The effect of Self-Help Groups on access to maternal health services: evidence from rural India (original) (raw)
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PLOS ONE
Background This study evaluates an eight-session behavior change health intervention with women's self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups. Methods Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using differencein-difference (DID) methods. Results Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to
EClinicalMedicine, 2020
Background: Despite the health system effort s, health disparities exist across sub-populations in India. We assessed the effects of health behaviour change interventions through women's self-help groups (SHGs) on maternal and newborn health (MNH) behaviours and socioeconomic inequalities. Methods: We did a quasi-experimental study of a large-scale SHG program in Uttar Pradesh, India, where 120 geographic blocks received, and 83 blocks did not receive health intervention. Data comes from two cross-sectional surveys with 4,615 recently delivered women in 2015, and 4,250 women in 2017. The intervention included MNH discussions in SHG meetings and community outreach activities. The outcomes included antenatal, natal and postnatal care, contraceptive use, cord care, skin-to-skin care, and breastfeeding practices. Effects were assessed using multilevel mixed-effects regression adjusted differencein-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, mostmarginalised and least-marginalised women. Concentration indices examined the socioeconomic inequality in health practices over time. Findings: The net improvements (5-11 percentage points [pp]) in correct MNH practices were significant in the intervention areas. The improvements over time were higher among the most-marginalised than least-marginalised for antenatal checkups (DID: 20pp, p < 0 • 001 versus DID: 6pp, p = 0 • 093), consumption of iron folic acid tablets for 100 days (DID: 7pp, p = 0 • 036 versus DID:-1pp, p = 0 • 671), current use of contraception (DID: 12pp, p = 0 • 046 versus DID: 10pp, p = 0 • 021), cord care (DID: 12pp, p = 0 • 051 versus DID: 7pp, p = 0 • 210), and timely initiation of breastfeeding (DID: 29pp, p = 0 • 001 versus DID: 1pp, p = 0 • 933). Lorenz curves and concentration indices indicated reduction in rich-poor gap in health practices over time in the intervention areas. Interpretation: Disparities in MNH behaviours declined with the effort s by SHGs through behaviour change communication intervention.
The Lancet Global Health, 2016
Background A quarter of the world's neonatal deaths and 15% of maternal deaths happen in India. Few community-based strategies to improve maternal and newborn health have been tested through the country's government-approved Accredited Social Health Activists (ASHAs). We aimed to test the eff ect of participatory women's groups facilitated by ASHAs on birth outcomes, including neonatal mortality. Methods In this cluster-randomised controlled trial of a community intervention to improve maternal and newborn health, we randomly assigned (1:1) geographical clusters in rural Jharkhand and Odisha, eastern India to intervention (participatory women's groups) or control (no women's groups). Study participants were women of reproductive age (15-49 years) who gave birth between Sept 1, 2009, and Dec 31, 2012. In the intervention group, ASHAs supported women's groups through a participatory learning and action meeting cycle. Groups discussed and prioritised maternal and newborn health problems, identifi ed strategies to address them, implemented the strategies, and assessed their progress. We identifi ed births, stillbirths, and neonatal deaths, and interviewed mothers 6 weeks after delivery. The primary outcome was neonatal mortality over a 2 year follow up. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN31567106. Findings Between September, 2009, and December, 2012, we randomly assigned 30 clusters (estimated population 156 519) to intervention (15 clusters, estimated population n=82 702) or control (15 clusters, n=73 817). During the follow-up period (Jan 1, 2011, to Dec 31, 2012), we identifi ed 3700 births in the intervention group and 3519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1000 livebirths in the intervention group and 44 per 1000 livebirths in the control group (odds ratio [OR] 0.69, 95% CI 0•53-0•89). Interpretation ASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India. Funding Big Lottery Fund (UK).
Women's Health Reports
Background: Millennium development goal 5 aimed at reduction of maternal deaths by three-quarters from 1990 to 2015: a target India commendably achieved, but this milestone remains overshadowed by inequalities in utilization of health services that are driven by determinants both at community and at individual level. Materials and Methods: We studied the utilization trends using descriptive statistics and analyzed the relative contribution of various socioeconomic predictors on the use of maternal health care services in rural India using binary logistic regression analysis on pooled data from three rounds of National Family Health Survey. Outcome variables included four or more antenatal care visits, skilled birth attendance, and postnatal care. Results: Although utilization of maternal health care services showed an upward trend from 1998-1999 to 2015-2016, factors such as illiteracy, female age ‡40 years, having five and more children, belonging to scheduled tribes, rural residence, and not possessing a health card were associated with significantly low utilization of maternal health care services. However, partner's education, good economic status, women's autonomy, and infrastructure at village level were associated with better odds of availing these services. Conclusions: The study generates evidence on the role of various socioeconomic determinants in maternal health care utilization and identifies gaps that must be strategically addressed to reach sustainable developmental goal maternal mortality target of 70 deaths per 100,000 live births by 2030. It reemphasizes the need for ensuring convergence among different stakeholders while structuring maternal health policies so that health reforms can be accomplished effectively at all levels of health care.
