Associations between community health workers' home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: A cross-sectional study

Andrea Katryn Blanchard*, Tim Colbourn, Audrey Prost, Banadakoppa Manjappa Ramesh, Shajy Isac, John Anthony, Bidyadhar Dehury, Tanja A.J. Houweling

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Introduction India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent to which exposure to ASHAs' home visits has reduced perinatal health inequalities as intended. This study aimed to examine whether ASHAs' third trimester home visits may have contributed to equitable improvements in institutional delivery and reductions in perinatal mortality rates (PMRs) between women with varying education levels in Uttar Pradesh (UP) state, India. Methods Cross-sectional survey data were collected from a representative sample of 52 615 women who gave birth in the preceding 2 months in rural areas of 25 districts of UP in 2014-2015. We analysed the data using generalised linear modelling to examine the associations between exposure to home visits and education-based inequalities in institutional delivery and PMRs. Results Third trimester home visits were associated with higher institutional delivery rates, in particular public facility delivery rates (adjusted risk ratio (aRR) 1.32, 95% CI 1.30 to 1.34), and to a lesser extent private facility delivery rates (aRR 1.09, 95% CI 1.04 to 1.13), after adjusting for confounders. Associations were stronger among women with lower education levels. Having no compared with any third trimester home visits was associated with higher perinatal mortality (aRR 1.18, 95% CI 1.09 to 1.28). Having any versus no visits was more highly associated with lower perinatal mortality among women with lower education levels than those with the most education, and most notably among public facility births. Conclusions The results suggest that ASHAs' home visits in the third trimester contributed to equitable improvements in institutional deliveries and lower PMRs, particularly within the public sector. Broader strategies must reinforce the role of ASHAs' home visits in reaching the sustainable development goals of improving maternal and newborn health and leaving no one behind.

Original languageEnglish
Article numbere044835
JournalBMJ Open
Volume11
Issue number7
DOIs
Publication statusPublished - 12 Jul 2021

Bibliographical note

Funding Information:
Funding This work was supported by the Bill & Melinda Gates Foundation (OPP1161429). AKB’s time was funded by University College London’s Overseas and Graduate Research Scholarships. TAJH’s time was funded by a Research Excellence Initiative grant from Erasmus University Rotterdam, The Netherlands. The funders had no role in the design of the study, data collection and analysis, planning or writing of the manuscript.

Funding Information:
The government of UP’s branch of the NHM has committed substantial resources towards reducing the burden of maternal and neonatal mortality. In 2013, UP’s NHM programme established a partnership with the India Health Action Trust and the University of Manitoba in Canada, under the auspices of the UP Technical Support Unit, funded by the Bill and Melinda Gates Foundation. This partnership was embedded within UP’s NHM programmes in its 25 high priority districts (HPDs), covering a population of over 83 million people.32 The government chose the HPDs by ranking districts using a composite health index that combined six health indicators from the state’s Annual Health Survey data.33 This study used data from the first round of the UP Technical Support Unit’s community-based, cross-sectional Community Behavioural Tracking Survey (CBTS-1) collected in April 2014 to February 2015, which included 100 blocks (sub-districts) of the 25 HPDs.

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