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Singh A, Kumar K, Yadav AK, James KS, McDougal L, Atmavilas Y, Raj A. Factors Influencing the Sex Ratio at Birth in India: A New Analysis based on Births Occurring between 2005 and 2016. Stud Fam Plann 2021; 52:41-58. [PMID: 33616232 PMCID: PMC8049007 DOI: 10.1111/sifp.12147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Previous research on sex ratio at birth (SRB) in India has largely relied on macro-analysis of census data that do not contain the breadth of factors needed to explain patterns in SRB. Additionally, no previous research has examined the differentiation of factors associated with SRB across birth orders, a key determinant in societies affected by son preference. This study aims to fill these gaps using micro-data related to 553,461 births occurring between 2005 and 2016 collected as part of the 2015-2016 National Family Health Survey. Analyses used multivariable logistic regressions stratified by birth order to examine associations with SRB at the national level. The SRB at birth order 1 was outside the biological normal limit, and generally increased with birth order. First births in households with wealth in the middle and richest quintiles, with mothers who desired a higher ideal number of sons than daughters, and in lower fertility communities had a higher probability of being male. Most SRB correlates were visible at birth orders 3 or higher. Programs and policies designed to address India's male-skewed SRB must consider the diverse factors that influence SRB, particularly for higher order births.
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Affiliation(s)
- Abhishek Singh
- Abhishek Singh is Professor, Department of Public Health & Mortality Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
| | - Kaushalendra Kumar
- Kaushalendra Kumar is Assistant Professor, Department of Public Health & Mortality Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
| | - Ajit Kumar Yadav
- Ajit Kumar Yadav is Research Analyst, GENDER Project, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
| | - K S James
- K. S. James is Director and Senior Professor, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
| | - Lotus McDougal
- Lotus McDougal is Associate Project Scientist, Center on Gender Equity and Health, University of California San Diego, San Diego, CA
| | - Yamini Atmavilas
- Yamini Atmavilas is Senior Programme Officer, Bill and Melinda Gates Foundation, New Delhi, India
| | - Anita Raj
- Anita Raj is Tata Chancellor Professor of Medicine and Director, Center on Gender Equity and Health, University of California San Diego, San Diego, CA
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward V, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ward VC, Raheel H, Weng Y, Mehta KM, Dutt P, Mitra R, Sastry P, Godfrey A, Shannon M, Chamberlain S, Kaimal R, Carmichael SL, Bentley J, Abdalla S, Pepper KT, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Nanda P, Tarigopula UK, Atmavilas Y, Bhattacharya D, Darmstadt GL. Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ward VC, Raheel H, Weng Y, Mehta KM, Dutt P, Mitra R, Sastry P, Godfrey A, Shannon M, Chamberlain S, Kaimal R, Carmichael SL, Bentley J, Abdalla S, Pepper KT, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Nanda P, Tarigopula UK, Atmavilas Y, Bhattacharya D, Darmstadt GL. Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India. J Glob Health 2020; 10:021005. [PMID: 33425329 PMCID: PMC7758913 DOI: 10.7189/jogh.10.021005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India. Methods Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed. Results An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR) = 2.3, 95% confidence interval (CI) = 1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR = 2.8, 95% CI = 1.9-4.2) and appropriate infant complementary feeding (OR = 1.9, 95% CI = 1.0-3.5). CARE India’s Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR = 1.64, 95% CI = 1.5-1.78) and exclusive breastfeeding (OR = 1.46, 95% CI = 1.33-1.62) in addition to birth preparedness practices. BBC Media Action’s Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P < 0.01) as well as maternal respondents’ trust in their frontline worker. Conclusions Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts. Study registration ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hina Raheel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | | | | | - Rajani Kaimal
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | - Dana Rotz
- Mathematica, Princeton, New Jersey, USA
| | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | | | | | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward VC, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health impact of self-help groups scaled-up statewide in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ward VC, Weng Y, Bentley J, Carmichael SL, Mehta KM, Mahmood W, Pepper KT, Abdalla S, Atmavilas Y, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Bhattacharya D, Nanda P, Tarigopula UK, Shah H, Darmstadt GL. Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward VC, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health impact of self-help groups scaled-up statewide in Bihar, India. J Glob Health 2020; 10:021006. [PMID: 33425330 PMCID: PMC7761401 DOI: 10.7189/jogh.10.021006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017. METHODS We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age. RESULTS SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children. CONCLUSIONS SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Indrajit Chaudhuri
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Janine Schooley
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andreea Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jess Wilhelm
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Darmstadt GL, Pepper KT, Ward VC, Srikantiah S, Mahapatra T, Tarigopula UK, Bhattacharya D, Irani L, Schooley J, Chaudhuri I, Dutt P, Sastry P, Mitra R, Chamberlain S, Monaghan S, Nanda P, Atmavilas Y, Saggurti N, Borkum E, Rangarajan A, Mehta KM, Abdalla S, Wilhelm J, Weng Y, Carmichael SL, Raheel H, Bentley J, Munar WA, Creanga A, Trehan S, Walker D, Shah H. Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. J Glob Health 2020; 10:021001. [PMID: 33414906 PMCID: PMC7757841 DOI: 10.7189/jogh.10.021001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.
