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Identification & management of high-risk pregnancies through Pradhan Mantri Surakshit Matritva Abhiyan in tribal communities of Pune district: Barriers & facilitators
For correspondence: Dr Rutuja Patil, Department of Community Health Research Unit, KEM Hospital Research Centre, Pune 411 011, Maharashtra, India e-mail: rutuja.patil@kemhrcvadu.org
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Received: ,
Accepted: ,
Abstract
Background & objectives
Tribal communities in Pune district of India have relatively high burden of low birth weight and preterm babies. The ‘Pradhan Mantri Surakshit Matritva Abhiyan’ (PMSMA), categorises pregnant women according to risk and provides intensive care to high-risk pregnant women until delivery. This study aimed to identify barriers, challenges and supporting mechanisms to implementing the PMSMA programme for the management of high-risk pregnancies and report recommendations in adapting these guidelines.
Methods
We used the consolidated framework for implementation research (CFIR), to guide the qualitative assessment of the implementation context and identify factors that could influence intervention implementation and effectiveness of PMSMA. Due to COVID-19 pandemic-induced delays in the study implementation, we conducted a rapid qualitative analysis of 20 in-depth interviews and two focussed group discussions.
Results
The study highlights challenges faced by high-risk mothers in accessing private sonography centres, including untimely ambulance services, connectivity issues, and out-of-pocket expenses. The lack of diagnostics at primary centres adds to these issues. Culturally, pregnancy is kept secret until the first 12 wk, causing delayed intimation and loss of crucial healthcare days. The tribal community perceives large babies as risks during delivery, depriving pregnant women of healthy food and iron supplements.
Interpretation & conclusions
The study suggests that health systems should utilize a government-funded food supplementation program and ensure proper coordination between departments for better implementation, recommending community awareness, staff training, and collaboration with local governments.
Keywords
Antenatal care
birth weight
domains of health
high-risk pregnancy
India
maternal & child health
Tribal communities in India have specific healthcare needs, arising from factors such as indigenous practices, accessibility barriers and financial concerns, among others. Maternal and child health indicators in tribal communities are poorer, especially affecting pregnant women and children1. In tribal communities of Pune district in western India, ∼25 per cent of newborns are estimated to have low birth weight and ∼17 per cent are born preterm2.
While multi-factorial causal pathways, including community, environmental, and health systems, may affect maternal healthcare status, effective antenatal care (ANC) is a crucial modifiable factor for a healthy pregnancy and outcomes3. The national ANC guidelines and other government programmes have been successful in increasing the number of ANC registrations, visits and institutional deliveries across the State4. However, effective management of pregnancies in tribal communities necessitates the need to overcome challenges, which range from cultural practices, health-seeking behaviour and healthcare system challenges.
In 2016, the Ministry of Health and Family Welfare (MoHFW) launched a program, ‘Pradhan Mantri Surakshit Matritva Abhiyan’ (PMSMA), wherein clinical practice guidelines are provided for public health staff to categorize risks of pregnant women and provide specialized and more intensive care of high-risk pregnant women until delivery5-8. This programme aims to identify high-risk pregnancies based on obstetric/medical history, existing clinical conditions and provide guidelines for appropriate birth planning and complication readiness at all levels of the public health system, including primary health facilities5-9. The local public health system has been implementing the PMSMA in Pune district, including tribal areas, however, there remains a scope of improvement in maternal and neonatal health indicators.
We conducted an implementation research study aimed at strengthening the PMSMA program delivery for managing high-risk population in tribal communities of Pune district. We report the findings of the formative phase of the study that focused on identifying barriers, challenges, and enabling factors, and informed the co-development of a revised PMSMA implementation strategy.
Materials & Methods
This implementation research was conducted jointly by KEM Hospital Research Centre, Pune and the State Health System Resource Centre, Pune, Maharashtra in two tribal blocks of Pune (Ambegaon and Junnar), which are served by six tribal primary health centres (PHCs) covering ∼140,000 people and reporting ∼1,300 pregnancies annually, alongside services from some private facilities. The study was approved by the Institutional Ethics Committee of KEM Hospital Research Centre, Pune as well as WHO Ethical Review Committee and was conducted as per the ICMR Guidelines for Ethics in Biomedical Research. The public health system was a partner as approved by the Additional Director, Public Health Department, Maharashtra, India.
