private sector health facilities compared to public sector facilities. It is often attributed
to factors such as patient preference, provider behavior, and profit motives. [7]

3. A cross sectional study on the topic ‘Factors affecting the choice of public vs private
healthcare institutions for delivery and postnatal care’ conducted in district Rajanpur, which
is predominantly a rural district in Pakistan by Sohail Akhtar, Zafar Ahmed and Asim
Mehmood (Faculty of Medicine and Health Sciences, UNIMAS, University Malaysia
Sarawak, Malaysia, Department of Health Informatics, Faculty of Public Health and Tropical
Medicine, Jazan University, Saudi Arabia).A multi-stage random sampling technique, 368
mothers of age 15-49, who delivered within 6 months prior to data collection in selected basic
health unit (BHU) areas were selected. The Multivariate binary logistic regression was applied
on primary data collected from Rajanpur district during 1st November, 2020 – 31st January,
2021. The results were; the mean age of the mother was approximately 28.3 years, with more
than 60% of them being between 20-30. Younger mothers who belong to lower than 20 years
are more than 99 percent less likely to use public health facilities. As the educational level
increases, facility preference is more likely to be private ,Mothers who are employed in the
government or private services are less likely to choose public facilities than who are
housewives. Self-employed households (OR=1.28) were more likely to prefer public health
facility for delivery care. Mothers with more living children had greater odds of choosing the
public sector hospital for their child births. The results indicated that the preferences are
influenced by education & economical status, accessibility, distance to health care facilities,
cost of transport and out of pocket expenditure.[10]

4.A study about out-of-pocket expenditure and its correlation with institutional deliveries
in private and public healthcare sectors in India: findings from NFHS 5 by Sayantani Manna ,
Damini Singh , Shishirendu Ghosal, Tanveer Rehman, Srikanta Kanungo and Sanghamitra
Patil. Increased coverage for institutional delivery (ID) is one of the essential factors for
improved maternal and child health (MCH). Though, ID increased over time, out-of-pocket
expenditure (OOPE) for the care-seeking families had been found to be growing, parallelly.
So they estimated OOPE in public and private health centers for ID along with their sources
and attributing factors and compared state and union territory-wise. So that financial risk
protection can be improved for MCH related services . Women’s data was collected from the
National Family Health Survey, 2019–2021 (NFHS-5). Reproductive aged women (15–49
 12

years) who delivered one live child in the last 5 years (n = 145,386) in any public or private
institutions, were included. Results showed overall median OOPE for ID was Rs. 4066
(median OOPE: private hospitals: Rs.25600, public hospitals: (Rs.2067). Health insurance was
not sufficient to slash OOPE down at private facilities. Factors associated significantly with
high OOPE were mothers’ education, elderly pregnancy, complicated delivery, birth order of
the latest child etc. [9]
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MATERIALS & METHODOLOGY

1. Study design : Cross sectional study

2. Study Setting : Field study

3. Study population : Mothers with children less than 5 years from Malappuram
district.

4. Sample size : Number of participants- 100

5. Sampling method : Convenient sampling

6. Study period : 20/04/24- 14/11/24

7. Study variables :
1. Place of delivery
2. Monthly income
3. Education of mother
4. Occupation of mother
5. Type of delivery
6. Medical Expenses
7. Distance to place of delivery
8. Maternal incentives
9. Environmental hygiene

8. Data collection tool/technique: Semi-structured questionnaire was used to collect

data from participants. Questions were asked in Malayalam and data collected via Google
form.

9. Data analysis: Final analysis was done using SPSS version 28

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10. Ethical consideration: Informed consent was taken from participants.

