Study Aim and Design
This study evaluated the impact of membership in an integrated microfinance and health literacy (IMFHL) program on the practice of birth preparedness and complication readiness (BPCR) by women during their last pregnancy in rural Uttar Pradesh. The study also, evaluated whether the IMFHL program contributed to the adoption of BPCR among women that did not participate in the IMFHL program as SHG members through a process of diffusion of behaviours from member households to neighbouring non-member households in villages where the program was implemented.
The study uses survey data, collected under the IMFHL project in two rounds, capturing the program’s pre-intervention characteristics in round I in 2015 followed by round II of data collection two years into the program in 2017 (58). Under the IMFHL project, a quasi-experimental survey design was used to collect cross-sectional survey data in each round to evaluate the program’s impact on mothers’ knowledge and health behaviours in low-income households in villages across UP (58)
IMFHL Program Context
The IMFHL program integrated a maternal and neonatal health literacy component within a microfinance based SHG platform to provide pregnant and recently delivered women with health messages in rural UP. The program was implemented over five years (2012-2017) through a consortium comprising a technical lead, an implementing partner, a research partner and an evaluation partner(58). A detailed description on IMFHL program context, selection of intervention, comparison and control blocks, is available elsewhere (58).
The design of the health literacy intervention was informed by the three delays framework and from successes of the previous non-microfinance based participatory community health programs such as the Shivgarh trial in UP, and the Makwanpur trial in Nepal (35,52,55). Health messages were directly provided to women by the IMFHL program using various inter-personal communication strategies, such as an invitation to SHG meetings for health discussion; postal letters to pregnant and new mothers with key health messages timed to delivery and neonate care; reinforced messages through house visits; and exposure to community health video shows developed by the program (58).
Woman’s SHG membership was determined when the woman was a SHG member herself or belonged to a household where someone else, usually a mother in law or sister in law, was a SHG member (58). In the latter case, perfect communication was assumed between the family members. These women (SHG members) represented the first tier of beneficiaries who directly received health information from the SHG, encouraging them to adopt desired health behaviours to promote maternal and neonatal health. The IMFHL project investigators also expected health information to reach non-member women in the same village where SHGs were established and health literacy provided. As members and non-members lived in the same village/environment, the IMFHL project investigators postulated that women receiving health information as SHG members would communicate new knowledge to neighbouring non-member households mainly through informal communication networks that would gradually lead to the adoption of desired behaviours. Previous social network analysis studies conducted on the IMFHL program showed that SHG membership increased recently delivered mother’s health advice networks and linkages with community health workers(65). The extent of these social networks in the transfer of health information and practices to non-members is also evaluated in this paper. This diffusion effect of knowledge from members (tier I) to neighbouring non-members (tier II) is depicted in figure 1 below.
Study Setting and Participants
Sampling Procedure
The survey sampling design followed Uttar Pradesh’s administrative hierarchy and collected data from households in gram panchayats (GP) or villages from 70 blocks in 20 districts, aiming for a representative sample from the program’s coverage area (66). Moreover, while the same gram panchayats, blocks and districts, were visited in both survey rounds; different households were sampled and interviewed in each round. A GP is the smallest administrative region in blocks where SHGs were established and from where household survey data was collected. The survey design used a three-stage sampling approach to select survey blocks, GPs or villages and finally, household as depicted in figure 2. A detailed description of the selection strategy is available elsewhere (58).
Sample Size
Different outcome measures were used by the IMFHL project investigators to calculate sample size based on the net increase in health behaviours due to program exposure with an expected response rate of 90 per cent (58). The sample size was estimated considering a net increase of seven percentage point in key reproductive maternal, neonatal and child health indicators (RMNCHN), for example, institutional delivery, the number of antenatal care visits and others, after program implementation with 85 per cent power to detect the change, with the usual 5 per cent level of significance and a design effect of 2 (58). Moreover, in order to detect the diffusion from SHG households to non-member households in program villages, the project investigators also separately determined the sample size based on an estimated five per cent net change in RMNCHN indicators over the two rounds with 80 per cent power, 95 per cent confidence interval, and a design effect of 1.5 (58).
