Cultural norms and traditional or supernatural beliefs.

Cultural beliefs play a significant role in influencing pregnancy-related behaviours, particularly in the early months. A widely held belief in many communities is the fear of the “evil eye” (Black eye), which discourages women from disclosing their pregnancy during the first trimester. This reluctance often results in delayed registration and limited access to antenatal care (ANC), in the early months of the pregnancy.

“In our family, mother-in-law advised me not to share the news of my pregnancy with anyone, not even with our relatives. She believes that disclosing it too early could attract the ‘evil eye,’ which might cause harm or even lead to a miscarriage, especially since I have experienced one before. Following this tradition, I did not reveal my pregnancy during the first four months and only visited the hospital in at the end of my fourth month only.”

[Women IDI-2]

In some minority religious communities within the study area, the practice of lactational amenorrhea, the concept that breastfeeding serves as a natural contraceptive, was identified as a contributing factor to unrecognized pregnancies. Many women assumed they could not conceive while breastfeeding, which led to delayed recognition of pregnancy and short inter-pregnancy intervals, often less than a year. As a result, antenatal care (ANC) registration was sometimes postponed simply because the pregnancy was not identified in its early stages. While these socio-cultural beliefs do contribute to delayed ANC initiation, the research team noted that the overall impact of this factor appears relatively limited at the population level, directing to a broader structural and behavioral barrier, playing a more significant role in hindering timely ANC uptake.

Traditional and supernatural beliefs remain deeply embedded in maternal care-seeking behaviour often shaping pregnancy related decisions. Some women rely on protective rituals and faith-based practices, believing that they can prevent pregnancy complications through spiritual interventions. Common practices include wearing tabeez (amulets) for protection, performing dhuni (incense fumigation) to ward off negative forces, and following strict dietary and activity restrictions prescribed by local customs. These beliefs stem from the perception that pregnancy loss or complications may be caused by supernatural forces, requiring non-medical interventions for protection. Furthermore, some women completely replace medical care with faith-based guidance from religious figures such as Maulvi (priest), instead of seeking professional maternal healthcare. It was noted that these practices offered emotional reassurance but contributed to delay in evidence-based medical care.

“After my first baby died, I believed it was due to upari chakkar (supernatural forces). During my next pregnancy, I burned Guggul (incense) for purification, but I still lost the baby. I believe wandering paret (spirits) in this area caused the loss. Until I return to my village and seek blessings from a Bhagat (spiritual healer), I will not try to conceive again.”

[Women IDI-9]

Patrilineal kinship societal system.

The rural setting revealed the pervasive influence of long-standing patrilineal kinship traditions, wherein male children are prioritized within social, economic, and familial structures. This cultural context significantly shapes maternal care-seeking behavior during pregnancy. It was found that, some families reportedly delay antenatal care (ANC) registration with the desire to determine the foetal sex. While foetal sex determination is prohibited under the Prohibition of Sex Selection (PCPNDT) Act, 1994 in India, respondents indicated that certain families may seek this information from unregistered healthcare providers either locally or in neighbouring states. The Pre-Conception and Pre-Natal Diagnostic Techniques (PC-PNDT) Act is an Indian law aimed at prohibiting sex selection and regulating the use of prenatal diagnostic techniques to prevent female feticide and address gender imbalance. According to some healthcare providers, these practices not only lead to delayed or unregistered pregnancies but may also contribute to selective continuation based on foetal sex. Additionally, the research found that this community follows an androcentric norm. A few women, particularly those with multiple daughters, were found to perceive their pregnancies as unwanted due to family pressure for a male child. As a result, they are less motivated to seek ANC or visit healthcare facilities. In cases where women conceived solely due to family expectations of having a son, they expressed low engagement with ANC services.

“I didn’t go to the hospital early because I never wanted this pregnancy. I had no desire to have another child. But my husband insisted, saying, ‘We already have four daughters, let’s see, maybe this time it will be a boy.’ Even my parents and family pressured me to carry this pregnancy, so I had no choice.”

[Women IDI-15]

“Most families don’t get the pregnancy registered in the early months because they want to find out the sex of the baby first... Here, the rules for identification of gender during ultrasonography are strict, so they go to nearby states or some unregistered practitioner to get the ultrasound done and, if it’s needed, they get the abortion.”

[Healthcare provider]

Preference for Traditional Birth Attendants (TBAs) and local health practitioner.

