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 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 189-196

Factors affecting accessibility of maternal health-care institutions in Meghalaya: A hospital-based study

1 Department of Economics, University of Science and Technology Meghalaya, Ri-bhoi, Meghalaya
2 Department of Economics, Assam Don Bosco University, Guwahati, Assam, India

Date of Submission29-Sep-2020
Date of Decision21-Mar-2021
Date of Acceptance24-May-2021
Date of Web Publication04-Aug-2021

Correspondence Address:
Dr. Pranti Dutta
Assistant Professor, Department of Economics, Assam Don Bosco University, Tepesia Garden, Guwahati, Assam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_188_20

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BACKGROUND: The present study determines to understand the maternal health-care infrastructure in Meghalaya, a state of Northeast India. The state has large number of population of 2,964,007 (Census 2011), however, the state has only two public District Hospitals related to maternal health-care services – one in East Khasi Hills District and the other one in West Garo Hills District. Furthermore, according to the National Rural Health Mission (2015–2016), the maternal mortality ratio of Meghalaya is 211/100,000 live births which is higher than the national average.
MATERIALS AND METHODS: A hospital-based mixed method study has carried out to identify the problems faced by the women during their maternity period and to assess the quality and availability of maternal care infrastructure in Meghalaya. To conduct the interview, the present study covered all 80 pregnant women who were admitted in the major two district maternal health-care hospitals of Meghalaya for maternity care (i.e., delivery and postdelivery period) during the period of hospital visit in October 2019.
RESULTS: The study shows that majority of the admitted women came from different villages of different districts of Meghalaya as those remote areas have no adequate maternal health-care institutions nearby other than dispensary or subcenter. The study also revealed that women who came to get treatment in hospital during pregnancy had to face difficulties like to travel a long distance, use public transport, bad road conditions, and financial problems.
CONCLUSION: To improve the health scenario of health-care system in the remote village areas, the Government should give more focus on infrastructure development in terms of availability of adequate facilities for handling any emergency cases of maternal care in remote areas of Meghalaya.

Keywords: Health infrastructure, hospital-based study, lack of maternal care, long distance, maternal health, Meghalaya

How to cite this article:
Momin BG, Dutta P. Factors affecting accessibility of maternal health-care institutions in Meghalaya: A hospital-based study. Int J Health Allied Sci 2021;10:189-96

How to cite this URL:
Momin BG, Dutta P. Factors affecting accessibility of maternal health-care institutions in Meghalaya: A hospital-based study. Int J Health Allied Sci [serial online] 2021 [cited 2022 Oct 1];10:189-96. Available from: https://www.ijhas.in/text.asp?2021/10/3/189/322986

  Introduction Top

Public health infrastructure is an important indicator to understand the health-care policy of welfare country since it provides capacity to prevent communicable and noncommunicable diseases, health promotions, and planning for health-care improvement.[1] Quality health infrastructure can be defined as the ability to access effective care on an efficient and equitable basis for health benefit for the whole population.[2] However, study shows that availability of maternal health-care services in public health-care system in India is insufficient in terms of infrastructure that severely affected the accessibility and adequate availability among disadvantage group of women.[3] According to National Health Profile, the public expenditure on health sector in India is only 1.28% of its GDP (2017–2018) which remains low as compared to other countries across the world. The Rural Health Statistics (2017–2018) shows that the low level of public spending on health sector results inadequate health infrastructures and its poor maintenances for which majority of Indian population suffer from inaccessibility of adequate public health care at large. The inadequacy of public health sector is clearly seen from the outcome indicators like prevailing rate of mortality and morbidity in the country. In the latest report of sample registration system (2014-2016), the maternal mortality ratio (MMR) of India is 130 per 1,00,000 live births. Although, MMR has declined, still remains a long behind the Sustainable Development Goals (SDGs) that set priority to reduce the MMR to <70/100,000 live births by 2030. Such outcome indicator has strong association with the availability of health infrastructure in the state.[4]

