Giving birth at home:
How to change the custom and create a descriptive norm on
hospital delivery in Jharkhand, India
Job Zachariah, UNICEF, India
UNICEF-University of Pennsylvania Program
Philadelphia, July 2012
Giving birth at home: How to change the custom and create a descriptive norm on institutional
delivery1 in Jharkhand, India
1. Introduction
Jharkhand, the east Indian state with a population of 33 million (Census, 2011), has poor socio- economic
indicators. About 40% of the population consists of Scheduled Castes and Scheduled Tribes2. Over 42 per
cent of the people in Jharkhand live below the nationally defined poverty line - percapita income less than
half a dollar per day (NSSO3, 2004-05) and about 55% of the children below 3 years are under- weight
(NFHS4-3, 2004-05). About one third (33%) are illiterate (Census, 2011) and 63% of the girls get
married before the legal age of 18 years in Jharkhand (NFHS-3).
2. The Challenge
About 850,000 babies are born in the state every year, of which about half (46% or about 400,000) are
born in homes, without the assistance of skilled birth attendants (HIMS5 Report, May 2012).The other
half (54% or 450,000) are delivered in hospitals. But the per cent of mothers giving birth in hospitals is
steadily increasing - from 12% in 1992-93, to 15% in 1998-99, 19% in 2005-06 and to 54% in 2012.
(NFHS-1, 2 &3 and HIMS, 2012).
In Jharkhand (and also in rest of India), hospital expenses on delivery of babies are borne by the
government under a programme ‘Janani Suraksha Yojana’6. Government provides cash incentive7 of $ 25
to mothers who deliver in hospitals, free transport to reach hospitals and also free escort service of the
‘Sahiya’ (the village health worker). Empirical evidence shows that incentives are not effective as it
amounts to clash of social norm and market norm8, but government thinks otherwise.
Despite the facilities, incentives and safety aspects, why do most women in Jharkhand deliver babies at
homes, increasing the risk of infant and maternal deaths? How can a descriptive norm created in favour of
delivery at hospital? How can the custom of home delivery changed?
1
Giving birth in a hospital as against giving birth at home, without adequate obstetric care
The most marginalized and deprived communities in India.
3 National Sample Survey Organisation
4 National Family Health Survey
5 Health Information Monitoring System
6 Under Janani Shishu Suraksha Karyakram, another programme, government bears the expenditure of delivery including Csection, drugs, consumables, diet, diagnostic tests, transport from and to and user fee for pregnant woman, as well as for
neonates for 30 days.
7 Although the incentive amount seems to be small, it is equivalent to 15 days wage of a working woman
8 Ariely. A, The cost of social norms: Why we are happy to do things, but not when we are paid to do them
2
2
3. Theoretical tools, Concepts and Framework9
It appears that two types of collective behaviours exist in villages10 in Jharkhand side by side, when it
comes to giving birth to babies. Some mothers deliver babies at home while some others deliver babies at
hospitals. Let us first examine whether the behaviour of giving birth at hospital or at home is a custom,
descriptive norm, legal norm or moral norm?
A social norm is a pattern of behaviour such that individuals prefer to confirm to it on the condition that
they believe that most people in their relevant network: a) conform to it (empirical expectation); and b)
believe that they ought to conform to it (normative expectation)11. In short, social norm has three elements
- conditional preference, empirical expectation and normative expectation. A custom12 is a pattern caused
by actors’ similar motivation and condition. Each acts individually and the result is an emergent pattern of
action13. In a custom, there is no empirical expectation, normative expectation or conditional preference.
Therefore, both these collective behaviours of delivering at home/hospital can be classified as customs, as
the following elements are present in both cases:

The preferences are unconditional. “Whatever other people do, I will deliver in hospital/home”.

There is no empirical expectation - “There are many people who deliver in hospital/ home, so what”.