Many families prefer traditional birth attendants (TBAs) over institutional healthcare providers. TBAs assure normal deliveries, reinforcing the fear of caesarean-sections. However, in several cases, TBAs misdiagnosed complications as false labour which delayed necessary and timely hospital care. Additionally, women often consult local village non-registered health practitioners for pregnancy-related concerns instead of seeking formal healthcare.

Additionally, in some areas, there is a prevailing misconception in the community that government hospitals favour caesarean sections (C-sections) as a faster alternative to vaginal delivery to reduce staff workload. Most of the women reported that the local community highly stigmatized C-sections, as women who undergo them often viewed as weak or unable to withstand labour pain. Families also fear that C-sections may compromise future fertility, reinforcing a preference for home births with TBA and further deterring institutional deliveries.

“We first went to a local health practitioner (gaon ki dai, village midwife) in xx village. Despite being advised at the hospital to terminate the pregnancy due to risk to my life, my family believed she could ensure a normal delivery. She checked the baby’s heartbeat, gave me injections and medicines, and I delivered a few hours later…..but the baby was already dead.

[Woman IDI-7]

Additionally, the study team noted that women from the poorest households more frequently described delayed antenatal registration, irregular follow-up, and reliance on informal or unregistered providers, often citing financial constraints, loss of daily wages, and lack of transport as key barriers to timely care.

Temporary birth migration.

Research team found some of the women with stillbirth had moved to their maternal house during pregnancy. This is longstanding practice in India for pregnant women to return to their maternal home for delivery and postpartum care and Palwal, Haryana was no different. However, this practice was found to disrupt the regular ANC services as women registered in one district cannot receive services in another. Women who forget or miss-place their Maternal and Child Protection (MCP) card faced additional barriers, as their previous medical records were not accessible in the new location. Furthermore, migrating women miss out on financial incentives under Government of India schemes like Janani Suraksha Yojana/ Janani Shishu Suraksha Karyakram, which are tied to their place of registration.

“In our family, there is this tradition that first child should be delivered in maternal home and my mother also insisted that I should be in maternal home from the early months of pregnancy that is why after the completion of my fourth month I stayed in my maternal home. I did everything and was taking care of me. But when I went there, the hospital refused to register my name, saying my records weren’t available. Since I didn’t have my documents with address of my in-laws place. I was completely fine so did not care much about it”

[Woman IDI-9]

Women’s autonomy overpowered by societal norms.

In the study setting, decisions regarding when and where to seek antenatal or delivery care were rarely made by the women themselves. Instead, these choices, such as whether to deliver at a public or private facility, or whether to remain at the maternal or marital home for childbirth, were predominantly influenced or dictated by husbands, fathers or mothers-in-law, or elder male members of the household. Some of the women reported needing permission from male family members to access healthcare services, delaying care even in the presence of complications. Additionally, a few women reported the fear of being blamed for adverse outcomes, particularly in cases of repeated pregnancy loss or the birth of a female child, discouraged them to open discussion and timely health-seeking. So, it was noted that women’s autonomy in healthcare decision-making remained constrained by patriarchal family structures and rigid gender norms in this setting.

“We live in a joint family, and decisions about check-ups and delivery are taken by elders, especially the mother-in-law. I did not even know where I would deliver until the last month. After my sister lost her baby soon after a hospital delivery, my family blamed the government hospital. Because of this, I chose not to express my preferences and let my husband decide.”

[Woman IDI-10]

Low motivation and competing priorities for women.

The research team noted that most of the low-income households often prioritized household responsibilities and childcare over healthcare visits. Many stated that managing domestic tasks and looking after other children took precedence over traveling to health facilities for ANC check-ups. The lack of support from husbands and family members further discouraged them from seeking care, reinforcing the expectation that maternal responsibilities should take precedence over personal health needs. Additionally, a few women with multiple daughters reported that the deliberately postponed ANC registration and healthcare visits. These women expressed low motivation to seek care, citing concerns that once the family discovered they were carrying another female child, they would face mistreatment and emotional neglect. This fear further contributed to delays in accessing maternal healthcare.

Economic barriers to care.

Economic constraints were reported as one of the major factors influencing antenatal healthcare utilization among women from low-income households, particularly those where husbands were daily wage labourers, unemployed, or where the woman herself was unemployed. Most of the women reported that the burden of household responsibilities, including managing multiple dependents with a single earning member, often created competing financial priorities and forced them to deprioritize healthcare in favour of sustaining household needs. Many women reported that the potential loss of daily wages due to hospital visits served as a major deterrent, as even a single day’s wage loss had severe financial consequences for their families.