The sample used in this study comprised a total of 17,244 eligible women, of whom 59 per cent or 10,097 women did not belong to SHGs, and 41 per cent or 7,147 women were SHG members. The data was collected at the individual, household and community levels using separate structured questionnaires. The survey collected data from currently married women aged 15 to 49 years who had delivered an infant in the 12 months preceding the survey, and from the household head and village representatives. The interviews were conducted by data collectors trained by evaluation partner who administered interviews in the local language, Hindi, after obtaining verbal informed consent from respondents using computer-assisted personal interview (CAPI) package designed the Census and Survey Processing System (CSPro), a public domain software used for census and survey data (58). As this study sought to capture individual, household and community level influences on BPCR practice among members and non-member women, we customised our study dataset by combining individual-level, household and village levels sub-datasets across rounds to capture the different levels of influence on birth preparedness and complication readiness.
Statistical Analysis
Multivariable logistic regression modelling was used to evaluate the intervention program’s impact on the level of birth preparedness and complication readiness practice among women in rural Uttar Pradesh. The main explanatory variable, IMFHL intervention, was categorised according to four levels of household’s exposure to IMFHL program. Covariates or other confounding variables were chosen based on the broader maternal and child health literature to represent individual, household, and community-level characteristics. Four separate regression models were fitted to the data with the first model (Model I) establishing the program’s main effect without any confounding variables but including the survey round variable. The second model (Model II) included an interaction term (IMFHL intervention by survey round) to draw out the change over time, in the effect of IMFHL program exposure. Confounders related to individual health were included in the Model III, while the full model, Model IV included socio-demographic, economic and area-level variables.
Outcome, explanatory and confounding variables
i. Outcome variable: The outcome variable, birth preparedness and complication readiness (BPCR) practice captured eligible women’s self-reported BPCR steps that were taken during the last pregnancy. A binary variable was constructed with ‘0’ representing partial or no BPCR preparation, and ‘1’ representing complete BPCR defined as when households practised all birth preparedness and complication readiness steps during last pregnancy as outlined by the WHO. In the IMFHL program, women belonging to SHGs in the intervention villages (SHG and health literacy) were provided with the guidance of key steps required for complete BPCR in the pregnancy. The survey collected data from all women on self-recalled steps of BPCR undertaken in the last pregnancy. In both survey rounds, eligible women, independent of the place of delivery, were asked to recall multiple responses to the question “What advance preparation did you/your family members make to manage in case of any pregnancy/delivery complications?”. The interview responses were marked against eight key steps required to fulfil birth and complication readiness such as: ‘Decided on the place of delivery-home or health facility’ ‘Knew the facility that could provide emergency care’; ‘Identified institution where to rush in case of emergency’; ‘Identified people to accompany the woman’, ‘Identified people to take care of children at home’, ‘Saved/arranged money for delivery expense or in case of emergency’, ‘Advance arrangement of transportation to go to the facility’ and ‘others -cloth, soap’. Although individual steps corresponded to either birth preparedness or only complication readiness were practised, complete BPCR was determined when a household followed all steps, in accordance with current WHO guidelines on BPCR. According to WHO, complete BPCR was defined when the woman and household fulfilled all the steps that provided families a greater opportunity for readiness in the event of a maternal emergency.
ii. Main explanatory variable. The exposure variable, the IMFHL intervention, comprised of four levels based on households’ exposure to the IMFHL program. An ordinal variable was created allowing to evaluate the program’s main effect on the practice of BPCR, that is, the magnitude of change in BPCR practice across levels of the IMFHL program exposure: intervention (SHG plus health), comparison (SHG only) and pure control (no SHG, no health) households. The coding of the IMFHL explanatory variable with description is shown below:
- Group 0: Comprised of households that were not SHG members (non-members) and were in villages without any program intervention (pure control households).
