Evaluating National Maternal Care Programs to Reduce Stillbirth in Rural Areas of Pune district: Findings from Qualitative data using the RE-AIM framework

Background: Stillbirth remains a critical yet under-prioritised public health challenge in India, despite global and national commitments to maternal and child survival. Evidence suggests that more than half of stillbirths are preventable through timely, high-quality antenatal and intrapartum care. The India Newborn Action Plan (INAP) was launched in 2014 to align with the Every Newborn Action Plan (ENAP) and to strengthen maternal, newborn, and child health interventions. However, rural regions—particularly those with large tribal and migrant populations—continue to face barriers in service delivery, access, and utilisation. In this context, this study aimed to assess the delivery of maternal care public health programs in rural Pune district, Maharashtra, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, to identify systemic, cultural, and logistical gaps that limit stillbirth prevention efforts. Methods: A qualitative, formative implementation research approach was employed as part of a larger mixed-methods study. Data were collected from three rural blocks of Pune district (Khed, Ambegaon, Junnar) through 49 in-depth interviews with pregnant women, mothers, community health workers (CHWs), and healthcare providers (HCPs) and one focus group discussion with the CHW. Interview guides included probes for each RE-AIM domain. Audio-recorded interviews were transcribed, translated, and thematically analysed according to the RE-AIM framework. Results: Even though maternal and child services under national public health programs are available, significant gaps remained across all RE-AIM domains. Reach was hindered by geographic isolation, lack of awareness, language barriers, and deep-rooted mistrust of public facilities among tribal and migrant populations. Effectiveness was constrained by inconsistent high-risk pregnancy (HRP) screening, delayed pregnancy registration, shortages of diagnostic kits, and cultural norms discouraging timely care-seeking. Adoption of standardised maternal health protocols was inconsistent across cadres and facilities, with varied definitions of stillbirth and heavy workloads impeding compliance. Implementation faced challenges from inadequate infrastructure, inefficient referral pathways, frequent stock-outs of medicines and supplies, and unreliable ambulance services, particularly at night. Maintenance was undermined by low CHW incentives, irregular training, absence of continuous professional development, and weak monitoring and feedback systems. Conclusion: Addressing these systemic and cultural barriers will require culturally adapted IEC, proactive pregnancy identification, uniform protocol enforcement especially for high-risk pregnancies, strengthened supply chains, sustained training for CHWs and HCPs, and streamlined digital health systems. Strengthening maternal care delivery through these strategies holds significant potential for reducing preventable stillbirths in rural Pune and similar LMIC contexts.