“My husband is a daily wage laborer who earns daily wages, and if he took a day off to take me to the hospital during pregnancy, we would lose that day’s income. That’s why I avoided going unless there was a serious problem. Even when I wanted to go, we didn’t have enough money for transport, and private hospitals charged too much. The government hospital is free, but they don’t have all the tests, and we would still have to spend money on medicines and scans. So, we just waited and hoped everything would be fine.”

[Woman IDI-03]

In addition to wage loss, out-of-pocket expenses for diagnostic procedures and transportation costs further limited healthcare-seeking behaviour. Advanced diagnostic tests, such as Level II ultrasounds, costing approximately ₹2,500 ($29), were reported to be unaffordable for economically disadvantaged women. The limited availability of such diagnostic services in government hospitals exacerbated this issue, forcing women to either delay necessary investigations or forgo them entirely. Additionally, the cost of private healthcare services, including consultation fees, medications, and laboratory tests, posed further financial challenges, making institutional care inaccessible for many women.

An informal practice known as “Badhai culture” was reported by a few women in the community as another financial barrier discouraging institutional deliveries. Families were expected to pay informal financial amounts to government hospital staff, amounting to ₹1,500 ($17) for female childbirth and ₹3,000 ($34) for male childbirth. These additional financial burdens disproportionately affected multigravida and low-income women, deterring them from choosing institutional deliveries due to the associated costs. As a result, many women opted for delayed or alternative maternal healthcare pathways like going to non-registered medical care practitioner or traditional birth attendant, further limiting access to safe and timely obstetric care. Additionally, a few women reported that ASHA workers provided extra support and assistance to certain families, particularly by regularly accompanying them to hospitals or ANC clinics, which they believed was linked to receiving additional incentives. As most of the women belonged to low-income households, they mentioned being unable to offer any extra incentives to ASHAs. Consequently, they perceived a disparity in the level of care received, feeling that families with better financial status received more attention and assistance.

“My family was happy when I went into labour, but I lost my baby. In the hospital, I saw families giving money to nurses after a healthy birth before the baby was handed over. Sometimes, families give money out of happiness, but in some cases, the nurses themselves ask for more. I kept wondering-if my baby had survived, would my family also have been asked to do the same?”

[Woman IDI-04]

Perceived and experienced quality of services in facilities.

The research team noted that women’s perceptions of healthcare quality were primarily influenced by their past experiences with maternal health services, whether from previous pregnancies or interactions with healthcare facilities. Some families also avoided certain hospitals due to previous negative experiences, such as the death of a family member at that facility. Instead, many opted to seek private care, fearing further referrals and inadequate management at government hospitals. Some women recounted harmful and abusive practices during labour and delivery. A few reported being physically restrained, with hands and legs tied and mouths blocked with cotton, purportedly to control their movement during extreme labour pain. Such actions caused distress, breathlessness, and exhaustion, further exacerbating their suffering. A few women also mentioned physical mistreatment, including slapping and forceful pulling of legs by birth attendants during labour. This poor treatment and hostile attitude from healthcare providers resulted in psychological distress, with some women expressing fear and reluctance to seek institutional deliveries, specifically at government set-up, for subsequent pregnancies.

Others mentioned non-compliance with iron and calcium supplements due to nausea, misconceptions about medication safety, and religious beliefs discouraging the use of modern medicine. Dissatisfaction with ASHA workers was also commonly reported, as this lack of active engagement from frontline health workers further weakened trust in public healthcare services.

“When I delivered my second child at a government hospital, I was sent from room to room and received no help. After multiple tests and long delays, we stopped going back. Because of this experience, I did not visit the hospital even once during my recent pregnancy.”

[Woman IDI-13]

Perceived need for Antenatal Care (ANC).

Many women reported not seeking ANC in the early months of pregnancy, believing it was only necessary in the presence of complications. A commonly expressed sentiment was, “I was not facing any issues, so I didn’t feel the need to visit the hospital and delay it till in occurrence of complication.” Pregnancy was largely perceived as a natural process that did not require medical intervention, leading women to deprioritize routine check-ups. Familial influence, particularly from mothers-in-law, further reinforced this perception. Several women shared that they were discouraged from attending ANC visits, as elder family members recounted their own pregnancies without medical supervision, reinforcing the belief that ANC was unnecessary unless complications arose. Among multigravida women, a casual approach to ANC was frequently noted. Many assumed that if previous pregnancies had been uncomplicated, subsequent ones would also be problem-free, leading them to forgo ANC visits unless health concerns became apparent. Their confidence in prior successful pregnancies often resulted in missed opportunities for early risk identification and preventive care.