Study design
For this study, the research team of the research organization is referred to as the Research and Support Team (RST) and the public health system team as the Implementation Team (IT). The RST provided technical assistance, supportive supervision, and carried out research activities, while the Pune district public health department was responsible for implementing the PMSMA programme, covering identification and management of high-risk population, referral systems, and availability of medicines and equipment. This clear division of roles ensured that the study reflected real program conditions, with the public health system leading implementation and assuming ownership.
Implementation factors and identification of barriers and facilitators of the PMSMA
We used the Consolidated Framework for Implementation Research (CFIR)10, to guide data collection, assess the implementation context, and identify factors influencing intervention implementation and effectiveness. The CFIR constructs adapted for our study were integrated into focus group and interview guides, encompassing five major domains and their associated sub-domains, as outlined in table.
| Construct | Description |
|---|---|
| Intervention characteristics: This indicates the core characteristics of the PMSMA itself | |
| Strength of evidence | Stakeholders` perception about the quality of evidence of PMSMA |
| Relative advantage | Stakeholders` perception about benefits (and risks) of a risk-based ANC strategy compared with a ‘flat’ ANC care approach |
| Adaptability | The extent to which the risk-based ANC strategy (PMSMA) can be modified as per special situations or adapted in different settings |
| Trialability | The ability to implement PMSMA in the public health system |
| Complexity | Perceived difficulty of PMSMA implementation in terms of scope, additional efforts, technical issues, etc. |
| Outer setting: This indicates the external aspect of the context for implementation | |
| Patient needs & resources | The extent to which the health needs of pregnant women are known is known to the public health system |
| Cosmopolitanism | The existence and strength of referral linkages for ANC between the public health system with non-governmental stakeholders |
| External policies | Exploring strategies to design policy & programmes as well as guidelines for risk-based ANC |
| Inner setting: This indicates the internal aspect of the context for implementation | |
| Structural & quality characteristics | The public health system structure, including the functional levels & hierarchical relationships & quality of ANC |
| Networks &Communications | The strength of formal and informal communication channels & referral linkages for ANC within the public health system |
| Culture | Values & attitudes toward ANC within the public health system, including assumptions, if any |
| Implementation climate | This includes perceptions about the relative priority of the programme, compatibility of the programme with existing processes & systems & the general motivation levels of public health staff |
| Individuals involved: This assesses the characteristics of individuals influencing intervention delivery | |
| Knowledge & beliefs about the intervention | Stakeholders` attitudes toward and value placed on a risk-based ANC strategy (PMSMA) as well as knowledge about the programme |
| Self-efficacy | Stakeholders` beliefs in their own capabilities to deliver PMSMA, as well as the individual level of capability as perceived by a stakeholder |
| Individual identification with organization | This describes the public health system stakeholders` belief in the system to deliver PMSMA and their degree of commitment to it |
| Process: This measures the progress toward attaining the outcomes of the intervention delivery | |
| Planning | The method of planning the PMSMA in the public health system |
| Engaging | The process of involving all relevant stakeholders who influence the delivery of PMSMA in the public health system |
| Reflecting & evaluating | Quantitative & qualitative feedback about the progress &quality of implementation of PMSMA |
PMSMA, Pradhan Mantri Surakshit Matritva Abhiyan; ANC, antenatal care
Baseline/situational assessment
We assessed the then-current status of PMSMA implementation using a mix of quantitative and qualitative data collection methods. The duration of the study was from December 2019 to November 2021. The qualitative data were collected from November 2020 until February 2021. Here we report findings from the qualitative data.
A comprehensive stakeholder list was developed, including public health officials, community members, and beneficiaries (tribal and migrant women and families). Documenting stakeholder roles in implementation guided the identification of potential study participants. The Research and Support Team (RST) conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with key stakeholders: two FGDs with auxiliary-nurse-midwives (ANM) (7–8 per group) on their roles in ANC and PMSMA, perceived barriers, benefits, and suggestions for improvement; IDIs with nine accredited social health activists (ASHA) (across 6 PHCs) on roles, barriers, benefits, and beneficiary attitudes; five medical officers (MO) (across 6 PHCs) on challenges, benefits, and leadership in implementation; and five women (beneficiaries) on service quality, difficulties, coping, and suggestions for care improvement. In addition, one gynaecologist providing ANC through a public–private partnership was interviewed. The RST comprised public health researchers experienced in tribal regions and trained in qualitative methods, who maintained reflexivity throughout data collection via regular discussions and note-taking.
