Study Design and Study Setting
This paper uses secondary data collected from 17,232 women from an Integrated microfinance and health literacy (IMFHL) program that was implemented in rural Uttar Pradesh India between 2012 and 2017. The program aimed to provide low-income women with maternal and newborn health literacy delivered through a microfinance platform (38,48). Under the program, a quasi-experimental survey design was used to collect cross-sectional survey data in two rounds (round 1 in 2015; round 2 in 2017) to evaluate the program’s impact on knowledge and health behaviours of women during pregnancy, delivery and post-delivery in Uttar Pradesh(38,48).
Program Context
The IMFHL program was implemented by a consortium comprising of Public Health Foundation of India (PHFI), Population Council (PC), Boston University (BU), and Rajiv Gandhi Mahila Vikas Pariyojan (RGMVP) but funded by the Bill and Melinda Gates Foundation (BMGF) (44).
The IMFHL program was a community-driven and rapidly scalable program that integrated health promotion activities in a microfinance platform that targeted women in low-income rural households across low developmental districts of UP (38,44). The health promotion component sought to address community-related barriers mainly related to low health literacy and poverty and to encourage women to adopt preventive health behaviours known to reduce maternal and neonatal mortality (38,44). The IMFHL program was built on previous participatory community programs such as the Makwanpur trial in Nepal and the Shivgarh trial in Uttar Pradesh that showed a reduction in maternal and newborn mortality achieved through the adoption of essential maternal and newborn care practices in households (29,52). Under the IMFHL program, the maternal health literacy component targeted eligible women at different stages of their pregnancy and provided them with information to recognise pregnancy-related complication signs in order to reduce delays in seeking care from a health facility in the event of any pregnancy-related complication (38,44).
IMFHL Program: Intervention and Comparison of Block
Under the IMFHL program, implementation districts were selected comprising high maternal and neonatal mortality burden with a higher percentage of scheduled caste (SC)/tribe (ST)[1] and low literacy (38,44). RGMVP selected 120 intervention blocks where health intervention was delivered through SHGs based on their operational principles. RGMVP separately identified 83 comparison blocks, roughly matched to the intervention blocks as per the percentage of SC/ST (38,44), where only SHGs were established. Additionally, pure control blocks that received no SHG or health intervention were selected to assess secular change in health indicators in rural Uttar Pradesh. Women in villages were identified for membership by RGMVP using a community participatory approach and inclusion criteria that sought to identify the most disadvantaged households often represented by landless poor households with low literacy, lower social class (and caste) with multiple (social) deprivations (38,44). In these villages, one woman from an eligible household was allowed with other eligible women in the same village to join SHGs that were nurtured by RGMVP’s field staff. Non-participating households were poor households in the same program villages that would not be facing similar credit constraints as poorer households from lower castes, therefore not targeted by the SHG program for membership (38,44).
A SHG member, trained as a health volunteer, facilitated health discussions involving pregnant and recently delivered women using various program strategies such as an invitation to SHG meetings, sending letters to pregnant and new mothers with key health messages, and reinforcing messages through house visits, and exposure to community health video shows developed by the program (38,44). Furthermore, the IMFHL program created three apparent groups of beneficiaries. The baseline tier was composed of pregnant women in SHG member households that received health messages directly through program strategies (IMFHL intervention group). Since villages are comprised of member and non-member households living in close proximity and communicating with each other, a process of community-based diffusion in knowledge sharing was expected from SHG plus Health (IMFHL intervention group) to tier I and to tier II households respectively to hopefully supplement direct program intervention efforts as depicted in Figure 2.
[1]A member from a community designated by the Indian Government to have historically faced ‘extreme social, educational and economic backwardness arising out of the traditional practice of untouchability' and afforded legislative protection and entitlements (54)
Diffusion of knowledge was expected to occur in SHG program villages through a process of collective socialisation in which better health aware SHG members serve as role models and help other non-members internalise biomedical norms around pregnancy and childbirth (30-41). This research examined the above-stated assumption to determine if the SHG platform encourages the sharing of health information from members receiving health literacy to non-members
Survey Sampling Approach and Study Population
Sampling Strategy
While UP is administratively subdivided into 75 districts, 822 blocks and 98,000 Gram panchayats (GP) with a total population nearing 200 million(53), the IMFHL program was implemented in only 203 blocks (38,44). However, the survey data from 70 blocks in 20 districts were collected to stand as a representative sample from the SHG program’s coverage area (38,44). In India, GPs are the smallest unit of administration within blocks where SHGs were established. Where data were collected, a GP may be classified as a larger main village with smaller peripheral villages attached to it and may have fewer houses attached as hamlets. The surveys followed a three-stage sampling approach for selecting blocks, GPs and finally, households, based on the state’s administrative hierarchy, and as depicted in Figure 2 below.