“I didn’t feel the need to go for check-ups because I had no issues. Pregnancy is natural, my mother-in-law always says that in our time, we never went to the hospital unless something was seriously wrong. So, I also thought it wasn’t necessary.”

[Woman IDI-8]

Physical accessibility of appropriate care.

Women residing in rural and remote areas reported significant transportation challenges in accessing healthcare facilities, particularly during antenatal care, labour, and childbirth. Some villages are located over 20 km from the district hospital, making timely access to emergency obstetric care extremely difficult. Several women also mentioned that their villages lacked direct transport connectivity, requiring them to walk or take some manual driven vehicle, for 7–8 km, to reach the nearest main road before they could access public transportation. In addition, a few women mentioned that certain health centers were not well-located geographically and had unpaved roads too. These women faced longer travel times, difficulties during emergency situations, and increased reliance on personal arrangements for transport, which many families could not afford.

“We don’t have our vehicle and even if we arrange a private vehicle, the roads are so bad that it takes too long to reach the hospital. During the rainy season, it becomes even worse because of mud as my house is in between the fields. Sometimes, I avoided visiting the health facility because the road is full of mud and water.”

[Woman IDI-14]

Dependence of the women for transportation.

A major barrier to timely ANC access, as stated by pregnant women, was their dependence on family members and community health workers, particularly ASHAs, for healthcare navigation. Several women mentioned relying on their husbands, other male family members, or ASHA workers to accompany them to health facilities. Many reported that the absence of an accompanying person often led to missed ANC appointments or complete avoidance of maternal healthcare. This dependence, as mentioned by women, highlights their limited agency in seeking care, leading to delays in timely healthcare access.

Another critical barrier identified was the inefficiency of ambulance services in reaching women in need of urgent maternal healthcare. The state-run ambulance service (dial “112”) was reported to be unreliable, often taking a significant amount of time to arrive at the requested location. A major challenge was that the number served as a centralized helpline for all emergency services, making it difficult to connect specifically for ambulance requests. Additionally, the follow-up questions routed through the IVR system often delayed the actual booking process. Additionally, the ambulances used were large vehicles that could not navigate the narrow, poorly maintained village roads, requiring families to physically transport the pregnant woman to a more accessible location where the vehicle was parked. These transportation delays sometimes resulted in childbirth occurring in transit.

“I cannot go to the hospital on my own. Because I don’t know the way to the hospital, and I have never gone out alone. I can only go if my husband or with my mother-in-law. Once, I was in severe pain, but no one was at home to take me, so I had to endure it the whole night…My husband and mother-in-law decide where I should go and which doctor to see. I just had to follow them.”

[Woman-IDI-1]

Community and family dynamics in healthcare-seeking.

Restrictions on movement were also widespread, with women being advised against traveling alone, particularly during the eighth and ninth months of pregnancy. Some women further reported superstitions surrounding water bodies (rivers, ponds, gher-ghat), as stepping outside during late pregnancy was believed to cause premature labor or harm the baby. Collectively, these cultural beliefs led to significant limitations on physical activity during pregnancy and some women reported that even if they felt the need to seek health facilities, they delayed seeking care.

In addition to restrictive practices, some women disclosed experiencing domestic violence, including physical and verbal abuse. Many women who lived in households where domestic violence was prevalent reported feeling fearful and hesitant to communicate pregnancy-related concerns, such as spotting, dizziness, or swelling of the legs to family members and husband. As a result, they often ignored these symptoms and delayed care seeking. But most of these women acknowledged that these could be early warning signs of complications. Sadly, a few women rationalized this mistreatment, stating that their husbands were exhausted from work and should not be blamed for their behaviour, if it did not directly harm the baby. A few women also mentioned being given specific plant stems or liquids to consume, as their families believed that such substances would ensure the birth of a male child. However, some women reported experiencing severe abdominal pain following these practices, which they suspected contributed to their stillbirth. However, these women delayed seeking care from hospitals as family didn’t allow them to do so.

Delays and inappropriate referrals.