There is no normative expectation14 on delivery at home or at hospital.
Descriptive norm, on the other hand, is a pattern of behaviour where individuals prefer to conform to it on
condition that they believe that most people in their relevant network conform to it (empirical
expectation). A descriptive norm, as opposed to a custom, has causal influence on behaviour 15. Therefore,
for creating a new descriptive norm, it is important to create empirical expectation.
There are factual beliefs16 in both cases of these customs on giving birth at home/hospital. The factual
belief about giving birth at home is that it is safe, convenient and comfortable as it happens in a familiar
setting among close relatives. They also hold the factual belief that delivery at hospital has many
problems- difficulty in getting transport from the remote village to the hospital, apprehension about the
absence of doctors and nurses in the hospital, quality of services in the hospital, and also indifference and
9
Italicized words in this section has specific meaning and definition
10
There are more than 35,000 villages in Jharkhand, of which about 15,000 are tribal villages
C. Bicchieri, 2006, 2012
12 In common parlance, a custom is often understood as a social or religious practice followed by all,
11
13
C. Bicchieri, 2012
14
However, there is a small section of the community (consisting of husband, mother-in-law, frontline health workers like
‘Sahiyas’ and ‘Anganwadi’ workers etc) who may expect the delivery ought to happen at home/ hospital, as the case may be. In
this case study, the weak normative expectation that may exist, is ignored
15 Bicchieri, 2006
16 Factual belief has a different connotation in social science. It is different from the layman’s perception that it is the truth
based on facts and ‘correct information’.
3
neglect of the staff. The factual belief in the case of institutional delivery is that it is safe; and it gives free
transport, cash incentive and free escort service to the hospital.
Ideally, social norm should be aligned and harmonized with legal and moral norm17. The success of the
Citizen Culture Approach of Antanas Mockus, experimented in Bigota in Columbia, was in harmonizing
the legal, normal and social norms18 In the case of institutional delivery, it cannot be made a compulsory
by law as India is a democratic country. Also, criminalization of the custom of giving birth at home, by
shame or fine, may also backfire in India.
According to the ‘social convention theory’, when a social norm is in place, decision making is an interdependent process, in which choice made by one family is affected by and affects the choices made by
other families; it is a reciprocal expectation19. Delivering baby at home or hospital is an independent and
individual action like washing hands with soap at critical times, immunizing children or using ORS
during diarrhea (although these acts have impact on the public health) and therefore, reciprocal
expectation does not exist. On the other hand, decision of one family on child marriage, foot binding or
FMG/C is affected by and affects the choice of other families. In Independent action like delivery at
home/hospital, attitude and behaviour would move closely side by side20 as shown below.
More Independent Action
Incividual action of Oral Rehydration Therapy
Attitude
80
% of Population
% of Population
100
More Interdependent Action
Community Adoption of Later Marriage Norm
Behaviour
60
40
20
0
0
10
20
30
Time
Attitude
100
80
60
40
20
0
Behaviour
0
5
10
15
20
25
30
Time
Creating common knowledge in the community about institutional delivery, through discussion and
dialogue is important. What are common to successful programs are a) engaging the entire community; b)
sharing information with the community; c) collective discussion and change of factual belief and
attitudes and d) collective decision to enact change21.
The community engagement, argumentation, dialogue and owning processes could be initiated by
identifying a core group (which could include mothers who have delivered in hospitals and mother-in17
Glossary of terms, Penn-UNICEF Summer program on advances in social norms and social change, 2012
Javier Guillot, 2012
19 The Dynamics of social change towards abandonment of FMG/C in five African Countries, UNICEF Innocenti Research Centre,
2010
20
Gerry Mackie, 2012
21 Dooley, 2012
18
4
laws and husbands who favour it) in villages; and diffusing to other members in the community and then
diffusing to other communities around. This strategy was successfully tried out in the cases of footbinding
in China, Female Genital Mutilation/ Cutting (FGM/C) in Senegal through the Tostan Community
Empowerment Programme, Saleema program in Sudan and the Community Approaches to Total
Sanitation (CATS) in many countries. Members of the core group should have trust22 . Persons like school teacher, health worker, religious leader- could act as a ‘bridge’ (Often, the bridge node has better
centrality and high degree) during the diffusion.
For creating or changing social norm, the strategies of ‘public declaration23’ and ‘celebrations’ are found
to be effective, as it increase and reinforce the empirical expectation. This was successfully deployed in
the cases of footbinding, FGM/C and CATS. Social marketing with catchy slogans, branding and out of
the box messages around hospital deliveries are likely to catch the public attention and increase social
expectations.
At present, the incentive system for institutional delivery is cash- based and individual-based. Although
the present cash incentive would not crowd out the intrinsic and image motivation in the case of
institutional delivery, government could add community based non-monetary incentives, which would
highlight the village pride.
4. Why Descriptive norm should be created
Of the total 850,000 deliveries, 2,100 mothers die every year in the State during pregnancy and delivery
(SRS24, 2009). Besides, about 36,000 infants die every year (100 infants every day) in Jharkhand (SRS,
2009). Why do we need to change the custom of delivering at home and create a descriptive norm on
hospital delivery? There are many reasons:

