Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India

Abstract

Introduction

Despite substantial global attention and resources devoted to maternal and child health over the past decade, annually more than 300,000 women die as a result of pregnancy and childbirth, and more than 2.6 million children die within their first month of life [1–4]. Great acceleration is needed to meet the ambitious goals set forth in the Sustainable Development Goals, including the reduction of the global maternal mortality ratio (MMR) to under 70 per 100,000 live births (current level MMR is 216/100,000) and the reduction of neonatal mortality rate (NMR) to 12 per 1000 live births or lower (current level NMR is 19/1000) [3, 4]. The model being widely supported to improve these outcomes is the continuum of care (CoC), in which quality, effective, evidence-based health services are provided as an integrated stream across levels and places of service delivery and life stages for women and children [2, 5, 6]. While coverage along the CoC has improved globally, it is still low, with little improvement seen over time for many key reproductive and maternal health services, including four or more antenatal care visits, skilled attendant at delivery, exclusive breastfeeding and met need for family planning [2]. Further, despite widespread advocacy for the CoC [5–7], much remains unknown as to how to effectively increase utilization across the entire continuum [8–10]. No rigorously evaluated intervention research has documented significant improvements in overall CoC utilization, though there is a large evidence base for the efficacy of the individual interventions that comprise it, and for the importance of linkages across those services [7, 11–14].

India is a critical setting in which to implement and evaluate programs designed to improve maternal and child health, as it accounts for some of the greatest numbers of maternal and child deaths in the world [3, 4]. Subnationally, there is enormous variability in health outcomes across Indian states. Bihar is one of the most populous, poorest and lowest-performing states in the nation, with great need for improvements in health services and outcomes [15]. More than 50% of adult women are illiterate, with fewer than one quarter of women receiving ten or more years of education [16]. Infant mortality, maternal mortality, total fertility are all above the national average, and gender equity is compromised, with 39% of women married at 18 years of age or less [15, 16]. Modern contraceptive use in married women has actually decreased over the past ten years, from 29% in 2006 to 23% (nearly 90% of which is female sterilization) [16]. Additionally, public health care access in Bihar is inadequate; the state has only 60% of the necessary primary health centers, and 9% of the required community health centers [15]. More than half of all institutional births take place in private, rather than public, facilities [16]. Reasons given for not seeking care from government health facilities include the poor quality of care received therein, and lack of nearby facilities [17]. Gender equity factors, including early age at marriage and childbirth, as well as restricted mobility and decision-making control, have also been implicated in low utilization of services and poorer maternal and child health outcomes, in India and Bihar [16, 18–23].

In response to these needs, the Bill and Melinda Gates Foundation partnered with the Government of Bihar in 2011 to implement a set of innovations under the Ananya program in 8 districts of Bihar [24]. This program uses supply- and demand-side interventions to improve reproductive, maternal, newborn and child health (RMNCH) services and outcomes, focusing in particular on interventions delivered through frontline workers (FLWs), i.e., those health workers engaging in community outreach and connection to women in communities and households. Improving outreach services provided by FLWs was prioritized (particularly through home-visits) as a means of identifying and engaging women not currently using the health system, improving retention along the continuum of care, and helping to address ongoing disparities in health service utilization and outcomes in Bihar, particularly for the poor, rural, less educated and religious and caste minorities. Initial evaluation of this program identified improvements in select reproductive, maternal and neonatal health (RMNH) behaviors, such as clean cord care and post-partum contraceptive use, but results were not consistent across social equity groups, with greater improvements seen within some socially marginalized groups [25]. This variability is particularly important given lower coverage of health service utilization among poorer, more rural and less educated women [2, 26, 27]. RMNH CoC co-coverage was not evaluated in the original study.

