The global health agenda has emphasized decreasing maternal and newborn mortality as key components of sustainable human development. Despite the progress, 830 women die every day from causes related to pregnancy or childbirth; of this, 20 percent are from India (1, 2). This country still has significant challenges, even if the maternal mortality ratio was reduced from 212 deaths per 100,000 live births in 2007 to 167 deaths in 2013 (3). However, in 2013, the highest number of neonatal deaths globally (0.75 million) was reported in India (4). Further, within the country, the neonatal mortality rate (NMR) nearly doubles in some rural and tribal areas compared to the urban areas since they face considerable inequalities in access to antenatal, intranatal, and postnatal healthcare services (4). Other reasons that contribute to this disparity in India are low public expenditure on health (1.02% of India’s Gross Domestic Product for 2015–2016), high dependency on private healthcare services (78%-outpatients and 60%-inpatients), and high out-of-pocket (OOP) expenditures especially in Nagaland (61.7%) compared to the rest of India (20.5%) (5–7). To address the aforementioned issues, the Indian Government launched the “Janani Shishu Suraksha Karyakaram” (JSSK) scheme in 2011 for pregnant women and newborns to decrease OOP and neonatal deaths by providing free transport, medicines, and consumables, diagnostic tests, blood transfusions, and food for the duration of a woman’s stay. Sick neonates are also entitled to free treatment and transport (5). Additionally, another program, the “Janani Suraksha Yojana” (JSY) program offers cash assistance to mothers and accredited social health activists (ASHA-local community health volunteers who promote access to health services, mobilize communities, and provide community care) to facilitate institutional deliveries (8).

The Northeast region of India accommodates the country’s largest proportion of scheduled tribes (ST) and ranks the lowest in social indicators (9). One such state in this region is Nagaland, where 61% of the people are multidimensionally poor and live in rural and remote zones that lack connectivity due to inadequate or non-existent public transport systems, which markedly influences timely, affordable, and accessible maternal and child public healthcare services (10). In 2016, the more developed states like Kerala and Tamil Nadu reported almost 100% institutional deliveries, but Nagaland reported only a third of its births in health facilities (11). Nearly 90% of the population living in Nagaland are tribal or indigenous. “Nagas” is a collective term for several indigenous communities in the Northeast Region of India and upper Myanmar that share similar social and cultural characteristics. In India, the majority of the Nagas live in the state of Nagaland, within 16 administrative districts inhabited by 17 major and sub-tribes. In India, Nagas are classified as a scheduled tribe (Indigenous people from India who are officially regarded as socially disadvantaged) under the Indian constitution article 342 (12).

While there is anecdotal evidence suggesting that political unrest, the rugged terrain, and the lack of transport greatly influence access to healthcare services, a paucity of data demonstrates that social and cultural factors also influence health-seeking behavior (HSB) exhibited by this community. This study employed a mixed methods approach to quantitatively study the utilization of maternal and newborn health services while adopting a salutogenic perspective to explore how cultural beliefs, perceptions, and practices influence the HSB of an indigenous tribal community in Northeast India.

A total of 57 community members participated in the seven FGDs (four FGDs with women of childbearing age and three FGDs with male relatives/partners) and 19 IDIs (five with women of childbearing age, four with male partners or relatives of women of childbearing age, four with the ASHAs, four with TBAs and traditional healers, and two with health professionals). Responses from interviews with 109 mothers residing in the 3 study villages were included in the cross-sectional survey.

In this concurrent mixed-methods study, we studied the HSB of the mothers and women from the Liangmai tribe and the factors that influence them. To our knowledge, this is the first study to be conducted in this region concerning this topic. The maternal HSB exhibited by this community was influenced by several social, economic, cultural, geographic, and political factors that were closely interlinked.