Women reported negative experiences in government hospitals, particularly multiple referrals during the intrapartum period. Some women reported prolonged delays in receiving appropriate care due to multiple referrals across different health facilities. Many were first referred from Primary Health Centers (PHCs) to Community Health Centers (CHCs) and then to District Hospitals (DHs), often without receiving necessary interventions at the earlier levels. Additionally, most of the women mentioned that the government hospitals have complete lack of respectful maternity care, and they are mistreated during intrapartum and delivery process. For some, the referral process itself was time-consuming, with delays caused by administrative formalities before transfer. A few women mentioned that hospital staff took significant time completing paperwork, further prolonging access to care.

“During labour, we first went to a gaon ka doctor (village doctor), who checked the baby’s heartbeat and asked for an ultrasound. The government hospital also refused treatment without an ultrasound and referred us elsewhere without explaining anything. By the time we reached the district hospital (DH), we were again referred to a medical college. People believe that once someone is referred to that hospital, the chances of survival are very low. Fearing the outcome, my family decided to take me back home.

[Woman IDI-18]

Most of healthcare staff mentioned that there was only one sub-optimally functioning First Referral Unit (FRU) and most of the Community Health Centers (CHCs) and Primary Health Centers (PHCs) lacked Comprehensive Emergency Obstetric Care (CeMOC) services, while the Basic Emergency Obstetric Care (BeMOC) facilities were not adequately equipped to handle obstetric emergencies. This deficiency in services led to frequent referrals to higher-level hospitals, further increasing delays in emergency care and the burden on women seeking institutional deliveries. Nevertheless, a few nurses and Auxiliary Nurse Midwives (ANMs) mentioned that families consulted religious figures (Maulvis) before deciding to visit the referred facility, leading to additional delays and women reached centers with full dilatation and it was difficult for them to handle such cases specifically during night hours. Most of the women who were referred to medical colleges or higher facilities often did not follow through with the referral due to long travel distances, unfamiliarity with the facility, and concerns about not having family support at these locations. Research team also noted that there was a complete lack of referral linkage between one center and another and in such cases, it was obvious that the families feels lost as they are already in a very precarious state and coming to a new hospital at end moment and not getting any assistance from the health system will make them feel scared and will add to their negative experience during child birth.

“We referred a woman from the CHC to the district hospital due to her condition, but her family consulted a Maulvi (religious priest), who advised them to stay. They performed kriya (religious rituals) and jhaad-phook (faith-based healing). The family refused referral, and by the time her condition worsened, it was too late.”

[Healthcare provider]

“We often refer patients because in some centers services for managing high risk conditions are limited, but there is no proper referral linkage. Families are told to go on their own, and many do not reach the next facility in time.”

[Healthcare provider]

High-risk pregnancies across all SES categories reported fragmented referrals and poor counselling.

Disorganized and inappropriate services at the healthcare facilities.

Women also reported some additional concerns included excessive documentation requirements, disorganized ANC services, scattered diagnostic and Outpatient Department (OPD) facilities, and the overall difficulty in navigating the system, which made hospital visits burdensome and time-consuming. Women also reported infrastructural inadequacies like lack of proper waiting areas and overcrowded spaces absence of basic amenities including clean drinking water, functional toilets, and cooling facilities, making it non-compliant especially during extreme summers. Women reported absence of structured consultation areas and poorly organized screening facilities contributed to suboptimal patient experiences, with women often forced to stand during outpatient consultations, receiving brief and impersonal interactions with healthcare providers Many also expressed frustrations over the non-availability of diagnostic services, citing limited ultrasound facilities at CHCs and PHCs and restricted access to Level II scans at district hospitals. Diagnostic tests such as Oral Glucose Tolerance Tests (OGTT) and thyroid function tests often required separate appointments, necessitating multiple hospital visits, increasing both financial and logistical burdens. Many women noted minimal assistance in arranging transportation to healthcare facilities and inadequate guidance on ANC services and available resources by ASHAs. A few women reported not receiving any antenatal supplements due to irregular supplies and distribution issues at government facilities.

“ Going to the hospital is very difficult. We are sent from one place to another for tests, made to stand in long lines, and often asked to return on another day just to collect reports. There is no proper place to sit, and sometimes we wait outside in the heat. After repeated experiences like this, it feels pointless to keep going.”

[Woman IDI-6]

“ASHA worker only came once during my sixth month. She just noted down some details and left. She didn’t say anything about what I should be careful about or what I should do for my health.”

[Woman IDI-5]

Inadequate skill of staff and gaps in clinical management.