Studies showed that in tribal areas, it is difficult to access health-care services due to its geographic isolations, poor economic status, traditional beliefs, and lack of health infrastructure.[5] A report published by the World Bank[6] showed that there is acute shortage of health facilities, lack of emergency transportations, and financial constraints in the tribal areas of India. The remote areas of tribal community could not get doctors at time and ambulances due to poor maintenance. Drugs are inadequate and health facilities are lacking of modern equipment to handle emergency cases. Contractor et al.[7] found that major barriers for tribal women of Odisha in accessing formal health care are due to long distance, cultural inappropriateness of service, language problem, and lack of trust due to adverse experiences. Sengupta[8] identified similar barriers in his study in tribal community of Chhattisgarh, India. Identified barriers are due to inaccessible, remote, and difficult terrains and scattered populations among tribal community of India.

Lyngdoh[4] found that health-care infrastructure in Northeast India is not satisfactory. The study revealed that there is shortage of subcenter, primary health centers (PHCs), and community health centers (CHCs) in all the states in the region. The number of problems has to face by the health care in Northeast India such as lack of infrastructural facilities, nonfunctioning of available infrastructure, and difficulty in access. Similar study done by Saikia and Das[9] showed that accessibility of public health-care facilities within physical reach is highly difficult in rural areas across all states of Northeast India.

Meghalaya, a state of Northeast India, comprises 86.15% of Scheduled Tribe Population to the states total populations (Census 2011). According to the National Rural Health Mission, the MMR of Meghalaya in 2015–2016 is 211/1, 00, 000 live births which is higher than the national average, i.e., 130/1, 00,000 live births. A recent study in Northeast India, Das and Guha,[10] showed that in case of maternal mortality rate, Meghalaya is one of the worst-performing states compared to the national average. The study also revealed that coverage of vaccination and nutritional status are less than the all India level. Deb[11] in his study on the utilization of safe motherhood services carried out among tribal population of East Khasi Hills, Meghalaya, found that home delivers are about 45% whereas deliveries in district hospitals are only 27%. However, deliveries in CHCs (1.5%) and PHCs (0.5%) were very poor. The main reasons for home deliveries among tribal population of East Khasi Hills are due to distance from health centers, absence of delivery facilities in the nearest CHCs and PHCs. In addition, nonavailability of other facilities such as transport and cost was also involved. [Table 1] shows that as per Census 2011, out of seven districts of Meghalaya, the number of PHCs and CHCs is highest in East Khasi Hills and West Garo Hills Districts of Meghalaya.
Table 1: Distribution of public health infrastructure

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Although the maternal health-care scenario is gloomy in Meghalaya, a limited number of studies are available in the state of Meghalaya. Second, Meghalaya is predominantly a tribal state and characterized by mountainous terrains. Different studies already showed that performance indicator of maternal health care is poor among tribal population especially in Northeastern region of India because of its geographical isolation from mainland India.

Therefore, under this backdrop, the present study determines to understand the maternal care health infrastructure in Meghalaya based on the women experiences with maternal care from the formal health system. The identified factors affecting in access health institutions by women during their maternity period indicate the bottlenecks of health infrastructure, which require special attention from policymakers to improve the maternal health-care outcome of tribal community in the hill areas of Meghalaya. The paper will contribute in the field of public health by enriching the literature on maternal care infrastructure for further research.

As such, the rest of the paper is organized as follows: Section 2 discusses the methodology of the study, Section 3 deals with limitation of the study and ethical clearance of the study, 4 and 5 sections focus the results and discussions, and Section 6 concludes the whole study and provides the contribution of the study to the existing literature.