We identified that the interpersonal and intrapersonal factors significantly influenced the HSB of this tribe. As their perception of risk was low, the tribe has an emergency-driven health-seeking behavior only with evident physical signs of danger. Thus, there is a low preventive-driven health-seeking behavior for ANC and PNC (21). This explains why only 4% of women reported four routine antenatal visits and 41% delivered at home. Functional health centers were better utilized for deliveries by locals living in that village than the villages with no or non-functional health centers. Another dominant reason for low healthcare facility utilization was that community members physically accessed biomedical services only when they perceived severe sickness, complications, or an emergency. It was sought secondary to failure of primary treatment with TM, home remedy, or self-medication. Similar findings were reported in a study of the socio-cultural and service delivery dimensions of maternal mortality in central India (22).

Since pregnancy for this tribe is a normal process and primarily not associated with a disease or a health problem, the decision to visit a health facility is often limited in childbirth, which is additionally determined by obstetric emergencies or in moments of fear. A similar emergency-driven HSB for newborn conditions was observed, except for seeking preventive health associated with receiving immunizations, perhaps because vaccines were most often available in the health centers. This protective behavior can be leveraged as an entry point for mothers and babies to access other health services. Since access to a health center is challenging in this arduous terrain and preventive health is not a priority to this community. Routine preventive antenatal, postnatal, and immunization services could alternatively be delivered monthly by a mobile medical unit linked with the health center allocated for that area in collaboration with the ASHAs as implemented successfully in other Indian states like Tamil Nadu (23).

Previous cases of death of the mother or newborn during childbirth influenced the HSB of the individuals, especially since infant mortality and spontaneous abortions were commonly reported and complemented by the survey results. This contradicts the governmental statistics, where only four stillbirths were reported in the district from 2018 to 19 (17). Any health event occurring in a healthcare facility is more likely to be captured formally by the health information system, but since access to these facilities is limited in remote tribal areas, deaths, and events occurring in these villages are likely to be missed. A national-level survey in India revealed that out of 10,109 scheduled tribe women, 44% reported difficulties accessing healthcare services because of the distance to the health facility and 42% due to inadequate transportation options (24). The results from the multivariable logistic regression analysis also supported this by suggesting that mothers residing in the villages without a health center or one that was not operational were more likely to deliver at home, suggesting that challenges in access may influence the decision to deliver at home.

Traditions and practices handed down from generation to generation influenced the current behavior of the tribe, which still firmly believes in faith healing. This belief is reinforced since TM healers are always locally available, accessible, and conforming to their religious beliefs. Therefore, culture determines the perceptions of the individual and the community regarding their definition of health and well-being (25). This also influences or shapes their sense of coherence, initiating or stopping the individual on the health-ease-disease continuum. In a medical pluralistic system, the Liangmais are struggling between traditional practices and the biomedical health system representing a mixed, interrelated, interdependent, and in a way, competing structure.

From a non-cognitive perspective, the individual’s socioeconomic status influences their decision to seek healthcare services, as highlighted by other studies conducted in Bangladesh and Africa (26–29). The direct and indirect costs incurred to access public services are strongly associated with considerable personal expenditure since the services are not perceived as free. Therefore, they chose to stick to their traditions and prioritize other financially viable options, such as TM or home remedies, as biomedical health expenditures pose a high economic burden on their families. Another study conducted in India also reported financial barriers associated with the lack of access to ANC and safe delivery with lower socioeconomic characteristics (4). The Government of Nagaland has also acknowledged this high OOP expenditure experienced by patients in the state in the State Human Development Report (7). Nevertheless, our observations indicate that in emergency situations, when alternative local healthcare options have been exhausted, financial resources do not play a determining role in visiting healthcare facilities.

When analyzing the adapted three-delays model, we noticed that a delay in one level significantly affects the other subsequent levels. The delay in providing adequate care strongly enhances the uncertainty in the decision to seek care with moderate influence from the delay in arrival to the facility, thus impeding people of the tribe from effectively and promptly seeking biomedical healthcare. Nevertheless, the community finds alternatives to the presented barriers by accessing TM actors, self-medicating using biomedical drugs, or home remedies. As observed in various medical pluralistic studies conducted in South America, a combination of the three alternate modalities has also been demonstrated by the Liangmais (30–32). Since access to essential biomedical medication in the village and health centers is difficult, women tend to store medicines at home and adopt various dosage mechanisms for their babies. Pregnant women and their babies risk experiencing untoward side effects or overdosage due to unsupervised self-medication, as described in a study conducted among pregnant women from Iran (33).