Several women mentioned encounters with inexperienced healthcare providers during labour and delivery. A few recalled that the attending staff appeared uncertain in their actions, frequently discussing cases among themselves before proceeding with medical interventions. In one instance, a woman reported experiencing severe pain following an unnecessary per vaginal (PV) examination in the government hospital, after which she noticed an absence of fetal movement. She strongly suspected that mishandling during the PV examination contributed to foetal distress and stillbirth. One woman described how she delivered without medical assistance at a CHC, as the nurse on duty was asleep despite repeated calls from family members. The baby was left unattended for 30–40 minutes, with the placenta still inside and no pain relief provided. Additionally, newborn resuscitation procedures were often delayed, as reported by a few women. In some cases, birth attendants attempted to revive the newborn without proper preparation, using tables cluttered with medical supplies for resuscitation. Women described watching their unresponsive newborns being handled without urgency, leading them to believe that efforts to save the baby were merely performative rather than genuine attempts to provide emergency care.

The research team also noted that there was absence or lack of appropriate counselling skills among the staff. Many women received no counselling regarding high-risk pregnancy (HRP) factors, despite attending antenatal check-ups. Several reported that although they had been categorized as high-risk, healthcare providers failed to explain the implications or offer guidance on dietary changes, lifestyle modifications, and follow-up care. A few recalled the term “high-risk” mentioned during consultations, but without context or explanation, leaving them uninformed about how to manage their condition. Some women left facilities with prescriptions for gestational diabetes or high blood pressure, but without clear instructions on medication adherence or lifestyle adjustments, further increasing their vulnerability to pregnancy complications. Additionally, there was no structured approach to educating women about ANC at the community level. Many ASHA workers, ANMs, and AWWs did not provide any guidance on the significance of monitoring pregnancy-related risks. Some women mentioned that ASHAs visited their homes only for documentation purposes, without offering meaningful health advice or emotional support.

“At the government hospital, no senior doctor was present at night. Young nurses examined me roughly without proper explanation, causing severe pain. Soon after, my baby’s movement stopped. Later, a madam (senior staff) examined me again and then said the baby had died, without explaining what happened.”

[Woman IDI-17]

Infrastructural and equipment deficiencies.

Many women described inadequate medical infrastructure as a significant barrier to quality maternal care. Some reported that critical diagnostic tools, such as ultrasounds, were either unavailable or required multiple hospital visits due to restricted access at government hospitals. A few mentioned that financial constraints prevented them from undergoing Level II scans, which are essential for detecting fetal abnormalities.

Frequent power outages and lack of power backup in some CHCs and PHCs further compromised care, especially for newborn resuscitation. Some healthcare staff reported that in certain cases, essential equipment such as warmers and Ambu bags were non-functional, delaying crucial interventions. A few healthcare staff acknowledged that these compromised the quality of care and reinforced negative perceptions of public healthcare facilities, prompting many women to seek care from private hospitals or forego institutional healthcare altogether.

“The reality is, we don’t even have basic facilities here. There’s no baby warmer, no power backup, no ventilators, and, most importantly, no pediatrician or gynecologist. We try our best, but when things go wrong, the families hold us responsible. They say, ‘Because the government hospital lacks facilities, our baby died.’ But what can we do? We don’t have the resources to save such critical cases.”

[Healthcare provider]

“The hospital asked me to get an ultrasound, but the machine was unavailable, and I was sent elsewhere. Because scans were costly and done only on certain days, I could not complete them. Later, I was told that earlier detection might have helped my baby, but I never got that chance”

[IDI-10]

The research found that the intersection of socio-economic vulnerability and high-risk pregnancy appeared to exacerbate delays, with women from poorer households with high-risk pregnancies experiencing compounded barriers related to affordability, mobility, and weak referral support.

Additionally, we examined both the continuity of postpartum care among women who experienced stillbirth and the broader implications of stillbirth on women’s health.

Absence of postpartum and bereavement care plan and procedures at the health-system level.

Most of the healthcare providers reported not having any clear clinical or operational guidelines for managing women after a stillbirth. Unlike live births, stillbirths were not followed by scheduled postnatal check-ups, referrals, or counselling sessions. Many health workers appeared ill-equipped or hesitant to address bereavement, possibly due to limited training in empathetic communication, grief counselling, or mental health screening.

Affected women reported that no formal follow-up care was provided after the stillbirth, either by facility-based providers or community health workers.