Data analysis
We conducted a rapid qualitative analysis of 20 IDIs and two FGDs. The sample size was guided by operational feasibility and continued until thematic saturation was reached, with no new major themes emerging from subsequent interviews. Rapid analysis is a newer method for qualitative data and is adapted from classical qualitative data analysis methods. This approach enables timely extraction of key findings that could inform the design and delivery of interventions within a short implementation window11,12. Rapid analysis includes coding and identification of findings from data, which is in the form of audio files and notes, without transcription and translation of the raw data.
Data were summarised using a CFIR-guided template, with interview domains listed in columns and corresponding data (including illustrative quotes) extracted from notes and audio files. Two researchers independently coded the data, cross-checked interpretations, and refined emerging themes through regular team discussions to strengthen trustworthiness. To validate the rapid analysis, we conducted a classical inductive qualitative analysis on two IDIs and compared the results, which showed consistency with the rapid approach. Secondary analysis of the summaries was also undertaken to ensure coherence and completeness, leading to consolidation into broad thematic categories. Descriptive summaries and participant quotations were added for context, and recommendations were supported with memos as evidence. Finally, a deductive thematic analysis was performed to cluster data into conceptual categories, identify patterns and relationships across themes, and generate a theoretical explanation of the phenomena under study.
Identifying action items and co-development of the implementation strategy
We then identified action items to overcome barriers and leverage facilitators identified across the CFIR constructs. Through a series of consultative meetings, the RST and IT jointly developed implementation strategies for each action item, ensuring alignment with existing PMSMA operational processes. We then categorised these action items into an action priority matrix to understand the efforts needed and expected impacts of each action item. This enabled us to prioritize and select the action items for implementation. While the priority matrix provided a structured basis for decision-making, the final selection was also informed by qualitative data from the baseline assessment.
For our implementation model, we adapted the knowledge-to-action (KTA) framework (Figure), which outlines the iterative steps in knowledge translation for the delivery of sustainable, evidence-based interventions. Our modified model included steps to assess, plan, operationalise, evaluate and refine the PMSMA guidelines.
- Implementation model of Pradhan Mantri Surakshit Matritva Abhiyan.
Once action items were finalized, RST and IT together developed an implementation strategy, along with the level of implementation, responsible person and supervisor, periodicity, mode of implementation and target audience for implementation. These strategies were compiled into an action plan matrix, with columns to track progress and record reasons for delays or insufficient progress, thereby enabling systematic monitoring.
Results
The facilitators and barriers were grouped according to the CFIR constructs although some findings overlapped across constructs10.
Intervention characteristics
Beneficiary respondents reported having faced challenges in accessing multiple facilities, including antenatal ultrasonography (USG) services, primarily due to large geographical distances and financial limitations. Beneficiaries are expected to be provided financial support through PMSMA to avail ultrasonography services in private facilities; however, this was not provided as per some respondents, which led to them missing USG examinations.
“I did sonography once, for the second time I needed to hire a private vehicle to go to a clinic in a nearby town.” (Beneficiary; Taleghar PHC)
The participants and beneficiaries reported insufficiency or at times, unavailability of urine pregnancy test kits, which led to delays in pregnancy confirmation. In addition, some diagnostics (e.g., thyroid testing) for at-risk women were often unavailable at PHCs. These led to delays in early identification of pregnancy complications and initiation of treatment. Medicines were sometimes out of stock, due to supply chain issues, forcing MOs and ANMs to prescribe them from and beneficiaries to purchase from private chemists. Further, in the absence of MOs, some ANMs reported low confidence in managing complications, leading to referrals and delayed treatment.
Outer setting
Some beneficiaries were not adequately informed about all government health programmes and about the facilities they could avail through the programme/s.
“I don’t know anything about PMSMA. Also, I never heard of any other programmes related to pregnant mothers.” (Beneficiary; Taleghar-ANC)
Transportation barriers emerged as a challenge faced by high-risk pregnant women in tribal communities. The study participants informed that due to the remoteness of villages, they could not contact ambulance drivers when needed.