The delay in providing adequate care was also attributed to all previous individual or community experiences, rumors, and beliefs related mainly to the low quality of the services available in the health facilities. Our findings corroborated with Singh et al.’s findings that the lack of resources and services in health centers affects institutional delivery rates in Northeast India (34). Significant concerns regarding the availability of healthcare professionals, opening hours, and lack of medicines and health services deterred them from even attempting to seek maternal or newborn biomedical healthcare services. This was complemented by a study conducted in rural Nigeria that reported that low utilization of government facilities was due to staff irregularities, low quality of services, and the high costs incurred to access them (35). Even health professionals agreed that the facilities were not offering adequate services, which demotivates them from promoting the services, obliging them to adopt risky treatment options and plan strategies for emergency referrals. Given the community’s perception that the quality of services provided at the health centers is defective, the conventional approach to increase the overall knowledge to improve HSB in these communities may prove futile unless the quality and quantity of services in the health centers improve. The state has launched a World Bank-aided project to strengthen a few health centers to mitigate this issue (36). However, this impact is yet to be ascertained in the few communities they serve.

The generalized feeling of shyness among women was an essential attitudinal determinant that discouraged them from consulting male doctors and visiting the health facility since they associate biomedical practices with examining reproductive and sexual organs. Similar findings where feelings of embarrassment influenced the HSB of mothers from Amazonian communities in Peru were reported by Westgard et al. (37). The gender of the healthcare provider (female TBAs, ASHAs, or nurses) is preferred during childbirth. However, this cannot be assumed as the only factor, as male relatives attended deliveries, also denoting a complementary behavior that prefers trust or familiar relationships over gender preferences.

There is no kinship or formal communication between the doctors and the traditional actors, which explains the misunderstandings or incompatibilities between the two systems. It can be assumed that reluctance toward TM originates from the health professional’s perspective. Nonetheless, TM actors see biomedicine, to some extent, as complementary. Some of these elements are also stated in a study of medical pluralism and its implications on health policy in Northeast India (38). Similarly, a rural Ghana study showed that health personnel did not consider traditional birth attendants’ contribution (39). There is also a weak relationship between the community and the doctors, as doctors are not perceived to be present in the facilities when needed. However, a better relationship exists between the community and the nurses, especially for delivery. The most substantial relationship was noted between the ASHAs and the women, especially in the village with a non-functional health center as corroborated by another study from India (40). ASHAs are perceived to have gained credibility in the community, leading to social recognition and increased legitimacy as service providers. Consequently, this kinship can be a potential mechanism to reduce maternal and newborn mortality and morbidity, considering community-oriented primary healthcare as an essential strategy to reduce inequalities by adequately training them and proportionately officially recognizing their efforts and health work, especially in rural, remote indigenous areas such as this. In addition to the ASHAs, traditional healers and TBAs are also primary contact points for mothers seeking treatment. They can also be sensitized and engaged in disseminating information regarding preventive health and be trained to recognize red flags to initiate early referrals.

Another approach to address the low uptake of health services is to strengthen a process named “Communitization,” which formulates a Health Centre Managing Committee (HCMC) that consists of members from the village council, FBOs, and staff from the health center located in the village to closely monitor the functioning of the health center along with the Government. Even before being endorsed nationwide by the National Health Mission, this system originated from a policy implemented by the Government of Nagaland in 2002, titled “The Nagaland Communization of Public Institutions and Services Act” (40). The health component of the scheme purports to ensure that the community is sufficiently and meaningfully represented and empowered to participate in the health center’s planning, implementation, and utilization of services. The HCMC can be further empowered to monitor the performance of government schemes that are intended to influence healthcare delivery uptake positively. The impact and challenges faced by HCMCs in Nagaland have been comprehensively documented by Tushi and Kaur (41).