  Methodology Top

The present study is a hospital-based mixed method study. Despite having a large number of population, i.e., 2,966,889 (Census 2011), Meghalaya has only two public District Hospitals for maternal health-care services, namely Ganesh Das Government Maternal and Child Health Hospital (GDGMCHH) in Shillong (East Khasi Hills District) and District Maternity and Child Health Hospital (DMCHH) in Tura (West Garo Hills District). Therefore, to understand the maternal health-care infrastructure in Meghalaya, the present study considered both the major hospitals to carry out the study, since both districts are considered as a gateway for Khasi and Garo people of Meghalaya in terms of health infrastructures. Subsequently, by using purposive sampling, i.e., based on availability of admitted women for maternal care, a hospital-based (all cases from a given hospital receiving patients from different settings [https://www.scielosp.org/article/gs/2009.v23n6/564-564/]) study was carried out in Shillong (East Khasi Hills District) and Tura (West Garo Hills, District) District Hospital that cover major public maternal health-care services. A semi-structured questionnaire that used to collect data on demographic characteristics of the respondent and an extensive interview method is adopted to collect data on access to maternal health-care services. During the process of interview, we could meet 80 (we have conducted the interview with all the women admitted in labor rooms and general wards for maternal care in both the selected hospitals during the period of hospital visit. No one of the admitted pregnant women and mother with infant was excluded from the interview process) patients (49 patients from GDGMCHH, Shillong and 31 patients from DMCHH, Tura) who were admitted for maternal care (i.e., delivery and postdelivery care) during the time of hospital visit in the month of October 2019. In addition, an in-depth interview was conducted with two health providers from both hospitals. Content analysis is used to analyze the data to examine maternal care health infrastructure in Meghalaya.

Limitation of the study

This study has certain limitation. It is quite possible that there could be many other factors associated with accessibility of Maternal and Child Healthcare (MCH) institutions, however, the study is limited to only two major MCH hospitals situated in Meghalaya. Therefore, problems of mother those who did not visit the hospital are missed out.

Ethical clearance

The study took consent of the participants during the process of data collection by providing them all information regarding the study and assured that responses will remain confidential and anonymous. Along with that, the participation of the respondents in the interview is completely voluntary. Therefore, the study is free from ethnical issues.

Finding of the study

Respondents profile

Hospital-wise patients category

[Figure 1] shows the percentage of women admitted in both hospitals for maternal care such as pregnant women for their labor pain, postdelivery illness, postpartum, miscarriage, and other maternal-related cases. It reveals that highest number of women admitted in postdelivery section in GDGMCHH, Shillong while, in DMCHH, Tura, a large number of pregnant women are found in labor room. The lowest number of women admitted in both GDGMCHH and DMCHH is in postpartum section, respectively. The figure signifies the care provided by the hospitals regarding maternal and reproductive health services.
Figure 1: Patients admitted in hospitals. Source: Field data, 2019-2020

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Age-wise distribution of the respondents

[Table 2] shows that highest numbers of respondents are belong to age group of 19–25 and 26–30 years in both hospitals.
Table 2: Age-wise distribution of the respondents

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Educational qualification

[Figure 2] shows the percentage-wise educational qualification of the respondents both Shillong and Tura. The highest number of educational qualification falls under the category of primary level followed by the illiterate, while only a few respondents have PG level education. Thus, respondents are more or less educated to express their views on problem they have faced.
Figure 2: Educational qualification of respondents. Source: Field Data 2019-2020, SSLC- Secondary School Level Certificate, HSLC- High School Leaving Certificate, PG- Post Graduate

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Occupation-wise distributions

[Figure 3] shows the occupation-wise distributions of the respondent. The majority of the respondents are housewife followed by farmer. A few respondents are engaged in own business and teaching. Thus, occupation wise it is observed that among the studied population, there is a very few households with regular salaried individuals, such as teachers.
Figure 3: Occupation-wise distributions. Source: Field Data 2019-2020

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Based on the background profile of the respondents, the following analysis has done to identify the problem face by women for maternal care resides in remote rural areas of Meghalaya.

Factors affecting in accessing health institutions by women for maternal care

Availability of Health Institutions

The following parameters represent the availability of public health institutions in remote village areas for maternal care.