About 74% of the maternal deaths25 (caused mainly by post-partum hemorrhage, eclampsia and
obstructed labour) could be prevented if the delivery happens in a hospital

About one-third of infant deaths26 (mainly caused by pre-term delivery complications and
asphyxia) could be averted if mothers had delivered in a hospital.

The per cent of mothers breastfeeding babies within one hour of birth (colostrum feeding) would
increase as the hospital would ensure this. This simple act alone would reduce the rate of infant
deaths by 22 % (Lancet, 2003). In Jharkhand, the initial breast feeding within one hour is very
low - only 11% (NFHS-3).
22
H. Mercier, 2012
In the Indian context, the appropriate phrase would be mass pledge or oath taking
24 Sample Registration Survey
25 Maternal Mortality Rate (MMR) in Jharkhand is 261 per 100,000 live births (SRS,2009)
26 Infant Mortality Rate(IMR) in Jharkhand is 40 per 1000 live births(SRS,2009)
23
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
The per cent of birth certification would increase as the hospital can ensure that the baby gets the
birth certificate27, before the mother leave the hospital after 48 hours of the delivery.

Babies will receive the first dose of BCG and oral polio in the hospital.

Girls will be empowered, as girls born in hospital in Jharkhand, will get conditional cash transfer
(CCT) certificate of $ 2,000 (this is equivalent to two years income of an average family of five
people)28.
Some may argue that a social norm around giving birth at hospital should be created, instead of a
descriptive norm. But it is difficult to create a social norm because it may not be possible to create
normative expectation around hospital delivery and to generate social sanction against giving birth at
home.
5. Work done so far to improve intuitional deliveries
Let us now assess what were the strategies and initiatives adopted in Jharkhand to improve the
institutional delivery.
First, a maternal death review of maternal deaths (referred to as MapeDIR) in the State was undertaken
by UNICEF in 2009 to know the medical / social causes for maternal deaths as well as to know why
mothers deliver at home; why do not they deliver in hospitals; and what are the social practices, customs
and beliefs around pregnancy and delivery. Among other findings, it brought out certain social practices,
beliefs and preferences around mode and place of delivery. These were:

Lack of vehicle to take the pregnant women from home in remote and scattered habitations to the
hospital, especially in the night, was a major impediment. Normally, it took 3-4 hours to arrange
transport and to reach the hospital.

Many women preferred to deliver at home in a familiar setting in the presence of parents and family
members, assisted by untrained village birth attendant.

Apprehensions about the indifference of hospital staff, absenteeism of doctors/ nurses and poor
facilities in the government hospitals.