The IMFHL program collected data in both rounds from three types of blocks, depending on the IMFHL program exposure: i) intervention blocks where households received health intervention through SHG program, ii) comparison blocks where households received SHG program only, and iii) pure control blocks where households did not receive any program exposure reflecting the natural change in health indicators. While the IMFHL program used SHGs in both intervention and comparison blocks, only households in intervention blocks received additional health intervention (see Figure 3). Moreover, both intervention and comparison blocks had SHG membership of similar duration (average duration of 18 months).
In the first stage, the intervention (SHG plus health) blocks were first arranged in ascending order of their associated percentage of Scheduled Caste (SC) and Scheduled Tribe (ST) population (SC/ST), a critical parameter for development (54). The required number of intervention blocks were then equally selected by random sampling within each SC/ST-based stratum (38,44). Comparison (SHG only) blocks were selected within the same district (or from a geographically adjacent district if comparison block were not available in the same district) to reduce the effect of socio-cultural diversity between study blocks (38,44). Although comparison blocks comprised of roughly similar proportions of SC/ST as intervention blocks, these comparison blocks were, however, not one-to-one matched pairs and were selected independently of the intervention blocks (38,44). The average proportion of SC/ST population in the intervention and comparison blocks were similar (45 per cent and 44 per cent). Lastly, pure control blocks (no SHG and no health intervention) were also selected based on block percentage of SC/ST as the criterion for matching with intervention and comparison blocks in the same districts (38,44).
In the second stage, Gram Panchayats (GPs) were selected within comparison and intervention blocks as per SHG population coverage, and village population size in pure control blocks as no SHGs were established in these blocks (38,44). In intervention and comparison blocks where SHGs had been established, GP’s were drawn in equal numbers from three strata of SHG coverage: 5-15 per cent, 16-30 per cent and 30-60 per cent. Outlier GPs with coverage of SHGs < 5 per cent and > 60 percent were excluded (43,51). Whereas GPs in pure control blocks (no SHG, no health) were selected based on GP population size and with a similar proportion of main village and hamlets as comparison arm (with SHG, no health intervention) to ensure similar population characteristics in these villages (38,44)
In the final stage, households were selected from all three categories of blocks following a house listing and mapping exercise to develop a sampling frame to identify the eligible woman in intervention and comparison block (38,44). While eligible women in SHG member and non-member households were selected in intervention and comparison blocks, only eligible women from non-member households were selected in pure control blocks (38,44). The listing and mapping exercise in intervention and comparison blocks showed that the number of SHG households with an eligible woman was almost equal to the sample size requirement; therefore, all SHG households with eligible women were selected for an interview in these blocks (38,44).
As SHG programs enrol one member from each household only, each individual woman in the survey represents a household. If more than one eligible woman was found in a household, a random procedure was used to select the eligible respondent (38,44). Furthermore, the house listing and mapping exercise in pure control blocks also provided a sampling frame to select non-member households following a systematic random sampling (38,44).
In the successive survey rounds, data was collected from the same GPs, but not the same households or women (38,44). Furthermore, as the survey used different selection criteria at the higher level (stratified and matched block selection using SC/ST) and at a lower level (stratified GP selection based on population coverage by SHGs members and non-members), this survey analyses all eligible women in households across the sampled GPs.
Diffusion of knowledge was expected to occur in SHG program villages through a process of collective socialisation in which better health aware SHG members serve as role models and help other non-members internalise biomedical norms around pregnancy and childbirth (30-41). This research examined the above-stated assumption to determine if the SHG platform encourages the sharing of health information from members receiving health literacy to non-members
Survey Sampling Approach and Study Population
Sampling Strategy
While UP is administratively subdivided into 75 districts, 822 blocks and 98,000 Gram panchayats (GP) with a total population nearing 200 million(53), the IMFHL program was implemented in only 203 blocks (38,44). However, the survey data from 70 blocks in 20 districts were collected to stand as a representative sample from the SHG program’s coverage area (38,44). In India, GPs are the smallest unit of administration within blocks where SHGs were established. Where data were collected, a GP may be classified as a larger main village with smaller peripheral villages attached to it and may have fewer houses attached as hamlets. The surveys followed a three-stage sampling approach for selecting blocks, GPs and finally, households, based on the state’s administrative hierarchy, and as depicted in Figure 2 below.
