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Table 6 Summary of key interview findings - interviews with pregnant women and mothers of children under 2

From: The challenges of institutionalizing community-level social accountability mechanisms for health and nutrition: a qualitative study in Odisha, India

Type of service used/available Issues identified by mothers Relation with FLWs
A. Access to health facilities Out of pocket expenditures: including for transportation to/from the facility, payments made once at the facility towards health staff or hospital attendants, and at times towards the purchase of equipment and medicine. (existing government policies mandate free transport, treatment and services for women from lower income groups). ASHAs play an essential role in facilitating access to services and cash entitlements,. This included check-ups and institutional deliveries, which were the services with highest demand among women. In such cases, ASHAs play a key role in arranging transportation by ambulance and, once at the facility, obtaining care promptly. Check-ups and institutional deliveries are also the main requirements for obtaining cash benefits under government schemes designed to encourage demand of health services among below poverty line women
Respondents faced delay in obtaining care due to referrals from lower-end facilities (such as Primary Health Centers) to higher facilities (such as Community Health Centers and District Level Hospitals). In some cases, referrals take place because of lack of adequate facilities and qualified health staff in lower hospitals.
Inadequacy of health facilities: for instance poor hygienic conditions and lack of services which discourage women from seeking institutional care
Discrimination on grounds of tribal status: respondents reported being treated poorly by health staff on the basis of their tribal status.
B. Take home rations Take home rations are distributed irregularly and the amount is not sufficient: reported waiting time ranged from weeks to three months (in one case). In most cases, availability of eggs was found to be particularly challenging. The quality of the relation with the AWW generally depends on mothers’ satisfaction with the delivery of take home rations. Although the lack of timely or sufficient distribution of rations may be due to issues beyond the control of AWWs, respondents associated the performance of AWW with the effectiveness and quality of the food received.
Poor quality: In some cases, rotten food distributed as take home ration caused sickness among women and children.
Inaccessibility: women find it difficult to collect the ration from the AWC due to long working hours (AWC distribution ends around 2 pm).
IYCF Counselling IYCF advice, through retained by mothers, is not being put into practice. Factors such as poverty, inability to purchase nutritious food, the need to work long hours and in harsh conditions even during pregnancy, prevent them from ensuring adequate nutrition to their children. Both AWWs and ASHAs are key players in IYCF counselling, which takes place through ad-hoc sessions (Village Health and Nutrition Days) usually held at AWCs. ASHAs also undertake home visits during which they provide IYCF counselling. Home-based care is highly valued by respondents albeit (or precisely because) is not perceived as a duty of ASHAs but rather an ‘extra-mile’ task that she does voluntarily.