The decision on whether the pregnant woman should be rushed to a hospital or not during a
complication was mostly taken by the husband or mother-in-law (62%) while only in 32% cases it
was decided by the pregnant woman29. .
27
Birth registration in Jharkhand is about 90%, but children with birth certificates are only 10% (Directorate of Birth and Death,
Jharkhand, 2011)
28 Under this new conditional cash transfer scheme ( Mukhyamantri Ladli Laxmi Yojana), launched by Jharkhand government in
2011 for promoting girls empowerment, the conditions include that a) girl should be born in a hospital, b) the certificate can be
encashed only after 18 years, c) the girl is not married before 18 years and d) the girl attends grade-12
29 This finding is corroborated by the KAP study on health and nutrition conducted by UNICEF in Jharkhand in May 2012
6
Second, drawing lessons from the findings, UNICEF designed and implemented a pilot in February 2010
in Khunti district of Jharkhand, with the support of the state government, to encourage institutional
delivery and to prevent maternal deaths. The programme had the following components:

Set up 24X7 call centre at the district hospitals to arrange transport for pregnant women to reach
hospitals in the district

Established a network of about 400 private transporters in villages to take the pregnant women to
hospitals day and night.

Painted phone numbers of 24X7 call centre was painted on the school and Anganwadi Centre in
all villages in the district.

Trained nurses in the sub-district hospitals ( referred to as Public Health Centres- PHC and
Community Health Centres-CHC) on skilled birth attendance (SBA)
6. What was not done?
The pilot addressed some of the barriers to institutional delivery (like lack of transport to go to hospital,
capacity of hospitals to take deliveries, etc). But it did not dialogue and discuss with the community for
creating a descriptive norm for promoting institutional delivery or diffuse information or employ the
strategy of public declaration to raise the social expectation. It had many other shortcomings.
However, the initiative showed some results. The institutional delivery in the district increased from 15%
in February 2010 to 62% in June 2011 and the number of maternal deaths decreased from 95 in 2009 to
65 in 2011.The per cent of mothers giving initial breast feeding within one hour increased in 2011.Birth
certification increased as birth certificates were issued in hospital before the mothers were discharged
from the hospital after mandatory 48-hur stay in the hospital. The most important outcome, however, was
that the Jharkhand government scaled up the programme in all the 24 districts in the State in AugustDecember 2011, recognizing the success of the programme
7. Plan of Action to promote institutional delivery- What else need to be done
What more could have been done in Jharkhand to promote institutional delivery. It is important to create a
descriptive norm on delivering babies in hospital, changing the custom of giving birth at home. A Plan of
Action is proposed, based on the learning from a) the pilot; b) conceptual and theoretical aspects of social
norms and collective behaviour, as learnt in U-Penn programme, 2012; c) successful models and
examples like Tostan, Saleema and CATS; and d) the understanding and expertise of UNICEF on social
and behavioural change communication, .
Suggested steps in the Plan of Action for creating a new social norm and promoting deliveries in hospital
would have the following steps and components:
7

Diagnostic study: Conduct a diagnostic study to understand the knowledge, attitude, practices,
behaviour as well as the social expectations around home/hospital delivery in Jharkhand

Communication plan30: Develop a communication plan and strategy (based on empirical evidence),
which would include communication approaches; media/channels; themes and messages; primary and
secondary audience; monitoring and evaluation framework.

Baseline: Conduct baseline, midline, and end line survey on knowledge, attitude, practices, beliefs
and social expectations around home/hospital delivery

Logframe: Develop a programme logframe with results to be achieved at impact, outcome and output
levels; activities; geographical area; indicators, target, baseline and means of verification; assumption
and risks; budget; timeline and monitoring framework.

Core Group: Strengthen the core group of mothers referred to as ‘mata samti’, which have been
established already in all villages in the state. The traditional tribal leader and the panchayat raj
member (elected member of the local self-government) and some members of ‘kishori mandal’
(group of adolescent girls), which already exist in all villages, could be added to this group. The
members will be oriented on messages, inter personal communication and facilitation.