11. Statistical analysis: significance were studied by analyzing p-value by Pearson chi
square test and Fischer's exact value .p-value < 0.05 considered significant. The sample size is
small which could affect the statistical power of the test. It would be helpful to know the
overall sample size to assess the representativeness of the data.
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RESULT

I. Place of delivery

Figure no : 1.0

Interpretation : Out of the 100 participants 51% delivered at government institution whereas
the rest 49% at private hospitals.
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II. Monthly income of family to place of

delivery

PLACE OF DELIVERY
MONTHLY
PRIVATE TOTAL
INCOME (RS) GOVERNMENT n(%)
n(%)
< 979 1 (1.96) 0 1
980-2935 2 (3.92) 2 (4.08) 4
2936-4893 9 (17.64) 3 (6.12) 12
4894-7322 2 (3.92) 1 (2.04) 3
7323-9787 4 (7.84) 3 (6.12) 7
9788-19574 25 (49) 19 (38.7) 44
>19575 8 (15.68) 21 (42.8) 29
Total 51 49 100
TABLE 2.0

GOVERNMENT PRIVATE TOT CHI- P-

n(%) n(%) AL SQUARE VALUE
VALUE

Monthly ≤9788 18 (35.3) 9(18.4) 27 3.633 0.057

income

>9788 33(64.7) 40(72.6) 73

Total 51 49 100

Table 2.1

Interpretation :
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● Out of the 49 participants delivered at private hospital majority (72.6%) have a

monthly income more than 9787 whereas 64.7 % in government hospitals

● The Chi-square test gives a p value of 0.057 shows a slight association i.e the
mothers who belong to having family income of more than 9788 likely to
choose private hospitals than government hospitals

III. Education of mother to place of

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delivery

MODIFIED KUPPUSWAMY SCALE

SCORE EDUCATION

1 Illiterate

2 Primary school

3 Middle school

4 High school

5 Intermediate/diploma

6 Graduate

7 Professional degree

Table 3.0

PLACE OF DELIVERY CHI-

EDUCATIO
GOVERNME TOTAL SQUARE P-VALUE
N PRIVATE
NT n(%) VALUE
n(%)
Middle school 2 (3.92) 2 (4.08) 4

High school 37 (72.5) 25 (51.02) 62

Intermediate/d
2 (3.92) 2 (4.08) 4 5.618 0.132
iploma

Graduate 10 (19.6) 20 (40.8) 30

Total 51 49 100

Table 3.1
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Interpretation:
Using Modified Kuppuswamy scale educational status of mothers were assessed
 Out of the 100 participants majority in both government and private are high school
pass outs.
 Mothers with an education level of 6 (66.6 % )choose private hospital (66.6%) whereas
mothers with an education level of 4 (71.1 %) were delivered in government
hospitals.
 Chi-square test gives p-value as 0.132 showing no significant association between
education of mother and place of delivery, in consistent to above data.
 20

IV. Occupation of mother to place of

delivery

OCCUPATION SCORE

Unemployed 1

Unskilled worker 2

Semiskilled worker 3

Skilled worker 4

Clerical/Shop/Farm 5

Semi Professional 6

Professional 10
Table 4.0

PLACE OF DELIVERY
GOVERNME
OCCUPATIO PRIVATE
NT TOTAL
N n(%)
n(%)
Unemployed 47(92) 43(88) 90

Skilled worker 1(2) 0(0) 1

Clerical/ shop/
0(0) 1(2) 1
farm
Semi
3(6) 5(10) 8
professional

Total 51 49 100

Table 4.1
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OCCUPATI
PLACE OF DELIVERY
ON
GOVERNM PRIVATE FISCHER’S
ENT n (%) TOTAL EXACT P VALUE
n (%) VALUE
Employed 47(92.2) 43(87.8) 90
Unemployed 4(7.8) 6(12.2) 10 0.538 0.521
Total 51 49 100
Table 4.2

Interpretation:

 92% of the mothers who chose government were unemployed and 8% were employed.
 88% of mothers who chose private were unemployed and 12% were employed.
 Fischer’s exact value test gives a P-value 0.521 which suggest no significant
association between occupation of mother and place of delivery.
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V. Type of delivery and place of delivery

PLACE OF DELIVERY
CHI-
GOVERNM PRIVATE SQUAR P-
TOTAL
ENT n(%) n(%) E VALUE
VALUE
Normal delivery 43(84.3%) 32(65.3%) 75