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Affiliation(s)
- Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | - Janine Schooley
- Project Concern International, Delhi, India, and San Diego, California, USA
| | - Indrajit Chaudhuri
- Project Concern International, Delhi, India, and San Diego, California, USA
| | | | | | | | | | - Sophia Monaghan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | | | | | | | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jess Wilhelm
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingjie Weng
- Quantitaitve Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hina Raheel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Quantitaitve Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wolfgang A Munar
- George Washington University Milken Institute School of Public Health, Washington DC, USA
| | - Andreea Creanga
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shamik Trehan
- CARE India, Patna, India
- Dr Reddy's Foundation, Hyderabad, India
| | - Dilys Walker
- Department of Obstetrics and Gynecology and Reproductive Services, University of California San Francisco, San Francisco, California, USA
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Abdalla S, Weng Y, Mehta KM, Mahapatra T, Srikantiah S, Shah H, Ward VC, Pepper KT, Bentley J, Carmichael SL, Creanga A, Wilhelm J, Tarigopula UK, Nanda P, Bhattacharya D, Atmavilas Y, Darmstadt GL. Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India. J Glob Health 2020; 10:021003. [PMID: 33427818 PMCID: PMC7757843 DOI: 10.7189/jogh.10.021003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017. METHODS Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase. RESULTS In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators. CONCLUSIONS Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | | | | | - Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Andreea Creanga
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jess Wilhelm
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | | | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Abdalla S, Weng Y, Mehta1, KM, Mahapatra T, Srikantiah S, Shah H, Ward VC, Pepper KT, Bentley J, Carmichael SL, Creanga A, Wilhelm J, Tarigopula UK, Nanda P, Bhattacharya D, Atmavilas Y, Darmstadt GL. Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ward VC, Weng Y, Bentley J, Carmichael SL, Mehta KM, Mahmood W, Pepper KT, Abdalla S, Atmavilas Y, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Bhattacharya D, Nanda P, Tarigopula UK, Shah H, Darmstadt GL. Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. J Glob Health 2020; 10:021011. [PMID: 33425335 PMCID: PMC7759017 DOI: 10.7189/jogh.10.021011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India. METHODS Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India. RESULTS At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P < 0.01) and skin-to-skin care (+14.8% vs +20.4%, P < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64). CONCLUSIONS Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Wajeeha Mahmood
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | | | - Dana Rotz
- Mathematica, Princeton, New Jersey, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | - Hemant Shah
- Bill and Melinda Gates Foundation, Delhi, India
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Darmstadt GL, Pepper KT, Ward VC, Srikantiah S, Mahapatra T, Tarigopula UK, Bhattacharya D, Irani L, Schooley J, Chaudhuri I, Dutt P, Sastry P, Mitra R, Chamberlain S, Monaghan S, Nanda P, Atmavilas Y, Saggurti N, Borkum E, Rangarajan A, Mehta KM, Abdalla S, Wilhelm J, Weng Y, Carmichael SL, Raheel H, Bentley J, Munar WA, Creanga A, Trehan S, Walker D, Shah H. Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward V, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. J Glob Health 2020; 10:021007. [PMID: 33425331 PMCID: PMC7759023 DOI: 10.7189/jogh.10.021007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. METHODS A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. RESULTS In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. CONCLUSIONS Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Indrajit Chaudhuri
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Janine Schooley
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andreea Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jess Wilhelm
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Mahapatra B, Walia M, Patel SK, Battala M, Mukherjee S, Patel P, Subramanium B, Atmavilas Y, Saggurti N. Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India. PLoS One 2020; 15:e0235094. [PMID: 32609731 PMCID: PMC7329078 DOI: 10.1371/journal.pone.0235094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/08/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex through consistent use of condoms sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying relationship between strengthening of COs, vulnerability reduction, and sustaining of consistent condom use behavior among FSWs. Methods We used a longitudinal study design to assess the change in outcomes. A three-stage sampling design was used to select FSWs for the study. Panel data of 2085 FSWs selected from 38 COs across five states of India was used to examine the change in various outcomes from 2015 (Survey Round 1) to 2017 (Survey Round 2). The CO level program pillar measuring institutional development assessed performance of COs in six domains critical for any organization’s functionality and sustainability: governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization. Overall, 32 indicators from all these domains were used to compute the CO strength score. A score was computed by taking mean of average dimension scores. The overall score was divided into two groups based on the median cutoff; COs which scored below the median were considered to have low CO strength, while COs which scored above or equal to median were considered to have high CO strength. Multivariable regression modeling techniques were used to examine the effect of program pillars on outcome measures. Results Analyses showed a significant improvement in the strength of the COs over time; percentage of COs having high strength improved from 50% in 2015 to 87% in Round 2. The improvement in CO’s strength increased financial security (Adjusted Odds Ratio [AOR]: 2.18, p<0.01), social welfare security (AOR: 1.71, p<0.01), and socio-legal security (AOR: 2.20, p<0.01) among FSWs. Further, improvement in financial security led to significant increase in consistent condom use with client among FSWs (AOR: 1.69, p<0.01) who were members of COs having high strength. Sustained consistent condom use was positively associated with young age (<30 years), ability to negotiate with clients for condom use, membership in self-help groups, high self-efficacy, self-confidence, and client solicitation in streets and brothels. Conclusions Improving financial security and strengthening FSW led CO can improve sustained and consistent condom use. In addition, the program should focus on enhancing ability of FSWs to negotiate with clients for condom use, promote membership in self-help groups and target FSWs who are 30 years or older, and soliciting from homes to sustain consistent condom use across all FSWs.