Journal of Health, Population and Nutrition
Background: Proper utilization of antenatal and postnatal care services plays an important role in reducing the maternal mortality ratio and infant mortality rate. This paper assesses the utilization of health care services during pregnancy, delivery and post-delivery among rural women in Uttar Pradesh (UP) and examines its determinants. Methods: Data from a baseline survey of UP Community Mobilization (UPCM) project (2013) was utilized. A crosssectional sample of currently married women (15 to 49 years) who delivered a baby 15 months prior to the survey was included. Information was collected from 2208 women spread over five districts of UP. Information on sociodemography characteristics, utilization of antenatal care (ANC), delivery and postnatal care (PNC) services was collected. To examine the determinants of utilization of maternal health services, the variables included were three ANC visits, institutional delivery and PNC within 42 days of delivery. Separate multilevel random intercept logistic regressions were used to account for clustering at a block and gram panchayat level after adjusting for covariates. Results: Eighty-three percent of women had any ANC. Of them, 61% reported three or more ANC visits. Although 68% of women delivered in a health facility, 29% stayed for at least 48 h. Any PNC within 42 days after delivery was reported by 26% of women. In the adjusted analysis, women with increasing number of contacts with the health worker during the antenatal period, women exposed to mass-media and non-marginalized women were more likely to have at least three ANC visits during pregnancy. Non-marginalized women and women with at least three ANC visits were more likely than their counterparts to deliver in an institution. Contacts with health worker during pregnancy, marginalization, at least three ANC visits and institutional delivery were the strong determinants for utilization of PNC services. Self-help group (SHG) membership had no association with the utilization of maternal health services. Conclusions: Utilization of maternal health services was low. Contact with the health worker and marginalization emerged as important factors for utilization of services. Although not associated with the utilization, SHGs can be used for delivering health care messages within and beyond the group.
American journal of public health, 2015
Objectives. We evaluated the effectiveness of the Sure Start project, which was implemented in 7 districts of Uttar Pradesh, India, to improve maternal and newborn health. Methods. Interventions were implemented at 2 randomly assigned levels of intensity. Forty percent of the areas received a more intense intervention, including community-level meetings with expectant mothers. A baseline survey consisted of 12 000 women who completed pregnancy in 2007; a follow-up survey was conducted for women in 2010 in the same villages. Our quantitative analyses provide an account of the project's impact. Results. We observed significant health improvements in both intervention areas over time; in the more intensive intervention areas, we found greater improvements in care-seeking and healthy behaviors. The more intensive intervention areas did not experience a significantly greater decline in neonatal mortality. Conclusions. This study demonstrates that community-based efforts, especially m...
2020
Background: Maternal mortality can be prevented in low-income settings through early health care seeking during maternity complications. While health system reforms in India prioritised institutional deliveries, inadequate antenatal and postnatal services limit the knowledge of danger signs of obstetric complications to women, which delays the recognition of complications and seeking appropriate health care. Recently, a novel rapidly scalable community-based program combining maternal health literacy delivery through micro nance-based women-only self-help groups (SHG) was implemented in rural India. This study evaluates the impact of the integrated micro nance and health literacy (IMFHL) program on the knowledge of maternal danger signs in marginalised women from one of India's most populated and poorer states-Uttar Pradesh. Additionally, the study evaluates the presence of a diffusion effect of the knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. Methods: Secondary data from the IMFHL program comprising 17,232 women from SHG and nonmember households in rural Uttar Pradesh was included. Multivariate logistic regression models were used to identify the program's effects on the knowledge of maternal danger signs adjusting for a comprehensive range of confounders at the individual, household, and community level. Results: SHG member women receiving health literacy were 27 per cent more likely to know all danger signs as compared with SHG members only. Moreover, the results showed that the SHG network facilitates diffusion of knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. The study found that the magnitude of the program impact on outcome remained stable even after controlling for other confounding effects suggesting that the health message delivered through the program reaches all women uniformly irrespective of their socioeconomic and health system characteristics. Conclusions: The ndings can guide community health programs and policy that seek to impact maternal health outcomes in low resource settings by demonstrating the differential impact of SHG alone and SHG plus health literacy on maternal danger sign knowledge. maternal deaths still occurred annually in 2017 with the majority disproportionately situated in Africa and South Asia (2). Moreover, the unmet gap in reducing maternal deaths from the MDG's period has now carried over to the Sustainable Development Goals (SDG) with an ambitious target of maternal mortality ratio of 70 per 100,000 live births by 2030 for all countries (3). Reducing maternal mortality in high burden regions requires addressing preventable causes of maternal mortality that may occur at any stage of maternity requiring high-quality person-centred care (4,5). These often manifest in pregnant women through physical signs related to underlying pregnancy-related complications, namely bleeding disorders, pregnancy-induced hypertension (eclampsia), delivery complications, post-delivery bleeding and infections (4,6). These physical signs act as an early warning or danger signs of maternal complications. Studies show that within Sub-Saharan Africa and South Asia, there is limited health