Since 2005, the National Rural
Health Mission (NRHM) program has been implemented
in India, and has many flexible and innovative strategies to
accelerate progress towards reaching MDG-4 and 5[13].
These include: promotion of institutional deliveries through
incentive schemes; setting up and strengthening the infrastructure
and resources to provide emergency obstetric and
newborn care services; mobilization efforts by frontline workers called ASHAs (accredited social health activists)a
and strengthening of referral linkages between facilities and
communities through ambulance services [13]. As a result
of these efforts, there has been a major increase in the
number of institutional deliveries over the last few years
[14]. However, this has not led to the expected reductions
in maternal mortality [15]. Evidence suggests that improved
service access and coverage are not enough, and that they
need to be complemented by improved service quality for
improvements in outcomes [10]. Quality improvement in
turn is dependent on the availability of skilled birth attendants,
as well as well-functioning health facilities [16].