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

Date Published: February 1, 2017

Publisher: Public Library of Science

Author(s): Lotus McDougal, Yamini Atmavilas, Katherine Hay, Jay G. Silverman, Usha K. Tarigopula, Anita Raj, Massimo Ciccozzi.


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).

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.

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. 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.

Partial Text

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

Participants were predominantly aged 20–24 years and had no formal education (Table 1). Women had similar characteristics across Ananya and non-Ananya districts at both baseline and follow-up, though at both timepoints, women living in Ananya districts tended to have higher numbers of births (women with 3 or more births = 45.5% vs. 39.7% at baseline, p = 0.004; 43.4% vs. 39.1% at follow-up, p = 0.04). At follow-up, both women and their husbands had a higher prevalence of primary education in Ananya areas vs. non-Ananya areas (28.2% vs. 24.4% for women, p = 0.046; 37.4% vs. 32.2% for husbands, p = 0.01), though secondary education in Ananya vs. non-Ananya areas was less prevalent for husbands, and marginally less prevalent for women (29.5% vs. 35.5% for husbands, p = 0.02, 18.6% vs. 22.5% for women, p = 0.06). At follow-up, a greater proportion of women in Ananya areas reported having received at least two FLW visits, a focus of the Ananya intervention, in their last trimester of pregnancy (37.7% vs. 29.2%, p = 0.01). In terms of gender equity among these recent mothers, while there were no significant differences between Ananya and non-Ananya areas at baseline, at follow-up, Ananya areas had significantly more early marriage (51.3% vs. 42.0%, p<0.0001), and more compromised decision-making (excluded from at least one decision: 63.1% vs. 51.6%, p<0.0001). The Ananya program, through its supply- and demand-side interventions for maternal and newborn health, significantly increased RMNH CoC co-coverage among this sample of recent mothers and infants in Bihar. The 0.41 gain in health services/behaviors represents a 13% improvement over baseline attributable to the Ananya program, and is important both because each intervention along this continuum was selected for its demonstrated importance in improving maternal and newborn health and survival, and because this achievement was realized in a population with substantial social and gender inequities. Improving CoC co-coverage is particularly important in this context given its very low level, with less than 5% of participants reporting six or more of the nine assessed behaviors/services at baseline.   Source:


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