The IMFHL program collected data in both rounds from three types of blocks, depending on the IMFHL program exposure: i) intervention blocks where households received health intervention through SHG program, ii) comparison blocks where households received SHG program only, and iii) pure control blocks where households did not receive any program exposure reflecting the natural change in health indicators. While the IMFHL program used SHGs in both intervention and comparison blocks, only households in intervention blocks received additional health intervention (see Figure 3). Moreover, both intervention and comparison blocks had SHG membership of similar duration (average duration of 18 months).
In the first stage, the intervention (SHG plus health) blocks were first arranged in ascending order of their associated percentage of Scheduled Caste (SC) and Scheduled Tribe (ST) population (SC/ST), a critical parameter for development (54). The required number of intervention blocks were then equally selected by random sampling within each SC/ST-based stratum (38,44). Comparison (SHG only) blocks were selected within the same district (or from a geographically adjacent district if comparison block were not available in the same district) to reduce the effect of socio-cultural diversity between study blocks (38,44). Although comparison blocks comprised of roughly similar proportions of SC/ST as intervention blocks, these comparison blocks were, however, not one-to-one matched pairs and were selected independently of the intervention blocks (38,44). The average proportion of SC/ST population in the intervention and comparison blocks were similar (45 per cent and 44 per cent). Lastly, pure control blocks (no SHG and no health intervention) were also selected based on block percentage of SC/ST as the criterion for matching with intervention and comparison blocks in the same districts (38,44).
In the second stage, Gram Panchayats (GPs) were selected within comparison and intervention blocks as per SHG population coverage, and village population size in pure control blocks as no SHGs were established in these blocks (38,44). In intervention and comparison blocks where SHGs had been established, GP’s were drawn in equal numbers from three strata of SHG coverage: 5-15 per cent, 16-30 per cent and 30-60 per cent. Outlier GPs with coverage of SHGs < 5 per cent and > 60 percent were excluded (43,51). Whereas GPs in pure control blocks (no SHG, no health) were selected based on GP population size and with a similar proportion of main village and hamlets as comparison arm (with SHG, no health intervention) to ensure similar population characteristics in these villages (38,44)
In the final stage, households were selected from all three categories of blocks following a house listing and mapping exercise to develop a sampling frame to identify the eligible woman in intervention and comparison block (38,44). While eligible women in SHG member and non-member households were selected in intervention and comparison blocks, only eligible women from non-member households were selected in pure control blocks (38,44). The listing and mapping exercise in intervention and comparison blocks showed that the number of SHG households with an eligible woman was almost equal to the sample size requirement; therefore, all SHG households with eligible women were selected for an interview in these blocks (38,44).
As SHG programs enrol one member from each household only, each individual woman in the survey represents a household. If more than one eligible woman was found in a household, a random procedure was used to select the eligible respondent (38,44). Furthermore, the house listing and mapping exercise in pure control blocks also provided a sampling frame to select non-member households following a systematic random sampling (38,44).
In the successive survey rounds, data was collected from the same GPs, but not the same households or women (38,44). Furthermore, as the survey used different selection criteria at the higher level (stratified and matched block selection using SC/ST) and at a lower level (stratified GP selection based on population coverage by SHGs members and non-members), this survey analyses all eligible women in households across the sampled GPs.
Table 1: Knowledge about Maternal Danger Signs of Obstetric Complications Among Women (Aged 15-49) during their last pregnancy.
|
Study Population (N=17,232)
|
Sl.no
|
Danger signs in Pregnancy/ Delivery & Post Delivery
|
Non-member Households
|
SHG Households
|
|
|
10,088
(59%)
|
7,144
(41%)
|
1
|
During Pregnancy
|
|
|
|
1. Severe headache /High blood pressure
|
964(10%)
|
656(9%)
|
|
2. Blurred vision/Convulsions
|
412(4%)
|
267(4%)
|
|
3. Absence or /less movements of foetus
|
478(5%)
|
376(5%)
|
2.