This paper assesses whether the Ananya program was able to increase overall RMNH CoC among women who gave birth in the previous six months. We also assess whether any observed impact of Ananya on RMNH CoC utilization in these recent mothers is moderated by gender equity factors, including young maternal age at marriage, decision-making control and freedom of mobility, as prior research from India documents that these factors compromise RMNH practices [18–20, 22, 23]. Findings from this work can not only inform RMNH programming in Bihar and similar settings, but also contribute to the growing understanding of how to improve CoC co-coverage.

Methods

Results

Participants were predominantly aged 20–24 years and had no formal education (Table 1). Women had similar characteristics across Ananya and non-Ananya districts at both baseline and follow-up, though at both timepoints, women living in Ananya districts tended to have higher numbers of births (women with 3 or more births = 45.5% vs. 39.7% at baseline, p = 0.004; 43.4% vs. 39.1% at follow-up, p = 0.04). At follow-up, both women and their husbands had a higher prevalence of primary education in Ananya areas vs. non-Ananya areas (28.2% vs. 24.4% for women, p = 0.046; 37.4% vs. 32.2% for husbands, p = 0.01), though secondary education in Ananya vs. non-Ananya areas was less prevalent for husbands, and marginally less prevalent for women (29.5% vs. 35.5% for husbands, p = 0.02, 18.6% vs. 22.5% for women, p = 0.06). At follow-up, a greater proportion of women in Ananya areas reported having received at least two FLW visits, a focus of the Ananya intervention, in their last trimester of pregnancy (37.7% vs. 29.2%, p = 0.01). In terms of gender equity among these recent mothers, while there were no significant differences between Ananya and non-Ananya areas at baseline, at follow-up, Ananya areas had significantly more early marriage (51.3% vs. 42.0%, p<0.0001), and more compromised decision-making (excluded from at least one decision: 63.1% vs. 51.6%, p<0.0001).

The mean number of services/behaviors used along the RMNH CoC was significantly higher in Ananya vs. non-Ananya areas at both baseline (3.2 vs. 3.0, p = 0.01) and follow-up (4.1 vs. 3.5, p<0.0001) (Table 2). The increase over time in Ananya areas was significantly larger than that seen in non-Ananya areas (0.94 vs. 0.51 health services/behaviors, p<0.0001). Very low and very high co-coverage scores were rare. Across groups (Ananya and non-Ananya assessed at baseline and follow-up), 1–3% of women reported zero CoC components (and this decreased from baseline to follow-up), 0–4% of women reported seven or eight CoC components, and no women reported all nine CoC components. The most commonly reported CoC components at both baseline and follow-up were skilled birth attendance (63%-76%) and exclusive breastfeeding (59%-80%) (Table 3). The least commonly reported CoC components were four or more antenatal care visits (13%-24%), postnatal care (11%-16%) and postpartum contraception (10%-19%). Coverage of individual components was similar across Ananya and non-Ananya areas at baseline with the exception of delay of first bath (55.1% in Ananya areas vs. 47.2% in non-Ananya areas, p = 0.003). At midline, coverage in Ananya areas was significantly higher for four or more antenatal care visits (24.2% vs. 16.9%, p<0.0001), clean cord care (33.3% vs. 24.0%, p = 0.001), skin-to-skin care (44.1% vs. 32.7%, p<0.0001), delay of first bath (67.0% vs. 55.8%, p<0.0001) and postpartum contraceptive use (19.2% vs. 11.3%, p<0.0001). After accounting for secular trends and prior to adjusting for covariates, there were significant increases in clean cord care (OR = 1.54, p = 0.01), skin-to-skin care (OR = 1.62, p = 0.03) and postpartum contraceptive use (OR = 2.27, p<0.01) attributable to the Ananya program.