Caesarean section 8(15.7%) 17(34.7%) 25

4.815 0.028
Total 51 49 100

Table 5.0

Interpretation:

● Table shows that , among 25 Caesarean section 17 (68% ) were in private hospital whereas
only 8 (32%) in government hospitals
● Chi -square test gives a p value of 0.028 shows a significant association
 23

VI. Medical expenses and place of delivery

FISHER
GOVERNMEN PRIVATE P-
TOTAL EXACT
T n(%) n(%) VALUE
VALUE

<5k 38 (74.5) 1(0.02) 39

Medical
expense 5k-25k 13(25.5) 21(42.8) 34
63.971 <0.001
>25k 0(0) 27(55.1) 27

Total 51 49 100

Table 6.0

Interpretation :

● 74.5 % of people deliver in government hospitals had a medical expenses Less than 5k
whereas 55.1 % of people deliver in private hospital had a medical expenses more than
25k
● Fischer’s exact test gives a p-value less than 0.001 which shows a significant
association between Medical Expenses and place of delivery
 24

VII. Distance to place of delivery

PLACE OF DELIVERY
CHI-
SQUA P-
GOVERNM PRIVATE
TOTAL RE VALU
ENT n(%) n(%)
VALU E
E
Distance less than or equal
28(54.9%) 35(71.4%) 63
to 10km (1)
Distance greater than 10km
23(45.1%) 14(28.6%) 37
(2)
2.928 0.087
Total 51 49 100

Table 7.0

Interpretation:
● 56.3 % of Hospitals within 10 km were private hospitals.
● Chi-Square test gives a p value of 0.087 which suggest no significant association
between distance from place of delivery to type of Delivery .
.
 25

VIII. Maternal incentives and place of

delivery

PLACE OF DELIVERY
CHI
SQUA
P-
GOVERNMENT PRIVATE TOT RE
VALU
n(%) n(%) AL VALU
E
E
Ye
34(66.6) 6(12.2) 60
s
Any maternal incentives
No 17(33.4) 43(87.8) 40 30.839 0.001
Total 51 49 100
Table 8.0

Interpretation:

 34 out of 51(66.6%) who delivered in government hospitals received maternal

incentives whereas 43 out of 49(87.8%) in private hospitals did not receive maternal
incentives.
 The Chi-square test gives a p-value 0.001 which shows a significant association
between maternal incentives and place of delivery.
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IX. Environmental hygiene and place of

delivery

PLACE OF DELIVERY

FISCHE P-
GOVERNMENT PRIVATE TO R'S VALU
n(%) n(%) TA EXACT E
L VALUE
The environment was Yes 45(88.2) 48(97.9) 93
hygienic 3.630 0.057
No 6(11.8) 1(2.1) 7

Total 51 49 100

Table 9.0

Interpretation:

● In government hospitals, 45 out of 51 (88.2%)were considered hygienic whereas in

private hospitals 48 out of 49 (97.9%) were considered hygienic.
● The Chi-square test gives a p-value 0.057 which shows a tendency to have significant
association between place of delivery and perceived environmental hygiene
 27

DISCUSSION
Several factors are considered by the woman and her family in choosing an institution for
delivery. Through our Questionnaire approach, there are various concerns the mothers raised.
Socio-economic status was one of the factors we assessed through monthly income of family,
education of mother, occupation of mother standardized using Kuppuswamy scale[8]. On
assessing income (table 2.0),it suggest that individuals with higher incomes are more likely to
choose private hospitals for delivery compared to those with lower incomes who choose
government hospitals. However chi-square value of 3.633 and p value 0.057 indicates a weak
association between income level and place of delivery. In a similar study in Chandigarh by
Trusty Khumukcham and colleagues highlights 47.3 % of women from lower socio-economic
background prefer public health institutions over private institutions (16.7 ℅) which show a
significant association of p-value < 0.01 . [6]

On analysis education of mothers (table 3.0) standardized by Kuppuswamy scale[8], it shows

that Mothers with an education level of Graduate (66.6 % )choose private hospital whereas
mothers with an education level of High school (71.1 %) were delivered in government
hospitals .Chi-square test gives p-value as 0.132 showing no significant association between
education of mother and place of delivery.