  Village wise coverage Top

Village-wise coverage indicates the intensity of women admitted in the central hospital from different villages of different districts of the state due to the lack of availability of adequate maternity facilitated health-care institutions in their respective village areas. Due to such condition, women have to travel to either GDGMCHH, Shillong, or DMCHH, Tura, for getting any maternal health-related treatment during their pregnancy period. [Figure 4] shows that the highest number of respondents is from different villages of East Khasi Hills and West Garo Hills Districts of Meghalaya in GDGMCHH and DMCHH, respectively.
Figure 4: The number of respondents admitted into the hospital by village wise. Source: Field Data 2019-2020

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  Distance wise distribution of village Top

[Table 3] presents the distribution of villages as per distance from central hospitals situated in Shillong and Tura to which women have to travel for their reproductive health care. It is observed that to visit central hospitals for maternity care in Meghalaya, highest number of admitted women traveled from villages within 30–60 km and within 60–80 km in Shillong and Tura, respectively. Interview with the admitted women also revealed that to travel 30–60 km in East Khasi Hills District, it requires more than 2 h by car while in West Garo Hills District requires more than 2 to 3 h to travel 60–80 km. It is also found that geographical isolation and bad road conditions are major reasons for which it requires more time than the usual time.
Table 3: Distance-wise distribution of village and admitted women

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  Number of women admitted Top

From [Figure 5], it is observed that in GDGMCHH, the highest number of patient admitted from East Khasi Hills District followed by West Khasi Hills. Whereas, in DMCHH, the highest number of admitted women are from West Garo Hills district followed by South Garo Hills. The figure indicates that due to lack of adequate facilities at nearby home, women had to travel GDGMCHH and DMCHH for better treatment.
Figure 5: Percentage of women admitted from different village. Source: Field Data 2019-2020

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Thus, all the mentioned parameters present that unequal distribution of maternal health-care institutions in rural areas of the State of Meghalaya for which women have to travel long distance to access the public health care for their reproductive health problems. Interview with the respondents also revealed that they do not have any maternity care health-care facility nearby of their respective village. As such, they got referral to GDGMCHH and DMCHH for better treatment. One of the respondents from GDGMCHH stated regarding why they have to travel long distance to access hospitals for maternity care:

“We do not have ambulance facilities at our PHC. Although PHC and Dispensary are available to us but those institutions are lacking of sufficient equipments, health workers, and ambulance facilities.”

Another admitted women in DMCHH replied that

“There are CHC but they cannot handle the C-Section due to insufficient medical stuff so had to travel long distance with difficulties.”

Women those admitted in GDGMCHH and DMCHH also argued that they have to face difficulty in traveling long distance to get a hospital to do ultrasound during their period of pregnancy. Most of the time, they have to go for private hospitals for maternity care, where facilities are available but costly.

An interaction with ward in-charge of both the hospitals reported that PHCs and CHCs are available at village level, although those health institutions are not adequate to handle emergency. As such, all referral cases of pregnancy from different parts of Meghalaya are treated in these two hospitals.

Thus, from the above discussion, we can conclude that due to the lack of maternal care services in the remote village areas, women have to travel long distance to get treatment in the central hospitals situated in Shillong and Tura. The analysis from categories of three different parameters – coverage of village, distance-wise distribution, and number of women admitted from different villages of different districts – reveals the nonavailability and nonaccessibility of public health care for reproductive health at the state.

Accessibility to health-care institutions

Universal coverage is one of the core aims of sustainable development goal by 2030. However, it is observed that women from remote and backward areas remain far away in accessing formal health-care institutions for their reproductive health. The present study showed that there is a lack of adequate maternal health institutions in remote areas of Meghalaya. For which, women have to travel long distance for any maternal-related cases. In such condition, they have to face various difficulties that can be seen from the following analysis.

[Figure 6] shows the problem faced by the patients while accessing both the hospitals GDGMCHH and DMCHH. Interview with respondents from both hospitals, the following problems are identified:
Figure 6: Hospital accessibility problem. Source: Field Data 2019-2020

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The study found that in East Khasi Hills, the main problem of accessing GDGMCHH hospital is due to long-distance travel from different villages. However, people who live in connecting villages to town have comparatively less difficulties regarding transportation, but those who come from interior village face difficulties in accessing the public transport from their remote village.