“108 ambulances are not available sometimes. The ambulance driver does not allow other family members inside the ambulance.” (ASHA worker; Aptale PHC)
Access to optimal nutrition during pregnancy was a challenge reported by beneficiaries. Health systems staff reported that though nutritional programmes such as Dr. Abdul Kalam Amrut Ahaar Yojana are being implemented, these may not reach all pregnant women due to distribution systems.
A few participants pointed out gaps in effective communication of health programmes and schemes as an issue hindering the successful implementation and uptake of health schemes.
“ASHAs don’t inform us about any government programmes and their benefits. Things needed to be arranged from outside the hospital had not organized anything.” (PNC Beneficiary)
An added challenge was faced during the COVID-19 pandemic, which disrupted outreach programs and affected beneficiary access to transportation and diagnostics.
Inner setting
The gynaecologist interviewed stated a lack of awareness among beneficiaries due to insufficient display of information, education and communication (IEC) material in SCs or PHCs. Our data further suggests a lack of clear communication among ASHAs and ANMs regarding relevant health programs. In addition, some participants perceive that ASHAs do not systematically follow up eligible couples and new pregnancies for providing care, and MOs are not always available during high-risk deliveries.
Individual characteristics
We came across a common community belief that consuming iron and folic acid (IFA) supplements leads to an increase in the baby’s weight, which will increase the possibility of caesarean section as compared to vaginal delivery, which is a preferred mode of delivery in the study area13. Further, the health system staff perceives that the quality of iron-folic acid (IFA) in the government sector is not up to the mark, as the women face digestive distress after consuming these IFA.
Process
Our data indicated that ASHAs may not possess the necessary knowledge to effectively communicate programme details and benefits to the beneficiaries.
“I have confusion between PMSMA and Pradhan Mantri Matru Vandana Yojana. Our training was done a year ago. Nobody resolves our queries.” (ASHA)
Discussion
Our findings highlight substantial gaps between the PMSMA guidelines and their implementation in tribal settings, driven by interconnected barriers across multiple domains. Despite recommendations for two financially supported USGs for high-risk populations, delayed payments and limited availability forced many women to not undergo essential scans. Insufficient distribution or limited availability of diagnostic kits and medicines led to increased out-of-pocket expenditure as the beneficiaries had to visit another facility or a private provider, which was also observed in other studies conducted in Telangana and Uttar Pradesh14,15. Geographical remoteness and inadequate emergency transport delayed timely care for high-risk pregnancies. Awareness of services remained low, consistent with previous studies that link limited community mobilization, underutilized communication channels, language and cultural barriers, and mistrust of government programmes to poor service uptake16. Our findings align with studies from Himachal Pradesh and Andhra Pradesh, which report that ambulance unavailability and weak mobile network coverage hinder timely emergency obstetric response17. Cultural norms like waiting for consent from elderly sometimes delayed care-seeking during labour17. Persistent misconceptions among beneficiaries, coupled with inadequate IEC display at service delivery points, reduced opportunities for beneficiaries to access timely, reliable health information.
Role ambiguity, which may be driven by unclear boundaries and perceived power hierarchies, weakened teamwork and service coordination. A lack of systematic identification and tracking of high-risk pregnancies led to missed or delayed interventions, inefficient resource allocation, and limited preparedness for complications. Communication gaps between PHC and referral facilities, combined with inadequate staffing at higher levels, reinforced dependence on private care18.
Provider-level gaps were evident as many ASHAs lacked adequate knowledge of PMSMA protocols and high-risk population management, limiting their ability to counsel women effectively on ANC, diet, and iron supplementation. Limited recognition of health workers’ efforts by local governance bodies (e.g., Gram Panchayats) potentially reduced motivation and engagement, undermining sustained programme delivery.
Collectively, these findings indicate that without addressing structural constraints, strengthening provider capacity, and enhancing community trust and awareness, the PMSMA programme in tribal areas may not achieve its intended impact on maternal and newborn outcomes. Systematic tracking of high-risk populations, streamlined reimbursement processes, robust supply chains, and culturally sensitive communication strategies will be essential to bridge the implementation gap.
