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


RESULTS
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.


CONCLUSIONS
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.
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.
Lotus
L
McDougal
Bill and Melinda Gates Foundation, New Delhi, India.
Yamini
Y
Atmavilas
Bill and Melinda Gates Foundation, New Delhi, India.
Katherine
K
Hay
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
JG
Silverman
Bill and Melinda Gates Foundation, New Delhi, India.
Usha K
UK
Tarigopula
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
A
Raj
D000293:Adolescent; D000328:Adult; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007194:India; D007223:Infant; D007224:Infant Care; D007231:Infant, Newborn; D008297:Male; D000068097:Maternal Health; D008427:Maternal Health Services; D008875:Middle Aged; D016017:Odds Ratio; D012737:Sex Factors; D012959:Socioeconomic Factors; D055815:Young Adult