Our study highlights that if the perceived basic needs of the community are unmet, all other efforts become irrelevant, and services will not be utilized satisfactorily by the community. In a setting such as this, where the community functions around socio-cultural norms, it may be pragmatic for policymakers to adopt a “bottom-up approach” and tailor programs by placing the community’s needs before national objectives. Policies must focus on primarily empowering local village councils, FBOs, and VHCs to monitor their health centers effectively. Inter-sectoral policies from the educational, economic, employment, infrastructure, housing, sanitation, and essential services must also be considered to address the social determinants contributing to this issue. It is relevant to design and implement salutogenic enabling environments that allow individuals to make informed decisions about their health. The objective is to attain health and well-being by guaranteeing substantive freedom and respect for the self-determination of indigenous people.

The HSB of this community is influenced by multiple social, economic, cultural, geographic, and political factors that are closely related. Health facilities are sought only in emergencies, secondary to locally available traditional medicine, determined primarily by the tribe’s perception of the quality of services provided and challenges in geographical access.

Economic reasons, low awareness, unrealistic reimbursements, and inadequate implementation of national schemes were pivotal in deterring access to health facilities. Engaging, recognizing, integrating, and supporting local actors like ASHAs, TBAs, TM healers, and FBOs may be a more realistic approach to influence individual or familial decisions to seek health facilities for maternal and child health. Community agents trained to consider the needs of vulnerable population groups represent a key catalyst in the community system. In addition, community perspectives can provide crucial insight into why health interventions may struggle or succeed in various locations. Moreover, community-led monitoring can provide a vital tool for accountability. This framework must also be supported with adequate financing for these community systems.

At the policy level, the two national programs to financially incentivize institutional deliveries and decrease OOP expenses failed to impact the local health center utilization rates due to inadequate program implementation at the grassroots as it did not consider this region’s cultural and geographical differences. The amount intended to incentivize mothers and ASHAs failed to cover the basic costs they incurred to reach a delivery point. The “one size fits all” approach to planning these policies implemented countrywide has to be tailored to the local needs of the region and must factor in the exorbitant direct and indirect costs involved with travel on rugged terrains.

Strengthening and empowering existing Health Centre Managing Committees to monitor their health centers may improve service quality. The crucial role and impact of communities stem from their strengths, which include but are not limited to legitimacy among individuals, a strong understanding of the contexts, trust, social solidarity, social motivation, and adaptation abilities. Community systems offer critical support in the areas where the conventional health system fails. The extent to which the terrain influences the delays in healthcare access should be comprehensively studied.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical Faculty, the Ruprecht Karls University of Heidelberg, Germany (#S-138/2019, 13.03.2019), and the Institutional Review Board (Research and Ethics Committee) of the Christian Institute of Health Sciences and Research, Nagaland, India. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

AD, ÁLC, RK, and RR developed the idea and designed the study. ÁLC and RR elaborated the methodology and data collection tools with the support of AD. ÁLC, PN, and RK collected the data. PN translated and transcribed the data. ÁLC analyzed the qualitative data with the backing of AD. RR analysed the quantitative data. ÁLC, RR, PN, RK, and AD contributed to data interpretation. ÁLC drafted the manuscript. ÁLC, AD, and RR revised the final version of this manuscript. All authors contributed to the article and approved the submitted version.

A research grant from the German Academic Exchange Service (DAAD) covered logistical costs for the fieldwork. All the other costs were covered by ÁLC. The Science and Engineering Research Board, Department of Science and Technology (Sanction Order: ECR/2016/002059), funded the community-based survey (Project on the use of Geographic Information Systems in Health Systems Research in Rural Areas of Nagaland). For the publication fee we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme “Open Access Publikationskosten” as well as by Heidelberg University.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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