On assessing a mother's occupation (table 4.2) categorized from unemployed to professionals,

it shows that92% of the mothers who chose government were unemployed and 8% were
employed .88% of mothers who chose private were unemployed and 12% were employed.
Fischers extact test gives a P-value 0.521 which shows no significant association between
occupation of mother and place of delivery .While the cross sectional study conducted in a
rural district of Pakistan shows mothers with good education status & employees are more
likely to choose private sector compared to Public sector. [10]

On analyzing factors like out-of-pocket expenditure and medical expenses, (table 6.0) it
shows that 74.5 % of people deliver in government hospitals had a medical expenses Less
than 5k whereas 55.1 % of people deliver in private hospital had a medical expenses more than
25k. Fischer’s exact test gives a p-value less than 0.001 which shows a significant association
between Medical Expenses and place of delivery. Studies conducted in Chandigarh by trusty
Khumukcham[6] give a cost difference of around Rs.4630 in public institutions and a
minimum of Rs.21,676 in the private sector, and a study of out-of-pocket expenditure
correlates with public & private institutions; OOPE for public institutions was Rs.2067 &
Rs.25,600 for private institutions.
 28

In our study 34 out of 51(66.6%) who delivered in government hospitals received maternal
incentives whereas 43 out of 49(87.8%) in private hospitals did not receive maternal incentives.
The Chi-square test gives a p-value 0.001 which shows a significant association between
maternal incentives and place of delivery.(table 8.0) . Studies conducted in Chandigarh by
trusty Khumukcham[6] ,more individuals who received maternal incentives delivered in
government hospitals (34) than in private hospitals, and more individuals who did not receive
maternal incentives delivered in private hospitals (43) than in government hospitals.

Increased incidence of cesarean section in the private hospital is one of the concerns raised by
mothers who choose the government hospital. On assessing ,(table 5.0) among 25 Caesarean
section, 17 (68% ) were in private hospital whereas only 8 (32%) in government hospitals.
Chi -square test gives a p value of 0.028 shows a significant association . According to a cross-
sectional study conducted in Chandigarh by Trusty Khumukcham and colleagues[6], the rate
of cesarean sections was notably higher in private hospitals (30%) compared to public
hospitals (17.3%) This was statistically significant, with a p-value <0.05. In another study
“High Prevalence of Cesarean Section Births in Private Sector Health Facilities in India—
according to DLHS-4 ” by Priyanka Singh 2018, [7] suggests that CS births are nearly four
times more in private as compared to public sector health facilities. i.e., the prevalence of
Cesarean section births was significantly higher in private sector health facilities (37.9%)
compared to public sector facilities (13.7%).

Hygienic practices of hospitals were assessed based on cleanliness and waste management.
Six among government institutions & 1 among private hospitals were found unhygienic. On
analysis it shows that the majority (about 93%) of respondents reported the environment as
“hygienic” while a small fraction (7%) found it “not hygienic”. Fischer extact test gives a p
value of 0.057 shows a tendency to chose private hospital due to their hygiene practices .

Also, the age of the mother, length of stay, facilities provided by the institution, behavior of
staff, and distance from the place of delivery did not show any significant association. Studies
show a significant improvement in the health delivery system in government hospitals,
providing good quality care with a satisfactory environment for mother & child at a meager
price. The approach of the community to the government can be changed by providing
advanced obstetric care hand in hand with private hospitals which will give a remarkable
change in IMR and MMR and ensure a healthy future .
 29

CONCLUSION
In conclusion, this study underscores the factors influencing decision-making around the place
of delivery for women like socio-economic status, education, occupation, and out-of-pocket
expenses. While income and education were not found to have a strong statistical association
with the choice of delivery location in this sample, other factors such as the higher cost and
increased likelihood of cesarean sections in private hospitals were significant.