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Affiliation(s)
| | | | | | | | | | - Prachi Patel
- Catalyst Management Services, Bengaluru, Karnataka, India
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Silverman JG, Fonseka RW, Dehingia N, Boyce SC, Chandurkar D, Singh K, Hay K, Atmavilas Y, Raj A. Associations between recent intimate partner violence and receipt and quality of perinatal health services in Uttar Pradesh. PLoS One 2020; 15:e0232079. [PMID: 32407320 PMCID: PMC7224484 DOI: 10.1371/journal.pone.0232079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND India suffers some of the highest maternal and neonatal mortality rates in the world. Intimate partner violence (IPV) can be a barrier to utilization of perinatal care, and has been associated with poor maternal and neonatal health outcomes. However, studies that assess the relationship between IPV and perinatal health care often focus solely on receipt of services, and not the quality of the services received. METHODS AND FINDINGS Data were collected in 2016-2017 from a representative sample of women (15-49yrs) in Uttar Pradesh, India who had given birth within the previous 12 months (N = 5020), including use of perinatal health services and past 12 months experiences of physical and sexual IPV. Multivariate logistic regression models assessed whether physical or sexual IPV were associated with perinatal health service utilization and quality. Reports of IPV were not associated with odds of receiving antenatal care or a health worker home visit during the third trimester, but physical IPV was associated with fewer diagnostic tests during antenatal visits (beta = -0.30), and fewer health topics covered during home visits (beta = -0.44). Recent physical and recent sexual IPV were both associated with decreased odds of institutional delivery (physical IPV AOR 0.65; sexual IPV AOR 0.61), and recent sexual IPV was associated with leaving a delivery facility earlier than recommended (AOR = 1.87). Neither form of IPV was associated with receipt of a postnatal home visit, but recent physical IPV was associated with fewer health topics discussed during such visits (beta = -0.26). CONCLUSIONS In this study, reduced quantity and quality of perinatal health care were associated with recent IPV experiences. In cases where IPV was not related to care receipt, IPV remained associated with diminished care quality. Additional study to understand the mechanisms underlying associations between IPV and care qualities is required to inform health services.
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Affiliation(s)
- Jay G. Silverman
- Center on Gender Equity and Health (GEH), University of California, San Diego, California, United States of America
| | - Ruvani W. Fonseka
- Center on Gender Equity and Health (GEH), University of California, San Diego, California, United States of America
| | - Nabamallika Dehingia
- Center on Gender Equity and Health (GEH), University of California, San Diego, California, United States of America
| | - Sabrina C. Boyce
- Center on Gender Equity and Health (GEH), University of California, San Diego, California, United States of America
| | | | - Kultar Singh
- Sambodhi Research and Communications Pvt. Ltd., Noida, Uttar Pradesh, India
| | - Katherine Hay
- Bill & Melinda Gates Foundation Seattle Office, Seattle, Washington, United States of America
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation India Country Office, Delhi, Uttar Pradesh, India
| | - Anita Raj
- Center on Gender Equity and Health (GEH), University of California, San Diego, California, United States of America
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Dehingia N, Dixit A, Atmavilas Y, Chandurkar D, Singh K, Silverman J, Raj A. Unintended pregnancy and maternal health complications: cross-sectional analysis of data from rural Uttar Pradesh, India. BMC Pregnancy Childbirth 2020; 20:188. [PMID: 32228511 PMCID: PMC7106893 DOI: 10.1186/s12884-020-2848-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/28/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND This study aims to explore the potential association between unintended pregnancy and maternal health complications. Secondarily, we test whether antenatal care (ANC) and community health worker (CHW) visits moderate the observed association between unintended pregnancy and maternal health complications. METHODS Cross sectional data were collected using a multistage sampling design to identify women who had a live birth in the last 12 months across 25 highest risk districts of Uttar Pradesh (N = 3659). Participants were surveyed on demographics, unintendedness of last pregnancy, receipt of ANC clinical visits and community outreach during pregnancy, and maternal complications. Regression models described the relations between unintended pregnancy and maternal complications. To determine if receipt of ANC and CHW visits in pregnancy moderated associations between unintended pregnancy and maternal complications, we used the Mantel-Haenzel risk estimation test and stratified logistic models testing interactions of unintended pregnancy and receipt of health services to predict maternal complications. RESULTS Around one-fifth of the women (16.9%) reported that their previous pregnancy was unintended. Logistic regression analyses revealed that unintended pregnancy was significantly associated with maternal complications- pre-eclampsia (AOR:2.06; 95% CI:1.57-2.72), postpartum hemorrhage (AOR:1.46; 95% CI: 1.01-2.13) and postpartum pre-eclampsia (AOR:2.34; 95% CI:1.47-3.72). Results from the Mantel Haenszel test indicated that both ANC and CHW home visit in pregnancy significantly affect the association between unintended pregnancy and postpartum hemorrhage (p < 0.001). CONCLUSION Unintended pregnancy is associated with increased risk for maternal health complications, but provision of ANC clinical visits and CHW home visits in pregnancy may be able to reduce potential effects of unintended pregnancy on maternal health.