|
During Labour and Delivery
|
|
|
|
4. Prolonged labour over 12 hours
|
181(2%)
|
129(2%)
|
|
5. Excessive vaginal bleeding
|
1,076(11%)
|
1,037(15%)
|
|
6. Delay in placental expulsion/Retained placenta
|
49(1%)
|
23(1%)
|
|
7. Severe abdominal pain
|
3,732(37%)
|
2,325(33%)
|
|
8. Rupture uterus
|
81(1%)
|
59(1%)
|
|
9. Baby in abnormal position
|
730(7%)
|
606(8%)
|
|
10. Cord prolapsed/Baby’s hand & feet coming out first
|
35(1%)
|
29(1%)
|
|
11. Cord around neck
|
40 (1%)
|
27 (1%)
|
3
|
Post-partum
|
|
|
|
12. High fever
|
569 (6%)
|
384 (5%)
|
|
13. Foul-smelling vaginal discharge
|
311 (3%)
|
319 (4%)
|
|
14. Other (specify)
|
177 (2%)
|
145 (2%)
|
|
15. Do not know
|
1253 (12%)
|
762 (11%)
|
4.
|
Knowledge of Danger Signs across phases
|
|
|
|
No knowledge of any danger signs
|
1,325 (13%)
|
809 (11%)
|
|
Knowledge of danger levels in at least 1 phase
|
346 (3%)
|
220 (3%)
|
|
Knowledge of danger levels in at least 2 phases
|
1,493 (15%)
|
873 (12%)
|
|
Knowledge of danger levels in all 3 phases
|
6,924 (69%)
|
5,242 (73%)
|
Note: Recalls under 1 per cent have been rounded to 1%, the total, therefore, may be > 100%
A detail list of the knowledge of all danger signs that were retrospectively collected from eligible women is provided in Table 1, which shows the frequency and percentage of danger signs across different phases of pregnancy/delivery and 42 days post-partum. The table, categorised across member and non-member households showed that most women (37 per cent) recalled severe abdominal pain, while only a minority (1 per cent) recalled danger signs related to placental expulsion or umbilical cord issues. Moreover, the distribution of danger signs showed that women were more likely to recall those danger signs that occurred in the pregnancy and delivery period as compared to the post-partum period. The Table 1 also shows that across member and non-member households, the majority (>69 per cent) of women knew danger signs in all three phases of pregnancy, delivery and post-delivery with only a minority (<15 per cent) of all women reporting no knowledge.
Table 2 presents the summary statistics of the explanatory variables for eligible women categorised across (SHG) member and non-member households that capture all type of households’ program exposure and associated characteristics and relevant factors (individual and community levels).
The sampled women in this analysis comprised of more women that were non-member (59 per cent) than SHG members. However, an almost equal proportion of women spread across both survey rounds, and a proportionate number of households were allocated within each level of program exposure.
In both groups, eligible women reported a mean parity close to 2.4 reflecting near current Indian fertility rates (median 2.2, range 2.1-4), and among them, close to 50 per cent women experienced an obstetric complication in their last pregnancy/delivery or post-partum period Furthermore, a quarter of all women across both groups reported experiencing a pregnancy loss either due to induced or spontaneous abortion. Although 83 per cent women reported delivering in an institution for their last pregnancy (public or private), only a minority (26 per cent) had received the minimum four antenatal care (ANC) visits in their last pregnancy with all required tests done in the last check-up, that are: urine, blood pressure, weight, abdominal and ultrasound tests. The summary statistics showed that among those women with an institutional delivery, the majority (70 per cent) were discharged within 12 hours after delivery which is less than the recommended 48 hours stay post-delivery for normal deliveries (55). Furthermore, only 10 per cent of total women reported receiving the recommended minimum of three post-natal care visits within the crucial first seven days post-delivery when maternal and neonatal complications commonly occur.
The villages were on average 5.4 kilometres (km) from the closest Primary Health Centre (PHC) and about 1.47 km to the closet town.
The summary statistics reflecting household’s economic status showed that only 16 per cent of women reported they were working to earn in cash or kind at the time of the survey, while almost 45 per cent belonged to households that were living below the poverty line -an income-based measure of household poverty.
Moreover, most women (60 per cent) were living in joint/extended households which is common in rural Uttar Pradesh. Almost 92 per cent of all women identified themselves as being part of Hindu households, the majority religion in Uttar Pradesh and India. Moreover, 45 per cent of women reported belonging to Scheduled Caste and Tribes (SC/ST), a proxy for social margination in the rural Indian content. Women across member and non-member households were comparable in relation to age (mean 26 years), and level of education. While 66 per cent of all women interviewed reported having some level of education, the summary statistics showed that husbands overall were more likely (88 per cent) to have had received some level of schooling. For the dependent variable, knowledge of danger signs in women, most women (70 per cent) had full knowledge of danger signs in all phases of pregnancy/delivery and post-delivery.