Stillbirths often remained underreported or misclassified, which meant women were not flagged for follow-up services in routine registers or maternal tracking systems. Once discharged, women who experienced stillbirths were not proactively followed up by ASHAs, ANMs, or Anganwadi workers, due either to lack of protocols or the assumption that no further care was needed. The research team also noted there was no formal mechanism to screen or support women after perinatal loss in most public health programs.

There are clear protocols for postnatal care after a live birth, but after a stillbirth, guidelines are not very specific. So, once the woman is discharged the follow-up…… counselling, or even when should the woman be visited remains unspecific

(Healthcare professional)

“Once the stillbirth happened, everything just stopped. They closed my file at the hospital, and after that no one from the health system contacted me. It felt like because the baby didn’t survive, my care also didn’t matter anymore”

[Women IDI-22]

“If the baby is stillborn, the case is recorded only for reporting. Health system don’t have a mechanism to flag women after stillbirth for home visits. ASHAs usually focus on mothers with live babies.”

(Healthcare provider)

Impact of absence of bereavement support.

Most of the participants mentioned receiving no home visit, counselling, or guidance on managing postnatal complications by the ASHA workers. Some of the women reported reliance on traditional practices and anecdotal advice from family members while some accessed over-the-counter medications or consulted local traditional care providers, they expressed confusion and anxiety over the safety of these treatments, especially regarding future fertility. Additionally, most of the women emphasized that they received no instructions from ASHAs, ANMs, or Anganwadi workers, and many were unaware of how to manage lactation following a stillbirth.

“After the stillbirth, my chest became hard and very painful. I was afraid to take medicines to stop the milk, so I followed traditional remedies suggested by my mother-in-law, like wearing an undershirt inside out. After a few days, the milk dried up, and I felt that the remedy had worked.”

[Woman IDI-18]

In addition to physical symptoms, women reported intense grief, anxiety, and recurring thoughts about their loss, yet none received any form of bereavement counselling or emotional support from the health system. Many women described feeling isolated, overwhelmed, and blamed by family members. One woman shared, “Everyone blames me. They keep saying it happened because of me… but I know I did nothing wrong.”

Several women who had lost male children or experienced multiple stillbirths described a deep sense of worthlessness and abandonment, particularly in households where sons are culturally preferred. “If my baby had survived, I would have mattered… but now, without a child, I have no worth,” stated one mother. For some, the fear of future pregnancy loss led to chronic anxiety. Women expressed ongoing worries about conceiving again, questioning whether the next pregnancy would also end in loss. As one noted, “I keep worrying, will I ever have a child? If I do, will they survive?” These emotional burdens were intensified by social stigma and the absence of structured mental health support.

Lack of awareness of need for care and entitlement among affected women.

The research team also noted that even among women who were employed in government jobs, there was a lack of awareness regarding basic entitlements after stillbirth. One government staff reported receiving only 45 days of paid leave following her stillbirth, on compassionate grounds. She reported experiencing complications and requirement of a longer recovery period was necessary. However, any leave taken beyond the 45 days was unpaid, placing her in a difficult position where she had to choose between her health and financial stability. Another woman, working as a house help, reported that she was denied any form of leave after experiencing a stillbirth. Her employer dismissed her need for rest, implying that recovery was only warranted if the baby had survived. She was pressured to return to work within a week and received multiple calls questioning the legitimacy of her absence.

“My supervisor madam gave me 45 days of leave, but I didn’t know whether it was official or not. Usually, maternity leave is for six months, but I was only given 45 days. My case was a bit complicated, so I needed more rest. That’s why I extended my leave for three more months, but all the leave after the 45 days was unpaid. I don’t even know if I got my full rights or not… but I had no choice but to take leave without pay”

[Women IDI-16]

“My madam didn’t give me leave. I only got one week off, but she kept calling me again and again. She said, ‘Why do you need leave? Your baby didn’t survive, why do you need a whole month of rest?’ They thought that leave is only needed if the baby is alive. But my health was also suffering… I was weak, I was grieving. But no one understood that I needed rest too.”

[Women IDI-24]

Deep grief and constant thoughts about the loss.

Most women described profound emotional distress after losing their babies. Several reported shock and an inability to process the event, leading to persistent grief. A few women who had lost male children expressed experiencing intensified sorrow, as their families placed higher value on male offspring. In some instances, families concealed the death of a male child from the mother to protect her from emotional distress, but this often resulted in greater feelings of detachment and confusion.