After adjusting for covariates, the Ananya program increased overall RMNH CoC co-coverage in this sample by 0.41 (p<0.001)) health services/behaviors (Table 4). Across the multiple measures of social and gender equity assessed, eight factors retained a strong impact on CoC co-coverage even after accounting for the impact of the Ananya program–wealth, education of both the respondent and her husband, religion/caste, parity, FLW visits in the last trimester of pregnancy, respondent’s age at marriage and decision-making control. Women in the lowest wealth quartile reported 0.14 fewer health services/behaviors than women in the wealthiest quartile (p = 0.04). Women with no education, or only primary education, had significantly decreased RMNH CoC co-coverage compared with women with at least secondary education (no education coefficient = -0.24, p<0.001; primary education coefficient = -0.13, p = 0.02). Similarly, women whose husbands had no education reported 0.13 fewer health services/behaviors than women with husbands educated at the secondary or higher level (p = 0.02). Identifying as a scheduled caste or scheduled tribe, or Muslim, was also associated with decreased RMNH CoC co-coverage (SC/ST coefficient = -0.18, p<0.001; Muslim coefficient = -0.24, p<0.001). There was slightly decreased RMNH CoC co-coverage for women whose index child was their second birth, compared with primiparous mothers (coefficient = -0.08, p = 0.04). FLW visits in the final trimester of pregnancy strongly affected RMNH CoC co-coverage, with women who received fewer than two FLW visits having 0.32 fewer health services/behaviors than those who received at least two FLW visits (p<0.001). Age at marriage was a significant determinant of RMNH CoC co-coverage, with women married as children reporting receipt of 0.18 fewer CoC components than their counterparts married at or after 18 years of age (p<0.001). In contrast, women who were excluded from at least one of the three assessed decisions reported 0.13 more RMNH services/health behaviors than their counterparts who were included in all three decisions (p = 0.001).

In addition to assessing Ananya’s effect on RMNH CoC co-coverage, program effect was assessed for each of the nine health services/behaviors included in the overall co-coverage metric. Ananya increased the odds of clean cord care by 72% (p<0.01), of skin-to-skin care by 59% (p = 0.03) and of postpartum contraceptive use by 130% (p<0.001)(Table 5; full models in S1 Table). There was no significant, attributable program effect on antenatal care, skilled birth attendance, delayed first bath, early initiation of breastfeeding, postnatal care within two days or exclusive breastfeeding.

Finally, analyses were conducted to further explore the influence of gender equity measures (age at marriage, decision-making control and limited mobility) on Ananya’s program effect on CoC co-coverage. Child marriage compromised Ananya’s program effect on antenatal care, skilled birth attendance and exclusive breastfeeding. Specifically, the program effect on four or more antenatal care visits among women married as adults was reduced by a factor of 0.36 for women married as children (aOR = 1.91 vs. aOR = 0.69; p = 0.003) (Table 5). Ananya program effect on having a skilled attendant at delivery among women married as adults was reduced by factor of 0.61 for women married as children (aOR = 1.34 vs. aOR = 0.81; p = 0.049), and program effect on exclusive breastfeeding among women married as adults was reduced by a factor of 0.56 for women married as children (aOR = 1.45 vs. aR = 0.82; p = 0.02). Limitations on decision-making and mobility did not influence the effect of the Ananya program on CoC co-coverage or any of the nine CoC component health services/behaviors. To further explore whether observed child marriage effects were an artifact of effects for the younger mothers in the sample, we also conducted a three-way interaction analysis with age of mother, and findings were not significant (results not shown).

Discussion

The Ananya program, through its supply- and demand-side interventions for maternal and newborn health, significantly increased RMNH CoC co-coverage among this sample of recent mothers and infants in Bihar. The 0.41 gain in health services/behaviors represents a 13% improvement over baseline attributable to the Ananya program, and is important both because each intervention along this continuum was selected for its demonstrated importance in improving maternal and newborn health and survival, and because this achievement was realized in a population with substantial social and gender inequities. Improving CoC co-coverage is particularly important in this context given its very low level, with less than 5% of participants reporting six or more of the nine assessed behaviors/services at baseline.