- Group 1: Comprised of households that were not SHG members (non-members) but were in program villages where either the SHG program alone or SHG program plus Health intervention was implemented (diffusion-control households).
- Group 2: Comprised of households that were SHG members in program villages where only SHG program was implemented (comparison households).
- Group 3: Comprised of households that were also SHG members but were in villages where both the SHG program and additional health intervention was provided. Only these households received health literacy intervention through the SHG (intervention households).
iii. Additionally, a survey round variable was created to assess the effect of intervention program over time (change in women’s BPCR in round II in 2017 compared to round I in 2015 when the program was yet to be implemented).
iv. Confounding variables: A comprehensive set of confounding variables capturing individual, household and community-level characteristics were identified from previous maternal and child health literature and included in models III and IV. Confounding variables in model III represented eligible woman’s maternal health status and broader maternal health service utilisation indicators such as parity, the experience of pregnancy-related complication in a previous pregnancy, number of previous pregnancy loss, knowledge of minimum ANC visits required, place of last delivery. Additional socio, demographic and area-level characteristics were included in the final Model IV, namely: type of family (nuclear versus joint or extended), religion, household’s social caste, education level of the eligible woman and her husband. Model IV also included a household wealth quintile, constructed for this analysis using Polychoric Principal Component Analysis (PCA), combining all household assets and amenities to evaluate BPCR association across five wealth gradients extending from marginally poor (reference category) to the poorest households.
Summary Results
Table 1 provides results of individual steps undertaken in the study sample towards birth preparedness and complication readiness (BPCR) practice in last pregnancy among women aged 15-49 in rural Uttar Pradesh (n=17,244). Table 1 and Figure 3 reveals, only 24 per cent of all women in this analysis had not practised any steps for birth or complication readiness; however, 76 per cent women had some level of BPCR readiness with 49 per cent had undertaken full BPCR in last pregnancy. Also, 6 per cent of women had taken steps fulfilling only birth preparedness while only 21 per cent of all women had undertaken the three steps required for complication readiness.
Table 2 presents the summary results for eligible women categorised across (SHG) member and non-member households across all variables used in this paper. The study sample comprised of more women from non-member households (59 per cent) but with an equal allocation of households within various levels of IMFHL program exposure levels. Surveyed women had a mean parity of 2·4(median 2, range 0-9) which similar as in rural UP, but, it is higher than the current Indian fertility rate (median = 2·2, range: 2·1 - 4)(44). Moreover, close to 48 per cent of all women reported experiencing a pregnancy complication in their last pregnancy, while only a quarter (25 per cent) had suffered a spontaneous or induced abortion. Furthermore, women on average had four contacts with frontline workers in the previous pregnancy, with 26 per cent of women receiving four ANC with all tests during the last pregnancy and only nine per cent women receiving the vital three post-natal visits in the first week after delivery. Contrary to this, 83 per cent of all women reported having an institutional delivery in a public or private facility. However, women reported a shorter duration of stay in a health facility after delivery with almost 67 per cent discharged earlier than the Indian government mandated 48 hours stay for normal (non-emergency or caesarean) deliveries(22). In terms of area-level characteristics, villages were at an average distance of 5·4 kilometres (km) to the closest primary health centre (PHC). Lastly, about 46 per cent of households had access to the Below Poverty Limit Card (BPL)
By design, the IMFHL program was implemented in poor rural areas of Uttar Pradesh which the statistics show with only 16 per cent of women working to earn cash or kind. Moreover, within households, the majority (92 per cent) of households belonged to the Hindu religion, the predominant religion in UP and India, while 45 per cent identified themselves as belonging to Scheduled caste and tribes. The sampled women had a mean age of 25 years, with 66 per cent of all women have received some form of education, while husband’s education level showed 83 per cent had received some form of schooling. Finally, according to the levels of BPCR, the outcome variable, 52 per cent of all SHG households had a complete BPCR plan in place in the last pregnancy, while 46 per cent of women in non-member households had all BPCR steps in place in the last pregnancy.