Drawing from the study findings and supported by insights from the participants and relevant literature, the following context-specific recommendations are proposed to strengthen PMSMA implementation in tribal communities:
(i). Strengthening access to essential services
Timely interventions for high-risk populations require reliable transport for at least two sonography appointments. Pre-funding sonography costs, increasing ANM–ANM-beneficiary coordination through more frequent ASHA visits, and issuing clear digital reimbursement protocols can improve uptake. Strengthening health communication with behaviour-change strategies can enhance awareness on ANC, birth spacing, diet, danger signs and iron supplementation. Gram Panchayats can be mobilized to provide emergency private transport alongside government ambulances. Encouraging PHC visits and enabling essential tests at subcentres by ANMs will further improve accessibility.
(ii). Capacity building and support for health workers
Regular retraining and orientation for ASHAs, MOs, ANMs, and ambulance drivers will improve skills and service delivery. Structured counselling sessions by MOs, ANMs, and key informants can provide emotional support to expectant mothers, while ASHA accompaniment during critical visits can ease logistical burdens. Promoting adherence to iron supplementation and clarifying potential side effects can address tolerance issues. Disseminating information on government health programmes through ASHAs and community networks can boost awareness and participation.
(iii). Improving coordination and monitoring
Early pregnancy detection and ANC registration should be strengthened through ASHAs or a digital tracking system. Improved coordination within the public health system can streamline service delivery, while rotational duty systems can ensure MO presence during high-risk deliveries. Home visits for high-risk populations and assessments of rural hospitals can address gaps that drive preference for private facilities. Expanding public-private partnerships to include regular specialist services and having the district health office oversee data tracking, reviews, and workforce allocation will enhance care. Closer collaboration of public health systems with ICDS, including joint training and monitoring, can ensure integrated nutrition support.
(iv). Role-specific action items
Community health workers
Organize awareness sessions, conduct frequent home visits, distribute IEC materials, and work with Tribal Development and WCD departments to support high-risk mothers.
Medical officers and taluka health officers
Strengthen knowledge of PMSMA guidelines, collaborate with Gram Panchayats, update HMIS, review data and payments, facilitate emergency transport, and enhance subcentre diagnostics.
District-level authorities
Allocate ANC/HRP resources promptly, streamline budget approvals, improve medicine supply chains, coordinate sonography transport, and establish robust reporting systems. Conduct PHC-wise reviews to foster private sector collaboration during monthly MO meetings.
Although this study provides many insightful learnings, the study’s geographic focus prevents it from being fully generalizable to other areas with varied sociocultural backgrounds and migrants. Secondly, due to the COVID-19 pandemic, we could not conduct member checking, and the research relied on qualitative approaches, which may have reduced the depth and scope of the data compared to a quantitative approach. Community voices and programme managers are not as representative as they may be because of the limited number of beneficiary interviews brought on by COVID-19 constraints. Lastly, while CFIR provided a useful structure for examining implementation determinants, we recognized that its original development in Western healthcare systems may not fully capture the sociocultural complexity of Indian tribal settings. As such, we took an interpretive approach to applying CFIR, ensuring that themes derived from the data were mapped thoughtfully to CFIR constructs. Although the findings of the study are still relevant, the data were collected in 2019, thus focusing on the need to collect more updated data.
This study highlights the need for context-specific strategies to improve maternal healthcare access in the implementation of PMSMA in tribal communities. Our study recommends the strengthening of behavioural change communication and community-level engagement by health systems and capacity building among frontline health workers. Addressing misconceptions related to iron and folic acid supplementation, ensuring systematic tracking of HRP, and enhancing communication between PHCs and higher healthcare facilities can contribute to improved maternal health outcomes. Furthermore, supply chain inefficiencies and resource allocation gaps must be addressed to ensure the uninterrupted availability of essential services and medications. While our study provides critical insights into PMSMA’s implementation, its findings are geographically specific and reflect the realities of a pre-pandemic context. Future research should focus on updated data collection to assess post-pandemic changes and evolving healthcare needs. Nevertheless, the findings remain highly relevant in guiding policy interventions and improving maternal healthcare services in resource-limited settings.
Acknowledgment
Authors acknowledge district health administration of Pune district, Maharashtra, for their support during the conduct of the study. We are grateful to the study participants for their time and insights offered during the study.
Financial support & sponsorship
The study received funding support from RAISE grant Alliance for Health Policy and Systems Research, World Health Organization (Grant reference no. 2020/1031292-D).
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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