Government hospitals remain a critical choice for lower-income and less-educated women,
offering more affordable care, while private hospitals attract those with higher income and
education levels, though at a higher cost and increased rates of medical interventions such as
cesarean sections.

The findings also suggest a need for policy interventions to improve the quality and
accessibility of care in public hospitals. Efforts to ensure that cesarean sections are performed
based on medical need, rather than economic factors, particularly in the private sector, could
help balance maternal health outcomes across both sectors. Improved referral systems and
maintaining high hygiene standards across all institutions could further enhance maternal care
services and reduce disparities in healthcare delivery.

Limitations
 Adequate sample size not available
 Geographical diversity lacking
 Selection bias present
 Demographic control not maintained
 Self-reporting bias present

Recommendations
 Promote quality service in public hospitals
 Upgrade infrastructure and staff training in public healthcare
 Reduce medical expense at private sector
 Promote public awareness campaigns regarding maternal incentives.
 Regularly gather and act on mothers feed back
 Strengthening public health facilities, promoting evidence-based decision-making, and
implementing policies to ensure appropriate use of CS.
 30

REFERENCE

1. Determinants of public institutional births in India: An analysis using the National Family
Health Survey (NFHS-5) factsheet data
Kar, Rohan Wasnik, Anurag Piyamrao
Journal of Family Medicine and Primary Care April 2024

2.Annual vital statistics report 2020

Department of economics and statistics , vital statistics division Thiruvananthapuram Kerala

3. Health Management Information system 2019-20

Statistics division ministry of health and family welfare, Government of India.
4.HFW/ Initiatives for Pregnant Women/22 July 2022/4

5.Critical comparison of maternity and delivery care patterns in Kerala and India using data
from the National Family Health Surveys
June 2022 Journal of Medical Science And clinical Research
Betsy Varghese (Medical College Trivandrum) Ria Elizabeth Thomas, Mini S , Indu D

6. Factors Influencing the Choice of a Public or Private Health Institutions Childbirth in

Chandigarh by Trusty Khumukcham Senior Resident,Tarundeep Singh Assistant Professor
Community Medicine, Manmeet Kaur Associate Professor of Health Promotion,Madhu Gupta
Associate Professor Community Medicine ,Rajesh Kumar Professor and Head School of
Public Health, of Post Graduate Institute of Medical Education and Research, Chandigarh.

7. High prevalence of cesarean section births in Private sector health facilities -analysis of
district level household survey -4 (DLHS-4) of India by Priyanka Singh, gulfam
hashmi,prafulla kumar swain

8. Kuppuswamy scale

9.out-of-pocket expenditure and its correlates for institutional deliveries in private and public
healthcare sectors in India: findings from NFHS 5 by Sayantani Manna , Damini Singh ,
Shishirendu Ghosal, Tanveer Rehman, Srikanta Kanungo and Sanghamitra Patil.

.
 31

10 .Factors Influencing mothers decision deliver in private or public institution study

conducted in district Rajanpur, which is predominantly a rural district in Pakistan by Sohail
Akhtar, Zafar Ahmed and Asim Mehmood (Faculty of Medicine and Health Sciences,
UNIMAS)
 32

ANNEXURE
Questionnaire

1. Biodata
Name :
Age :
Address :
Education:
Occupation of mother :
Husband's name :
Occupation :
No. of children :
Income of family :
Nearest delivery care availability:
Distance to the place delivered:
Type of delivery - Normal delivery / Caesarean section
Place of delivery : Public hospital / Private Hospitals

2. Finances

SL YES
NO. /NO
1 Any Maternity insurance
2 Any incentives or support from the hospital

3. Medical expenses in the hospital

 1K-10k
 10K- 50k
 More than 50k

4. Miscellaneous expenses
 33

Mention if any

5. Environment hygienic : Yes or No