Diffusion: Members of the core group, mothers who have delivered babies in hospitals and mother-inlaws who favour hospital delivery will spread the message to 10 homes in each habitation and then
will diffuse the message through the village health and nutrition day (VHND)31 . Focus will be on
community dialogue and consultation with important stakeholders like husbands, pregnant women
and mother-in-laws. Gram sabha32 meeting of the gram panchayat33 will be convened for diffusion of
the message from one village to another village.

Public declaration: The village will hoist a flag and declare that all deliveries will be done only in
the hospital.

Message and script: During the campaign, out-of-the box messages and un-expected scripts will be
developed (as in the case of Mockus in Bigota) with the support of creative groups. Theme of the
messages will be around ‘safety’, ‘pride’, ‘good mother’, ‘healthy baby’ and ’loving mother-in-law’

Visibility and Social marketing: The program will work to give high visibility and media coverage as
done by Mockus. Catchy slogans and one-liners will be developed like “My daughter got $2,000, did
you get it”. Local folk art forms will use the theme of institutional delivery. UNICEF celebrity
ambassadors will urge mothers to give birth in hospitals. They will make ‘surprise’ visits to hospitals,
which will also be widely covered.
30
UNICEF Jharkhand office has already commissioned a study to know the knowledge, attitude, belief and practices of people
around health and nutrition and also to develop a communication plan
31 A package of services are provided to children, pregnant women, lactating mothers and adolescent girls on health check-up,
immunization, ante natal check-up , growth monitoring during VHND, held in every village every month
32 Meeting of all villagers in a gram panchayat
33 Local self-government unit consisting of 7-10 villages
8

Award: An award will be instituted to honor villages, gram panchayat, block and district which
achieve 100 per cent institutional delivery with 100% birth certification in a year. As evidence shows,
community based non-monetary incentives may not back fire, like individual based cash incentive.

Delivery of services: Even if a new descriptive norm is created in favour of institutional delivery, it
can be sustained only if the services (mostly services in hospitals) is accessible and of good quality.
To improve the quality and access of the services, a range of measures need to be taken. This
includes:

Strengthen the 24X7 call centre, which arrange transport for pregnant women to reach
hospitals quickly and widen the network of transporters.

Train nurses in hospitals and health sub-centres on skilled birth attendance (SBA)

Ensure doctors and nurses are present 24X7 in the hospital and absenteeism is addressed

Equip CHCs and PHCs34 with neonatal corners and blood storage units

Streamline the system for issue of the birth certificate, cash incentive and CCT certificate