Despite program implementation, no recent mothers in this sample reported all nine services/behaviors measured, and very few reported seven or eight of the assessed components. Coverage of many of these interventions was low at the inception of the Ananya program–four of the assessed services/behaviors had coverage below 20% at baseline—and thus the challenges of sustained service utilization/behavior were substantial. The health services/behaviors that make up the RMNH CoC in this study can be broadly grouped into two categories: health service encounters (antenatal care, skilled birth attendance and postnatal care) and health behaviors (i.e. clean cord care, skin-to-skin care, delayed first bath, early initiation of breastfeeding, exclusive breastfeeding and postpartum contraceptive use), the latter of which could be facilitated by FLWs or other providers. The increase in co-coverage was primarily driven by significant improvements in health behaviors: clean cord care, skin-to-skin care and postpartum contraceptive use. The 2.3 times increased odds of postpartum contraceptive use is particularly striking given that both baseline and follow-up samples were comprised of mothers of 0–5 month olds (and lactational amenorrhea was excluded from our measure of postpartum contraceptive use). These are key interventions—clean cord care can reduce neonatal mortality by approximately 37%, and skin-to-skin care has been associated with neonatal survival in this and similar populations, and can reduce neonatal mortality among premature newborns by 30–50% [31–33]. Modern contraceptive use is associated with antenatal care acquisition, childhood immunization and maternal and neonatal mortality [34, 35]. When assessed individually, there were no negative associations between low education levels (for the respondent or her husband) and clean cord care, skin-to-skin care or postpartum contraception, indicating that a key social inequity may have been overcome for these outcomes in this context, though wealth, caste/religion and gender equity were still compromised.

In terms of health encounters, findings suggest that Ananya requires some alteration to better support best practices among these recent mothers. None of the three encounter-based outcomes (antenatal care, skilled birth attendance and postnatal care) increased in this sample based on receipt of this program. The primary factors associated with decreased utilization of these encounters were social equity measures such as wealth, education and religion/caste. Additional outreach to these marginalized groups may be necessary to improve utilization, a suggestion supported by the strongly protective association of FLW visits in the last trimester with all three health encounter outcomes. Improved quality of care in this context may also support better utilization, as previous research has documented that poor quality care in Bihar keeps individuals from seeking services [17, 33, 36, 37]. This is a reasonable response given that quality issues such as inadequate numbers of providers, poor hygiene in care practices, and mistreatment by providers are well documented in Bihar and India and such quality issues are associated with increased maternal and child health outcomes and even death [38–41].

The implications of this lack of effect on health encounters in this sample are concerning, as from a continuum perspective, sustained linkages across all three services have demonstrated benefit for reducing neonatal mortality [14]. Individually, beyond its benefits for mortality and morbidity reduction [6, 42, 43], antenatal care is an important area for initial contact with regards to continuation through the continuum of care, in this population and others [33, 42]. Skilled birth attendance can improve maternal survival, and reduce stillbirths and neonatal mortality (by 23–45% and 11–17%, respectively) [6, 26, 44]. Postnatal care is a critical encounter in which to provide care and education, with the potential to reduce neonatal mortality by 30–60%, an association also seen in Bihar [33, 45–49]. As institutional deliveries and skilled birth attendance have more than doubled over the past decade, women who are still not using institutional deliveries and skilled birth attendance may have greater utilization barriers than women who have shifted their delivery practices since the initiation of the Government of India’s JSY initiative, which involves cash transfer for facility delivery [50]. Similar cash transfer approaches may offer an opportunity to quickly increase coverage of four or more antenatal care visits, and postnatal care within two days, but sustainability considerations are key. It is also important to note that the three health encounter metrics assess the presence/quantity of these encounters, rather than the quality of services received therein, and as noted above, service may be key to helping promote use of these services [38–41].