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Affiliation(s)
- Nabamallika Dehingia
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego School of Medicine, La Jolla, CA USA
- Joint Doctoral Program in Public Health (Global Health track), University of California San Diego/San Diego State University, San Diego, USA
| | - Anvita Dixit
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego School of Medicine, La Jolla, CA USA
- Joint Doctoral Program in Public Health (Global Health track), University of California San Diego/San Diego State University, San Diego, USA
| | - Yamini Atmavilas
- Bill and Melinda Gates Foundation, 5th Floor, Capital Court, Olof Palme Marg, Munirka, New Delhi, India
| | - Dharmendra Chandurkar
- Sambodhi Research and Communications Pvt. Ltd., C-126, Sector -2, Noida, Uttar Pradesh 201301 India
| | - Kultar Singh
- Sambodhi Research and Communications Pvt. Ltd., C-126, Sector -2, Noida, Uttar Pradesh 201301 India
| | - Jay Silverman
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego School of Medicine, La Jolla, CA USA
| | - Anita Raj
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego School of Medicine, La Jolla, CA USA
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Bhan N, McDougal L, Singh A, Atmavilas Y, Raj A. Access to women physicians and uptake of reproductive, maternal and child health services in India. EClinicalMedicine 2020; 20:100309. [PMID: 32300752 PMCID: PMC7152807 DOI: 10.1016/j.eclinm.2020.100309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Low availability of women physicians in rural areas can compromise women's health care seeking, where need can be greatest. We examined the associations between availability of women physicians and maternal and child health service utilization in India. METHODS We analyzed cross-sectional district-level data from all 256 districts in 18 states, from India's District-Level Household and Facility Survey (2012-13) and the National Family Health Survey (2015-16). Assessed measures included lady medical officers (LMOs) availability at Primary Health Centers (PHCs, which are largely rural serving), modern contraceptive use, antenatal care (ANC), skilled birth attendance (SBA), maternal postnatal care (PNC), infant PNC, and child immunization. Multilevel regression models nesting districts in states examined associations between LMO availability and health service utilization, adjusting for district-level socioeconomic status (SES) indicators (e.g., women's education, household water access), urbanicity, health insurance coverage and sampled PHCs (15 on average) within districts. FINDINGS Only 72 of 256 districts (28.1%) reported >50% of PHCs with LMOs. In multivariable models, LMO availability in PHCs was associated with higher district prevalence (%) of modern contraceptive use [β=0.04 (95% CI: 0.007, 0.08)], 4+ ANC [β =0.07 (95% CI: 0.008, 0.13)], skilled birth attendance [β=0.09 (0.03, 0.14) and maternal PNC [β=0.08 (95% CI: 0.03, 0.12)], but not infant PNC or child immunization. INTERPRETATION Higher district availability of women physicians is associated with higher maternal health care utilization but not child health care utilization. Improving gender parity in the physician workforce and rural women physician access may improve maternal health care use in India.
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Key Words
- ANC, antenatal care
- ANM, Auxiliary Nurse Midwife
- Abbreviations. AHS, Annual Health Survey
- BCG, bacillus Calmette Guerin
- DHS, Demographic and Health Surveys
- DLHS, District level Household and Facility Survey
- DPT, diphtheria pertussis and tetanus
- Female physicians
- Gender equity
- HIC, high income countries
- HMIS, Health Management Information System
- Health workforce
- IIPS, International Institute for Population Sciences
- ILO, International Labor Organization
- IPHS, Indian Public Health Standards
- LHV, lady health visitor
- LMIC, low-and-middle income countries
- LMO, Lady Medical Officer
- Maternal and child health services
- MoHFW, Ministry of Health & Family Welfare
- NFHS, National Family Health Survey
- NHM, National Health Mission
- NHRM, National Rural Health Mission
- NUHM, National Urban Health Mission
- OLS, ordinary least squares
- PHC, Primary Health Center
- PNC, postnatal care
- RMCH, reproductive, maternal and child health
- Women doctors
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Affiliation(s)
- Nandita Bhan
- Center on Gender Equity and Health, University of California, San Diego, CA, United States
- Corresponding author.
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego, CA, United States
| | - Abhishek Singh
- Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India
| | - Yamini Atmavilas
- Gender Equality, India Country Office, Bill & Melinda Gates Foundation, New Delhi, India
| | - Anita Raj
- Division of Social Sciences Director, Center on Gender Equity and Health (GEH), University of California, San Diego, CA, United States
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Walia M, Irani L, Chaudhuri I, Atmavilas Y, Saggurti N. Effect of sharing health messages on antenatal care behavior among women involved in microfinance-based self-help groups in Bihar India. Glob Health Res Policy 2020; 5:3. [PMID: 32055688 PMCID: PMC7006374 DOI: 10.1186/s41256-020-0132-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 02/03/2020] [Indexed: 11/28/2022] Open
Abstract
Background Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors. Methods The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups. Results Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76–13.7, p < 0.05), consumption of iron-folic acid for at least 100 days (ATE = 8.7, 95% CI: 5.0–12.5, p < 0.001) and complete ANC (ATE = 3.6, 95% CI: 2.3–4.9, p < 0.001), when compared to women not exposed to the health intervention. Conclusions The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach’s sustainability needs to be further examined.
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Affiliation(s)
- Monika Walia
- 1Population Council, Zone 5A, Ground Floor India Habitat Centre, Lodi Road, New Delhi, Delhi 110003 India
| | - Laili Irani
- 1Population Council, Zone 5A, Ground Floor India Habitat Centre, Lodi Road, New Delhi, Delhi 110003 India
| | - Indrajit Chaudhuri
- Project Concern International, 38, Okhla Phase 3 Rd, Okhla Phase III, Okhla Industrial Area, New Delhi, Delhi 110020 India
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation, Capital Court, 5th Floor, Olof Palme Marg, Munirka, Delhi India
| | - Niranjan Saggurti
- 1Population Council, Zone 5A, Ground Floor India Habitat Centre, Lodi Road, New Delhi, Delhi 110003 India
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Hazra A, Atmavilas Y, Hay K, Saggurti N, Verma RK, Ahmad J, Kumar S, Mohanan P, Mavalankar D, Irani L. Effects of health behaviour change intervention through women's self-help groups on maternal and newborn health practices and related inequalities in rural india: A quasi-experimental study. EClinicalMedicine 2020; 18:100198. [PMID: 31993574 PMCID: PMC6978187 DOI: 10.1016/j.eclinm.2019.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite the health system efforts, 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 socio-economic 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 difference-in-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, most-marginalised and least-marginalised women. Concentration indices examined the socio-economic 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 check-ups (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 efforts by SHGs through behaviour change communication intervention.