system capability in providing emergency maternity care, that contributes to the overall high rates of maternal death (4,7). Therefore, achieving the maternal health SDG target would require novel strategies that complement existing country-level efforts, especially among low resource and high disease burden regions where substantial maternal deaths are avoidable (1,4). According to the World Health Organization (2019), the majority (99 per cent) of maternal deaths still occur in low-income regions of South Asia and Sub-Saharan Africa where selected countries contribute the substantial burden (1,4,8,9). Within South Asia, India alone accounts for an estimated 10 per cent of global maternal deaths or 45,000 maternal deaths annually and 20 per cent of global under-5 child mortality with 1.04 million deaths estimated annually (1,10,11). India accelerated the rate of maternal death decline in the latter half of the MDG period (2006-2015) due to strategic health system reforms that prioritised community health care and incentivised institutional delivery, leading to a national average of 80 per cent institutional deliveries across rural and urban populations(10-12). Importantly, the rise in institutional deliveries has not been matched with adequate provision of Basic and Emergency Medical Obstetric Care (EMOC) in facilities in rural areas (13). Previous studies from India found that institutional deliveries alone, in the absence of high-quality EMOC and adequate referral system, is weakly associated with maternal mortality reduction (14-16). Studies from other countries also showed that prioritising institutional deliveries alone, without adequate investments to ensure skilled high-quality care, increases the risk of negligence in maternal health care facilities (17,18). In India, substantial regional disparities account for select northern states traditionally reporting low development and maternal health indicators. Notably, the state of Uttar Pradesh (UP) accounts for the highest number of maternal deaths in India, which is partly attributed to the state population (200 million) (10,19,20). The Maternal Mortality Ratio (MMR) in Uttar Pradesh stands at 188 per 100,000 live births compared to the national MMR of 130 per 100,000 live births (21). Institutional delivery in rural regions in UP is substantially lower at 66 per cent as compared to the national rural average of 75 per cent (22,23). Importantly, UP reported 34 per cent home deliveries in 2016, among which only four per cent were attended by a skilled birth attendant (23).
PLOS ONE, 2016
Background There is a need for studies evaluating maternal health interventions in low-income countries. This paper evaluates one such intervention designed to promote maternal health among rural women in Nepal. Methods and Results This was a five-year controlled, non-randomised, repeated cross-sectional study (2007, 2010, 2012) of a participatory community-based maternal health promotion intervention focusing on women's groups to improve maternal health services uptake. In total 1,236 women of childbearing age, who had their last child two years ago, were interviewed. Difference-inDifference estimation assessed the effects of the intervention on selected outcome variables while controlling for a constructed wealth index and women's characteristics. In the first three years (from 2007 to the 2010), the intervention increased women's likelihood of attending for antenatal care at least once during pregnancy by seven times [OR = 7.0, 95%CI (2.3; 21.4)], of taking iron and folic acid by three times [OR = 3.0, 95%CI (1.2; 7.8)], and of seeking four or more antenatal care visits of two times, although not significantly [OR = 2.2, 95%CI (1.0; 4.7)]. Over five years, women were more likely to seek antenatal care at least once [OR = 3.0, 95%CI (1.5; 5.2)], to take iron/folic acid [OR = 1.9, [95% CI (1.1; 3.2)], and to attend postnatal care [OR = 1.5, [95% CI (1.1; 2.2)]. No improvement was found on attending antenatal care in the first trimester, birthing at an institution or with a skilled birth attendant. Conclusion Community-based health promotion has a much stronger effect on the uptake of antenatal care and less on delivery care. Other factors not easily resolved through health promotion PLOS ONE |
International Journal for Equity in Health
Background: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health. Methods: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity. Results: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers. Conclusion: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.
Journal of Women's Health Care, 2018
Background: The uptake of maternal healthcare services by young women in rural India is limited. This study aims to assess the effectiveness of community intervention model to improve the maternal healthcare service uptake of young married couples (15-24 years) in rural India. A three year project was carried out to reach young married women through a multi-pronged community intervention involving sensitizing family members, community mobilization, and capacity building of frontline health functionaries. Methods: The study was conducted among the young married couples aged 15-25 years in states of Uttar Pradesh and Rajasthan of India. A quasi-experimental evaluation design was adopted for this study. Two rounds of cross-sectional surveys at baseline and end line were carried out at both intervention and control sites. Net impact of intervention (Difference-inDifference and multivariate regression) on key outcomes was assessed adjusting for control variables. Composite maternal healthcare uptake score significantly increased in intervention area compared to control area. Results: Women who were able to discuss about delivery care with family, were five times more likely to go for institutional delivery, also the utilization of maternal health care services was higher among these women (β=1.58). Likelihood of uptake for more than three visits for antenatal care (3+ANC) service indicated three times (OR=3.14, p<0.001), and more than three visits. Postnatal care (3+PNC) service indicated two fold (OR=1.82, p<0.001) increase in intervention area than those in control area. Regression result on composite maternal health care uptake score significantly increased by 2.5 (β=2.23, p<0.001) in intervention area compared to control area. Conclusion: This study demonstrated that the community intervention to foster enabling environment was effective in improving the awareness and uptake of maternal healthcare services.