An additional key finding of this study is the beneficial effect of FLW visits during pregnancy for these recent mothers, which were strongly and positively associated with increased RMNH CoC co-coverage overall, and for the component outcomes of antenatal care, skilled birth attendance, early initiation of breastfeeding, postnatal care visits within two days, exclusive breastfeeding and postpartum contraceptive use, above and beyond the benefit seen from the FLW-focused aspects of the Ananya program. This finding builds on prior work demonstrating the utility of trained and supported FLWs, in particular community health workers, to help mobilize communities to engage in healthier neonatal and postnatal health practices [25, 51–55]. FLWs may also be key to facilitate linkages across the place component of the continuum of care, connecting interventions delivered at home, in the community and in health facilities–the importance of this role, and its association with reduced neonatal and maternal mortality, has been demonstrated elsewhere [14, 54], and merits greater focus in this setting.

Despite these promising findings regarding Ananya impact for recent mothers, program effects in this sample appear to be compromised by gender inequity, specifically child marriage. The benefits of the Ananya program were not strong enough to neutralize the depressed co-coverage scores of recent mothers who married as minors, as well as those who were poor, who had low education levels or husbands with low education, higher parity or were of marginalized caste/religion (all factors related to child marriage) [18]. Additionally, moderation analyses indicate a significant interaction of child marriage on program impact, with a lesser effect of the Ananya program on antenatal care, skilled birth attendance and exclusive breastfeeding specifically, for recent mothers married as minors compared to those married as adults. These findings suggest that Ananya and programs like it would benefit from more focused efforts for women married as minors. Exploratory analyses indicating that age of mother did not moderate impact where child marriage did suggests that youth-focused programming alone will not address this issue. Screening for this history may be an important element of service tailoring to better meet the needs of this population. Larger structural changes preventing child marriage and supporting greater gender equity for women would also be beneficial, and such an approach has been recommended more broadly for maternal and child health programming [56, 57].

Less clear from the current analyses are findings related to women’s decision-making control and CoC utilization, which indicated that women in this sample with limited decision-making agency used significantly more RMNH CoC services/behaviors than their counterparts with greater decision-making control, though that did not significantly influence the Ananya program effect for any assessed outcome. These findings may be an issue of the measure used, as there are some concerns with the validity of this measure across national contexts [58]. However, it may also be that decision-making control does not impede health care utilization if others in greater control are supportive of evidence-based RMNH practices, or even compel use of some services, measures which were not assessed in these data. An additional possible explanation is that quality of care is low for facility-based services provided in Bihar (also not comprehensively assessed within this data, but indicated elsewhere [17, 33]), and that women with greater agency would be more discerning about where and from whom they sought care.

This analysis has several limitations. The study design is quasi-experimental, not randomized, allowing for potential differences between groups not otherwise considered; comparability on demographics and behaviors at baseline alleviate some but not all of this concern. Inability to measure outcomes over time for the same participants, and lack of clarity regarding quality and intensity of the Ananya program exposure, impedes full understanding of program impact. All data used are based on women’s self-report, and therefore susceptible to recall and social desirability bias, though the former is lessened by the fact that questions focused on the most recent pregnancy, which occurred within the six months prior to interview. Finally, findings are limited to Bihar, and cannot be assumed to be generalizable to other states within India or other countries, though findings may be more generalizable to very low resource contexts like Bihar, where disproportionate burden of maternal and neonatal concerns exist.

Supporting information

Acknowledgments

Funding Statement

This manuscript and the Ananya Program and data collection were supported by the Bill and Melinda Gates Foundation (BMGF www.gatesfoundation.org). LM, JGS and AR received funding from BMGF directly [OPP1163682] and via Sambodhi Research and Communications Private Limited [UCSD 2016-3182]. KH, YA and UKT are BMGF staff who participated in the development of this study and the generation of this manuscript, and are recognized as coauthors. In their roles with BMGF, they were involved with the design and conduct of the Ananya Program and evaluation study design from which data for this study were obtained. They provided some oversight of data collection and management, and gave input into analyses included in this manuscript. They assisted with the interpretation of this paper and reviewed and approved this final manuscript.

Data Availability

The dataset used in this analysis is available on Harvard Dataverse, at the following URL: http://dx.doi.org/10.7910/DVN/XNUYPB.

References