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Affiliation(s)
- Avishek Hazra
- Population Council, New Delhi, India
- Corresponding author. Avishek Hazra, Senior Program Officer, Population Council, Zone 5A, Ground Floor, India Habitat Centre, Lodi Road, New Delhi – 110003, India. Phone: +91 11 24642901/02
| | | | - Katherine Hay
- Bill & Melinda Gates Foundation, Seattle, United States
| | | | | | | | - Sampath Kumar
- Rajiv Gandhi Mahila Vikas Pariyojana, Uttar Pradesh, India
| | - P.S. Mohanan
- Rajiv Gandhi Mahila Vikas Pariyojana, Uttar Pradesh, India
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Carmichael SL, Mehta K, Srikantiah S, Mahapatra T, Chaudhuri I, Balakrishnan R, Chaturvedi S, Raheel H, Borkum E, Trehan S, Weng Y, Kaimal R, Sivasankaran A, Sridharan S, Rotz D, Tarigopula UK, Bhattacharya D, Atmavilas Y, Pepper KT, Rangarajan A, Darmstadt GL. Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India. J Glob Health 2019; 9:0204249. [PMID: 31788233 PMCID: PMC6875677 DOI: 10.7189/jogh.09.020424] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource – especially hard-to-reach – settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes. Methods The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups. Results The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted. Conclusions Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.
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Affiliation(s)
- Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Kala Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | | | | | - Indrajit Chaudhuri
- CARE India, Patna, India.,Current affiliation: Project Concern International, Delhi, India
| | | | | | - Hina Raheel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Evan Borkum
- Mathematica Policy Research, Princeton, New Jersey, USA
| | - Shamik Trehan
- Mathematica Policy Research, Princeton, New Jersey, USA.,Current address: Dr. Reddy's Foundation, Hyderabad, India
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
| | - Rajani Kaimal
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
| | | | | | - Dana Rotz
- Mathematica Policy Research, Princeton, New Jersey, USA
| | | | | | - Yamini Atmavilas
- India Country Office, Bill and Melinda Gates Foundation, Delhi, India
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
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21
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Silverman JG, Boyce SC, Dehingia N, Rao N, Chandurkar D, Nanda P, Hay K, Atmavilas Y, Saggurti N, Raj A. Reproductive coercion in Uttar Pradesh, India: Prevalence and associations with partner violence and reproductive health. SSM Popul Health 2019; 9:100484. [PMID: 31998826 PMCID: PMC6978494 DOI: 10.1016/j.ssmph.2019.100484] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/11/2019] [Accepted: 09/13/2019] [Indexed: 11/23/2022] Open
Abstract
Increasing modern contraceptive use and gender equity are major foci of the recently ratified Sustainable Development Goals for 2030 and the Government of India. Coercion and sabotage by husbands and in-laws to inhibit women's access, initiation, continuation, and successful use of modern contraception methods (i.e., reproductive coercion) may contribute to low usage rates and unintended pregnancy in India; however, little is known about the extent of this problem. The current study assesses the prevalence of reproductive coercion, both husband and in-law perpetrated, among a large population-based sample. Data were collected from currently married women of reproductive age (15–49 years; N = 1770) across 49 districts of Uttar Pradesh as part of an evaluation of a broad effort to improve the public health system in the state. Dependent variables included modern contraceptive use in the past 12 months, unintended pregnancy, and pregnancy termination. Independent variables included ever experiencing reproductive coercion (RC) by a current husband or in-laws and lifetime experience of physical and sexual intimate partner violence (IPV) by a current husband. Approximately 1 in 8 (12%) women reported ever experiencing RC from their current husbands or in-laws; 42% of these women reported RC by husbands only, 48% reported RC by in-laws only, and 10% reported RC by both husbands and in-laws. Among women experiencing RC, more than one-third (36%) reported that their most recent pregnancy was unintended; these women had 4 to 5 times greater odds of unintended pregnancy and a more than 5 times decreased likelihood of recent use of modern contraceptives than women not experiencing RC, after accounting for effects of demographics and physical and sexual IPV. Scalable and sustainable interventions in both clinical and community settings are needed to reduce RC, a potentially key factor in effective strategies for improving women's reproductive autonomy and health in India and globally. 1 in 8 women in Uttar Pradesh report reproductive coercion from husbands or in-laws. Husbands and in-laws were responsible for RC in similar measure (42% and 48%). Experiencing RC related to 4–5x greater odds of recent unintended pregnancy. Experiencing RC related to 5x decreased odds of recent contraceptive use. Reducing RC is key to improving women's reproductive autonomy and health.
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Affiliation(s)
- Jay G Silverman
- Center on Gender Equity and Health, Division of Global Public Health, University of California San Diego School of Medicine, La Jolla CA, USA
| | - Sabrina C Boyce
- Center on Gender Equity and Health, Division of Global Public Health, University of California San Diego School of Medicine, La Jolla CA, USA
| | | | - Namratha Rao
- Center on Gender Equity and Health, Division of Global Public Health, University of California San Diego School of Medicine, La Jolla CA, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation in New Delhi, India
| | - Katherine Hay
- Bill and Melinda Gates Foundation in Seattle, WA, USA
| | | | | | - Anita Raj
- Center on Gender Equity and Health, Division of Global Public Health, University of California San Diego School of Medicine, La Jolla CA, USA
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22
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Patel SK, Mukherjee S, Mahapatra B, Battala M, Jayaram M, Kumta S, Atmavilas Y, Saggurti N. Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey. PLoS One 2019; 14:e0223961. [PMID: 31639161 PMCID: PMC6804955 DOI: 10.1371/journal.pone.0223961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/02/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India. Data and methods This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment. Results There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5–4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs. Conclusions Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.