Provide waiting rooms for the family and the pregnant women to stay, in case they come
from far- off places.
8. Conclusion:
Jharkhand, probably, is on the verge of the tipping point, with almost half of the people already opting
for institutional delivery. The increase in the per cent of people choosing this route is rapidly increasingfrom 12% in 1992-93, to 15% in 1998-99, to 19% in 2005-06 and suddenly shooting up to 54% in 2012.
Creating a new descriptive norm around institutional delivery at this point of time may put an end to the
custom of delivery at home. The practice of footbinding, which had been practiced for 800 years in China,
came to an end in ten years in the beginning of 20th century. The custom of delivering babies at home,
practiced by people ever since the origin of life, could come to an end in Jharkhand, forever, very soon.
34
Community Health centres and Public Health centres, which cover about 50,000- 100,000 people
9
Executive Summary
Jharkhand, the east Indian state, with a population of 33 million (Census, 2011), has poor socioeconomic indicators. Over 42% of the people in Jharkhand are poor, about 55% of the children below 3
years are under- weight and one third (33%) are illiterate (Census, 2011).
The Challenge: Out of 850,000 babies born in the state every year, half are born in hospital and the rest
in home. Government bears all delivery expenses of mothers in hospital, besides providing cash incentive
of $25 to mothers, free transport to reach hospital and free escort service of Sahiya. In addition,
Jharkhand government provides a conditional cash transfer (CCT) certificate of $ 2,000 for every girl
born in the hospital. Despite the facilities and the incentives, why do many women in Jharkhand deliver
babies at homes, increasing the risk of infant and maternal deaths? How can a descriptive norm created in
favour of delivery at hospital?
Why Descriptive norm has to be created: About 2,100 mothers (pregnancy related) and 36,000 infants
die every year in Jharkhand. About three -fourth of the maternal deaths and one third of the neonatal
deaths can be prevented if babies are born in hospitals. Delivery in hospital would also improve initial
breastfeeding within one hour, and also issue of birth certificates. It would also empower girls because of
the conditional cash transfer of $2,000, for girls born in hospitals.
Theoretical tools, Concepts and Framework: Giving birth at home/hospital is a custom and not a
social norm because there is no empirical expectation, normative expectation or conditional preference.
Both customs (giving birth at home and hospital) exist side by side in all villages because of different
factual beliefs.
Delivering baby at home or hospital is an independent and individual action like washing hands with soap
and therefore the ‘social convention theory’ does not apply. For creating a new descriptive norm like
delivering babies in hospitals, it would be required to create common knowledge in the community about
institutional delivery, through discussion and dialogue, and then diffuse from core group to community.
Public declaration and social marketing are also important steps for creating the new descriptive norm.
What was not done? The present initiative, piloted in one district of the state, addresses some of the
barriers to institutional delivery (like lack of transport to go to hospital, capacity of hospitals to take
deliveries, etc). But it did not dialogue and discuss with the community for creating a descriptive norm or
diffuse information or employ public declaration to raise the empirical expectation.
Plan of Action to create a Descriptive norm on giving birth at hospital: Suggested steps in the Plan
of Action for promoting institutional deliveries and creating a new descriptive norm would have the
following steps and components.
10

Conduct a diagnostic study to understand the knowledge, attitude, practices, behaviour as well as the
social expectations around home/hospital delivery in Jharkhand and develop a communication plan
and strategy based on empirical evidence.

Develop a programme logframe with results to be achieved; geographical area; indicators, target,
baseline and MOV; assumption and risks; budget; timeline; and monitoring framework.

Strengthen the existing core group of mata samti in every village. The core group members facilitate
community dialogue and engagement and diffuse information on village health and nutrition day and
gram sabha.

The village will declare 100% hospital delivery and a flag will be hoisted.

The campaigns, with out-of-the box messages and un-expected scripts, will be given high visibility
and media coverage. Catchy slogans and one-liners will be developed like “My daughter got cash
certificate of $2,000, did you get it”.

Chief Minister in a high voltage function will award blocks and districts that achieve 100%
institutional delivery.

A new descriptive norm can be sustained only if the delivery of services is improved. To improve the
quality and access of the services, a range of measures need to be taken. This includes:

Strengthen the 24X7 call centre, and the network of private transporters.

Train nurses in hospitals and health sub-centres on skilled birth attendance (SBA)

Ensure doctors and nurses are present 24X7 in the hospital

Ensure emergency obstetric care round the clock with labour room, neonatal care centres and
blood storage units in all CHCs and PHCs in the state

Streamline the system for issue of the birth certificate, the cash incentive, and CCT certificate
Conclusion: Jharkhand, probably, is on the verge of the tipping point, with almost half of the people
already opting for institutional delivery. The increase in the per cent of people choosing this route is
rapidly increasing- from 12% in 1992-93, to 19% in 2005-06 and suddenly shooting up to 54% in 2011.
Creating a new descriptive norm around institutional delivery at this point of time may put an end to the
custom of delivery at home. The practice of footbinding, practiced for 800 years in China, came to an end
in ten years in the beginning of 20th century. The custom of delivering babies at home, practiced by
people ever since the origin of life, could come to an end in Jharkhand, forever, very soon.
11