In Shillong, majority of the women responded that they had to face long-distance problem while accessing the GDGMCHH, Shillong. Although they visited their nearest dispensary or the CHCs for their monthly checkup, however, for any emergency cases (C section or Anemia), they were referred to the District Hospital (DH). At that point of time, they had to travel to the DH though it is long distance from their villages. While referring from CHC, some of them get the ambulance services while some due to nonavailability of ambulance, they had to use public transport at their own cost.

While, in West Garo Hills, Tura, half of the interviewed women responded that they faced with the long-distance problem while accessing District Hospital, i.e., DMCHH. During the hospital visit, there were three women who were admitted traveled longest distance, i.e., 103 km from South Garo Hills, since there is a lack of adequate maternal care facility nearby health-care institutions.

The another finding of the study is that majority of the respondents in both GDGMCHH, Shillong, and DMCHH, Tura, are engaged in farming and daily wage earner. Therefore which, they are not financially stable. Due to their financial problem, they are facing problem to visit long-distance district hospital for maternal care. Apart from that, it is also observed that due to lack of financial assistant, patients have less access to nutritional diet for which they mostly faced with anemia during pregnancy.

One of the important findings of the study is that in GDGMCHH, Shillong, some of the respondent faced with poor road conditions those who came from interior villages. However, in case of Tura, the bad road condition is identified as a major barrier to access DMCHH which is agreed by majority of the respondents. The road condition of some villages connected to the main town Tura is still kutcha and rocky road. An interaction with respondents from DMCHH viewed that

“it is difficult to travel for pregnant women in such a poor road conditions. Most of the time, pregnant women have to deliver their baby on the way to hospital”.

The road conditions are worst during rainy seasons. Responds from the interview it is noticed that women have to face much difficulties in their pregnancy during rainy seasons while traveling to district hospitals. Due to bad road conditions, ambulances could not reach to them as such pregnant women have to travel by herself to get the ambulance by crossing such muddy and rocky roads in the rainy days.

Finally, the study finds that transportation is another problem faced by the admitted women in the hospitals, however, respondents found it comparatively less problematic in both studied hospitals. Transportation was less problematic among the women as both private and public transportations were available in the studied area. Sometimes, they have faced problem in traveling to long distance for health institutions as they have to hire car or private ambulance at a higher cost.

  Discussion Top

The present study determined to examine the maternal health-care infrastructure in Meghalaya where it tried to identify the problem faced by the women to access the maternal health-care institutions in Meghalaya. The analysis of the hospital-based study identified some key barriers to access maternal health-care facilities in the state of Meghalaya such as nonavailability of functioning maternal care health institutions at village level, inadequate health equipment, and human resources is the major reasons for which women have to travel to the central hospitals situated in town areas. Study shows that travel time from home to central hospital was more than 2–3 h. While accessing central hospitals for better treatment, they have to travel long distance with difficulties such as poor road conditions and transportation facilities and financial hindrance.

Therefore, distant hospitals and poor road condition are one of the reasons that need to be addressed to improve the maternal health outcome of the state. The results of the present study are consistent with several existing literature. Study in Nepal by Wagle et al.[12] found that a distance of more than 1 h to the maternity hospital increased the risk of home delivery. Another study done in Sierra Leone, a West African county, found that distance and lack of transport and direct and indirect financial obstacles influenced the decision making for childbirth in health institutions among the women of rural areas. The study suggested that policymakers should address the structural constraints and health inequities for universal access to maternal health-care services.[13] Similarly, a study carried out in Assam by Dutta and Sengupta found that factors such as lack of ambulance facilities and nonavailability person at home to take care of pregnant women have strong relation with shaping the health-seeking behavior among the pregnant women. If the health institutions are not available at nearby home, it is difficult to get transportation as well as accompanied person as it involves with financial factors such as extra expenses on lodging and fooding.[14] Bhattacharyya and Pala[15] in their study in East Khasi Hills Districts found that distance to the health institutions is the major barriers to the health-care utilization. Similarly, results found in recent study in Meghalaya by Sarkar et al.[16] showed that distant hospitals and bad road conditions are the main reasons for women preferred to go for home delivers in rural Meghalaya.