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Affiliation(s)
| | | | | | | | | | - Sameer Kumta
- Bill & Melinda Gates Foundation, New Delhi, India
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23
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Carmichael SL, Mehta K, Raheel H, Srikantiah S, Chaudhuri I, Trehan S, Mohanty S, Borkum E, Mahapatra T, Weng Y, Kaimal R, Sivasankaran A, Sridharan S, Rotz D, Tarigopula UK, Bhattacharya D, Atmavilas Y, Munar W, Rangarajan A, Darmstadt GL. Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India. BMJ Glob Health 2019; 4:e001146. [PMID: 31543982 PMCID: PMC6730593 DOI: 10.1136/bmjgh-2018-001146] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/29/2019] [Accepted: 06/01/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction We evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition. Methods This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year. Results The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial’s goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning. Conclusion Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW–beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes. Trial registration number NCT03406221
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Affiliation(s)
- Suzan L Carmichael
- Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Kala Mehta
- Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Hina Raheel
- Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | - Evan Borkum
- Mathematica Policy Research, Princeton, New Jersey, USA
| | | | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
| | - Rajani Kaimal
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
| | | | | | - Dana Rotz
- Mathematica Policy Research, Princeton, New Jersey, USA
| | | | | | | | - Wolfgang Munar
- Department of Global Health at the George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | | | - Gary L Darmstadt
- Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
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24
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Dandona R, Kumar GA, Bhattacharya D, Akbar M, Atmavilas Y, Nanda P, Dandona L. Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar. BMC Med 2019; 17:140. [PMID: 31319860 PMCID: PMC6639919 DOI: 10.1186/s12916-019-1372-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/18/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. METHODS Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. RESULTS The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days. CONCLUSIONS To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.
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Affiliation(s)
- Rakhi Dandona
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India. .,Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA.
| | - G Anil Kumar
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India
| | | | - Md Akbar
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Priya Nanda
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Lalit Dandona
- Public Health Foundation of India, Sector 44, Institutional Area, Gurugram, National Capital Region, India.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
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25
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Saggurti N, Porwal A, Atmavilas Y, Walia M, Das R, Irani L. Effect of behavioral change intervention around new-born care practices among most marginalized women in self-help groups in rural India: analyses of three cross-sectional surveys between 2013 and 2016. J Perinatol 2019; 39:990-999. [PMID: 30940930 PMCID: PMC6760593 DOI: 10.1038/s41372-019-0358-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 02/13/2019] [Accepted: 03/01/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effects of new-born care intervention through self-help groups in improving new-born healthcare practices in rural India. METHODS A quasi-experimental design was used to evaluate behavioral change intervention integrated in >25,000 microfinance-based self-help groups in rural Bihar. Three rounds of cross-sectional surveys were conducted to understand the impact of intervention on new-born healthcare practices by talking to women who delivered a baby in the last 6 months. RESULTS Intervention groups showed greater improvement than control groups in the timely initiation of breastfeeding (adjusted odds ratio (AOR) = 6.3, 95% CI: 2.8, 14.3), exclusive breastfeeding on day 1 (AOR = 4.3, 95% CI: 1.9, 9.9), initiation of skin-to-skin care (AOR = 1.9, CI: 1.0, 3.8), and delayed bathing (AOR = 2.8, 95% CI: 1.4, 5.9) with greater effect of on home deliveries where clinical care is often absent. CONCLUSION Sharing messages on appropriate new-born practices through self-help groups improve new-born care practices.
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26
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Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, Raven J, Shabalala F, Fielding-Miller R, Dey A, Dehingia N, Morgan R, Atmavilas Y, Saggurti N, Yore J, Blokhina E, Huque R, Barasa E, Bhan N, Kharel C, Silverman JG, Raj A. Disrupting gender norms in health systems: making the case for change. Lancet 2019; 393:2535-2549. [PMID: 31155270 PMCID: PMC7233290 DOI: 10.1016/s0140-6736(19)30648-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022]
Abstract
Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.
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Affiliation(s)
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Valerie Percival
- Norman Paterson School of International Affairs, Carleton University, Ottawa, ON Canada
| | - Sarah Henry
- Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Jeni Klugman
- Georgetown Institute for Women, Peace and Security, Georgetown University, Washington, DC, USA; Women and Public Policy Program, Harvard Kennedy School, Cambridge, MA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Rebecca Fielding-Miller
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Arnab Dey
- Sambodhi Research & Communications, Noida, Uttar Pradesh, India
| | | | - Rosemary Morgan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | | | | | - Jennifer Yore
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Elena Blokhina
- Vladman Institute of Pharmacology, Department of Psychiatry, First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | | | - Edwine Barasa
- Kemri-Wellcome Trust, Kenya Research Programme, Nairobi, Kenya
| | - Nandita Bhan
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Jay G Silverman
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA.
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27
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Singh A, Kumar K, McDougal L, Silverman JG, Atmavilas Y, Gupta R, Raj A. Does owning a bank account improve reproductive and maternal health services utilization and behavior in India? Evidence from the National Family Health Survey 2015-16. SSM Popul Health 2019; 7:100396. [PMID: 31016224 PMCID: PMC6468192 DOI: 10.1016/j.ssmph.2019.100396] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/05/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022] Open
Abstract
Ownership of a bank account is associated with improved reproductive and maternal health services utilization and behaviour. Observed associations are strongest in states where the utilization of studied services is far below the national average. No association is found between women's ownership of a bank account and institutional delivery.