Some women mentioned having persistent thoughts and worries about the stillbirth. They frequently reflected on the efforts they had made during pregnancy, the complications they endured, and the financial burden their families faced, questioning why their baby did not survive despite all these sacrifices.

“I already have four daughters, and now, even this boy is gone… I do all the work, but my head starts hurting whenever I think about it. I keep wondering, if God had just given me a healthy baby, there would be no worries. But what can I do now? I am just exhausted.”

For some women, stillbirth deepened fears regarding future pregnancies, particularly in cases of recurrent pregnancy loss. One woman reported constant nervousness about whether her next pregnancy would also end in loss, especially if she conceived another male child. This apprehension about future pregnancies and child survival led some women to hesitate before conceiving again.

Physical health issues.

Several women experienced breast engorgement (extreme pain and swelling due to milk retention) following stillbirth. Women reported tightened veins, severe discomfort, and fever due to the condition.

To manage this, some women followed traditional practices, such as wrapping their breasts with their husband’s towel (Pati ka Angocha) for four days to two weeks to stop milk production. A few women mentioned wearing their husband’s vest inside out or reversing their own innerwear as part of cultural healing methods.

Medical interventions included taking prescribed medication from local village doctors or hospitals. Some women with young children fed them the retained breast milk, while others used breast pumps to relieve discomfort.

“When my milk started coming in, I used a machine to express it. But my mother and mother-in-law told me not to take out all the milk. They said to leave some in my breasts, or else if the baby’s soul lingered, the milk would keep coming. No one, no ASHA, no Anganwadi worker, ever told me anything about what to do. Since I wasn’t taking all the milk out, my chest felt heavy and painful for two or three days. But after that, it just dried up.”

Reduced family care and social isolation.

A few women reported a noticeable decline in care and attention from their families after experiencing a stillbirth. Some mentioned feeling ignored or neglected by their household, with family members no longer prioritizing women’s well-being as they would have had the baby survived.

Several women also faced stigma and avoidance from neighbours and community members. One woman shared that her neighbours stopped responding to her greetings and actively avoided conversations, leaving her feeling isolated. This social exclusion led some women to withdraw from social gatherings and public interactions to avoid judgment and scrutiny.

Earlier, people would respond when I greeted them with ‘Namaste’ or ‘Ram-Ram’ (traditional greetings). After losing my babies, they stopped speaking to me. People say, ‘She kills her babies,’ and because of this, I no longer go out or talk to anyone.”

[Woman IDI-16]

In many households, stillbirth was not recognized as a significant medical or emotional event. Families often expected women to “move on” quickly, resuming household chores without emotional processing or recovery time. Women were often expected to prioritize family duties over their own recovery, with little consideration for their mental or physical well-being. Some women reported being avoided or blamed by neighbours and relatives, further disincentivizing disclosure or care-seeking.

Blame and domestic violence.

Some women reported being blamed by their families and communities for the loss of their baby. These women internalized feelings of guilt and helplessness, believing they were responsible for their child’s death. A few women also experienced domestic violence or harsh treatment from family members following the stillbirth. One woman mentioned that the abuse intensified after her loss, as her family believed the child’s survival would have prevented conflicts. In some cases, the loss of a male child heightened tensions, leading to emotional and physical distress for the bereaved mother.

“They dragged me out of the house, holding my hand. At that moment, I was so furious, I didn’t know what I was saying… and then I left. All of this is happening because the baby is gone. If my baby had survived, I would have mattered… but now, without a child, I have no worth.”

[Woman-IDI 23]

Reliance on traditional practices after experiencing stillbirth.

Several women relied on traditional and supernatural practices to safeguard future pregnancies. A few women visited spiritual healers (Hafiz or Baba) for protective measures, receiving amulets, written prayers (nakkash), and herbal remedies. A few described rituals such as burning spiritual writings and inhaling the smoke for purification, while others chose complete isolation, staying indoors throughout pregnancy to avoid exposure to harmful external influences. Fear of supernatural entities such as upari chakkar (evil spirits), paret (ghosts), and buri aatma (malicious spirits) was deeply ingrained. One woman believed she lost her baby due to wandering spirits near her home, leading her to perform protective rituals before planning her next pregnancy. Another postponed conceiving until she could return to her village and undergo traditional spiritual cleansing. While some women simultaneously sought medical interventions, family influence often encouraged blending traditional and clinical care, reinforcing the interconnectedness of cultural beliefs and maternal health practices.