However, due to financial constraints, the present study is only limited to one state of Northeast India. Furthermore, the time framework for the survey period is only for 1 month. Therefore, further research can be extended to cover more hilly areas of Northeast India, and also, sample size can be increased by increasing the survey time period.

  Conclusion Top

The analysis of the study has been demonstrated the gap between both the supply side and the demand side factors of health-care sector. For instance, people are willing to seek care from government hospitals such as primary health center (PHCs) and CHCs available nearby. However, these facilities are not adequate from the provider side. As such, patients have to travel long distance to access government hospitals to Shillong and Tura. Study found that while traveling to Shillong and Tura for treatment, pregnant women have to face many barriers such as long-distance travel, financial problems, poor road conditions, and lack of transportation. Therefore, the Government should give more focus on infrastructure development in terms of availability of adequate facilities for handling any emergency cases of maternal care in remote areas of Meghalaya. This study provides a bird view of the availability and adequacy of maternal heath-care infrastructure in remote areas of Meghalaya. Therefore, study has contribution to the interest related to maternal health in health-care improvement and performance that helps to bring up more of health-care services to the villages in Meghalaya.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Powles J, Comim F. “Public Health Infrastructure and Knowledge.” Trade, Foreign Policy, Diplomacy and Health; 2010. Available from: https://www.who.int/trade/distance_learning/gpgh/gpgh6/en/index11.html. [Last accessed on 2020 Jan 27].  Back to cited text no. 1
Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med 2000;51:1611-25.  Back to cited text no. 2
Nair H, Panda R. Quality of maternal healthcare in India: Has the National Rural Health Mission made a difference? J Glob Health 2011;1:79-86.  Back to cited text no. 3
Lyngdoh LM. Inter-state variations in rural healthcare infrastructure in North-East India. NEHU J 2015;13:31-48.  Back to cited text no. 4
Prabhakar H, Manoharan R. The tribal health initiative model for healthcare delivery: A clinical and epidemiological approach. Med Soc 2005;1:197-204.  Back to cited text no. 5
World Bank. Improving Health Services for Tribal Populations. Washington DC, USA: World Bank; 2012.  Back to cited text no. 6
Contractor SQ, Das A, Dasgupta J, Van Belle S. Beyond the template: The needs of tribal women and their experiences with maternity services in Odisha, India. Int J Equity Health 2018;17:134.  Back to cited text no. 7
Sengupta A. Maternal health in underserved tribal India. Sex Reprod Health Matters 2019;27:1581534.  Back to cited text no. 8
Saikia D, Das KK. Access to public health-care in the rural Northeast India. NEHU J 2014;12:77-100.  Back to cited text no. 9
Das T, Guha P. Direction of uneven health-care expenditure: Evidence from Northeast India. Indian J Public Health 2017;61:81-5.  Back to cited text no. 10
[PUBMED]  [Full text]  
Deb R. Utilization of services related to safe motherhood among the tribal population of East Khasi Hills (Meghalaya): An overview. Stud Ethno Med 2017;2:137-41.  Back to cited text no. 11
Wagle RR, Sabroe S, Nielsen BB. Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: An observation study from Nepal. BMC Pregnancy Childbirth 2004;4:1-10.  Back to cited text no. 12
Treacy L, Bolkan HA, Sagbakken M. Distance, accessibility and costs. Decision-making during childbirth in rural Sierra Leone: A qualitative study. PLoS One 2018;13:1-7.  Back to cited text no. 13
Dutta P, Sengupta B. Barriers of maternal health seeking behavior: A bayesian analysis survey based evidence from Assam, India. J Womens Health Care 2018;7:1-2.  Back to cited text no. 14
Bhattacharyya H, Pala S. Assessment of delivery pattern and factors influencing the place of delivery among women in East Khasi Hills Districts of Meghalaya. J Evol Med Dent Sci 2012;1:391-9.  Back to cited text no. 15
Sarkar A, Kharmujai OM, Lynrah W, Suokhrie NU. Factors influencing the place of delivery in rural Meghalaya, India: A qualitative study. J Fam Med 2018;7:98-103.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3]


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