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Affiliation(s)
- Abhishek Singh
- International Institute for Population Sciences, Mumbai, India
| | | | - Lotus McDougal
- Center on Gender Equity and Health, University of California San Diego, San Diego, USA
| | - Jay G Silverman
- Center on Gender Equity and Health, University of California San Diego, San Diego, USA
| | | | - Raksha Gupta
- International Institute for Population Sciences, Mumbai, India
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, San Diego, USA
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28
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Mahapatra B, Bhattacharya R, Atmavilas Y, Saggurti N. Measuring vulnerability among female sex workers in India using a multidimensional framework. PLoS One 2018; 13:e0204055. [PMID: 30252879 PMCID: PMC6155505 DOI: 10.1371/journal.pone.0204055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/31/2018] [Indexed: 11/18/2022] Open
Abstract
Measuring vulnerability and identifying determinants of vulnerability are key to designing interventions for marginalized groups like sex workers. The current study introduces a new approach of measuring vulnerability among female sex workers (FSWs) by adopting a multidimensional poverty measurement framework. A multidimensional vulnerability index was created from four dimensions and 16 indicators using a dual cut-off approach. The study found that 55% of FSWs were multidimensionally vulnerable with 48% of intensity in vulnerability. The overall value of multidimensional vulnerability index was 0.265. FSWs in Maharashtra were most vulnerable (82%). Lack of financial security contributed mostly to FSWs’ vulnerability. Further, compared to less vulnerable FSWs, multidimensionally vulnerable ones were more to engage in behaviors that put them at risk such as inconsistent use of condoms with clients, alcohol consumption, engaging in anal sex with clients and experiencing sexually transmitted infections. Findings suggest that structural, social and financial vulnerabilities of FSWs need to be addressed concurrently.
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Affiliation(s)
| | - Ruchira Bhattacharya
- Population Council, Zone 5A, India Habitat Center, New Delhi, India
- National Institute of Rural Development and Panchayati Raj, Rajendranagar Mandal, Hyderabad, India
| | - Yamini Atmavilas
- Bill & Melinda Gates Foundation, The Capital Court, New Delhi, India
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29
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Dhar D, McDougal L, Hay K, Atmavilas Y, Silverman J, Triplett D, Raj A. Associations between intimate partner violence and reproductive and maternal health outcomes in Bihar, India: a cross-sectional study. Reprod Health 2018; 15:109. [PMID: 29921276 PMCID: PMC6009820 DOI: 10.1186/s12978-018-0551-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 06/06/2018] [Indexed: 01/24/2023] Open
Abstract
Background Bihar, India has higher rates of intimate partner violence (IPV) and maternal and infant mortality relative to India as a whole. This study assesses whether IPV is associated with poor reproductive and maternal health outcomes, as well as whether poverty exacerbates any observed associations, among women who gave birth in the preceding 23 months in Bihar, India. Methods A cross-sectional analysis of data from a representative household sample of mothers of children 0–23 months old in Bihar, India (N = 13,803) was conducted. Associations between lifetime IPV (physical and/or sexual violence) and poor reproductive health outcomes ever (miscarriage, stillbirth, and abortion) as well as maternal complications for the index pregnancy (early and/or prolonged labor complications, other complications during pregnancy or delivery) were assessed using multivariable logistic regression, adjusting for demographics and fertility history of the mother. Models were then stratified by wealth index to determine whether observed associations were stronger for poorer versus wealthier women. Results IPV was reported by 45% of women in the sample. A history of miscarriage, stillbirth, and abortion was reported by 8.7, 4.6, and 1.3% of the sample, respectively. More than one in 10 women (10.7%) reported labor complications during the last pregnancy, and 16.3% reported other complications during pregnancy or delivery. Adjusted regressions revealed significant associations between IPV and miscarriage (AOR = 1.35, 95% CI = 1.11–1.65) and stillbirth (AOR = 1.36, 95% CI = 1.02–1.82) ever, as well as with labor complications (AOR = 1.27, 95% CI = 1.04–1.54) and other pregnancy/delivery complications (AOR = 1.68, 95% CI = 1.42–1.99). Women in the poorest quartile (Quartile 1) saw no associations between IPV and miscarriage (Quartile 1 AOR = 0.98, 95% CI = 0.67–1.45) or stillbirth (Quartile 1 AOR = 1.17, 95% CI = 0.69–1.98), whereas women in the higher wealth quartile (Quartile 3) did see associations between IPV and miscarriage (Quartile 3 AOR = 1.55, 95% CI = 1.07, 2.25) and stillbirth (Quartile 3 AOR = 1.79, 95% CI = 1.04, 3.08). Discussion IPV is highly prevalent in Bihar and is associated with increased risk for miscarriage, stillbirth, and maternal health complications. Associations between IPV and miscarriage and stillbirth do not hold true for the poorest women, possibly because other risks attached to poverty and deprivation may be greater contributors.
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Affiliation(s)
- Diva Dhar
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, San Diego, CA, 92093-0507, USA
| | | | | | - Jay Silverman
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, San Diego, CA, 92093-0507, USA
| | - Daniel Triplett
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, San Diego, CA, 92093-0507, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, San Diego, CA, 92093-0507, USA.
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30
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Vilms RJ, McDougal L, Atmavilas Y, Hay K, Triplett DP, Silverman J, Raj A. Gender inequities in curative and preventive health care use among infants in Bihar, India. J Glob Health 2018; 7:020402. [PMID: 28959437 PMCID: PMC5592115 DOI: 10.7189/jogh.07.020402] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background India has the highest rate of excess female infant deaths in the world. Studies with decade-old data suggest gender inequities in infant health care seeking, but little new large-scale research has examined this issue. We assessed differences in health care utilization by sex of the child, using 2014 data for Bihar, India. Methods This was a cross-sectional analysis of statewide representative survey data collected for a non-blinded maternal and child health evaluation study. Participants included mothers of living singleton infants (n = 11 570). Sex was the main exposure. Outcomes included neonatal illness, care seeking for neonatal illness, hospitalization, facility-based postnatal visits, immunizations, and postnatal home visits by frontline workers. Analyses were conducted via multiple logistic regression with survey weights. Findings The estimated infant sex ratio was 863 females per 1000 males. Females had lower rates of reported neonatal illness (odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.6–0.9) and hospitalization during infancy (OR = 0.4, 95% CI = 0.3–0.6). Girl neonates had a significantly lower odds of receiving care if ill (80.6% vs 89.1%; OR = 0.5; 95% CI = 0.3–0.8) and lower odds of having a postnatal checkup visit within one month of birth (5.4% vs 7.3%; OR = 0.7, 95% CI = 0.6–0.9). The gender inequity in care seeking was more profound at lower wealth and higher numbers of siblings. Gender differences in immunization and frontline worker visits were not seen. Interpretation Girls in Bihar have lower odds than boys of receiving facility–based curative and preventive care, and this inequity may partially explain the persistent sex ratio imbalance and excess female mortality. Frontline worker home visits may offer a means of helping better support care for girls.
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Affiliation(s)
- Rohan J Vilms
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
| | | | | | - Daniel P Triplett
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Jay Silverman
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
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Boyce SC, McDougal L, Silverman JG, Atmavilas Y, Dhar D, Hay K, Raj A. Associations of intimate partner violence with postnatal health practices in Bihar, India. BMC Pregnancy Childbirth 2017; 17:398. [PMID: 29187158 PMCID: PMC5706152 DOI: 10.1186/s12884-017-1577-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 11/15/2017] [Indexed: 11/12/2022] Open
Abstract
Background Reducing neonatal mortality is a global priority, and improvements in postnatal health (PNH) practices in India are needed to do so. Intimate partner violence (IPV) may be associated with PNH practices, but little research has assessed this relationship. Methods A cross-sectional analysis of data from a representative household sample of mothers of neonates 0–11 months old in Bihar, India was conducted. The relationship between lifetime IPV experience (physical violence only, sexual violence only, or both physical and sexual violence) and PNH practices [clean cord care, kangaroo mother care, early initiation of breastfeeding (EIBF), delayed bathing, receipt of a postnatal care visit, exclusive breastfeeding, and current post-partum contraceptive use] was assessed using multivariate logistic regression. Results Over 45% of the 10,469 mothers experienced IPV in their lifetime. The three types of IPV experiences differentially related to PNH practices. Adjusted analyses revealed that compared to those who had never experienced IPV, women who experienced physical violence only (29.0%) had higher odds of skin-to-skin care (AOR = 1.67, 95% CI = 1.42, 1.96) and delayed bathing (AOR = 1.19, 95% CI = 1.03, 1.37), but lower odds of EIBF (AOR = 0.81, 95% CI = 0.70, 0.93) and exclusive breastfeeding (AOR = 0.83, 95% CI = 0.71, 0.96). Mothers who had experienced sexual violence only (2.3%) had lower odds of practicing EIBF (AOR = 0.52, 95% CI = 0.36, 0.76). Those who had both experiences of physical and sexual violence (14.0%) had increased odds of postpartum modern contraceptive use (AOR = 1.35, 95% CI = 1.07, 1.71) and lower odds of delayed bathing (AOR = 0.76, 95% CI = 0.63, 0.91). Conclusions The results of this study found differing patterns of vulnerability to poor PNH practices depending on the type of IPV experienced. Efforts to increase access to health services for women experiencing IPV and to integrate IPV intervention into such service may increase PNH practices, and as a result, reduce neonatal mortality.
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Affiliation(s)
- Sabrina C Boyce
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - Jay G Silverman
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
| | | | - Diva Dhar
- Bill and Melinda Gates Foundation, New Delhi, India
| | | | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA.
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McDougal L, Atmavilas Y, Hay K, Silverman JG, Tarigopula UK, Raj A. Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India. PLoS One 2017; 12:e0171002. [PMID: 28146586 PMCID: PMC5287473 DOI: 10.1371/journal.pone.0171002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/13/2017] [Indexed: 12/31/2022] Open
Abstract
Background Improvements in continuum of care (CoC) utilization are needed to address inadequate reductions in neonatal and infant mortality in India and elsewhere. This study examines the effect of Ananya, a health system training and community outreach intervention, on reproductive, maternal and newborn health continuum of care (RMNH CoC) utilization in Bihar, India, and explores whether that effect is moderated by gender equity factors (child marriage, restricted mobility and low decision-making control). Methods A two-armed quasi-experimental design compared districts in Bihar that did/did not implement Ananya. Cross-sections of married women aged 15–49 with a 0–5 month old child were surveyed at baseline and two year follow-up (baseline n = 7191 and follow-up n = 6143; response rates 88.9% and 90.7%, respectively). Difference-in-difference analyses assessed program impact on RMNH CoC co-coverage, defined by 9 health services/behaviors for the index pregnancy (e.g., antenatal care, skin-to-skin care). Three-way interactions assessed gender equity as a moderator of Ananya’s impact. Findings Participants reported low RMNH CoC co-coverage at baseline (on average 3.2 and 3.0 of the 9 RMNH services/behaviors for Ananya and control groups, respectively). The Ananya group showed a significantly greater increase in RMNH CoC co-coverage (.41 services) compared with the control group over time (p<0.001), with the primary drivers being increases in clean cord care, skin-to-skin care and postpartum contraceptive use. Gender equity interaction analyses revealed diminished intervention effects on antenatal care, skilled birth attendance and exclusive breastfeeding for women married as minors. Conclusion Ananya improved RMNH CoC co-coverage among these recent mothers, largely through positive health behavior changes. Child marriage attenuated Ananya’s impact on utilization of key health services and behaviors. Supporting the health system with training and community outreach can be beneficial to RMNH CoC utilization; additional support is needed to adequately address the unique issues faced by women married as minors.
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Affiliation(s)
- Lotus McDougal
- Center on Gender Equity and Health, Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, United States of America
| | | | | | - Jay G Silverman
- Center on Gender Equity and Health, Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, United States of America
| | | | - Anita Raj
- Center on Gender Equity and Health, Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, United States of America
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