Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens

Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India. Utilising survey-weighted logistic regress...

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Published in:	Journal of global health Vol. 10; no. 2; p. 021011
Main Authors:	Ward, Victoria C, Weng, Yingjie, Bentley, Jason, Carmichael, Suzan L, Mehta, Kala M, Mahmood, Wajeeha, Pepper, Kevin T, Abdalla, Safa, Atmavilas, Yamini, Mahapatra, Tanmay, Srikantiah, Sridhar, Borkum, Evan, Rangarajan, Anu, Sridharan, Swetha, Rotz, Dana, Bhattacharya, Debarshi, Nanda, Priya, Tarigopula, Usha Kiran, Shah, Hemant, Darmstadt, Gary L
Format:	Journal Article
Language:	English
Published:	Scotland Edinburgh University Global Health Society 01.12.2020 International Society of Global Health
Subjects:	Behavior Breast feeding Breastfeeding & lactation Child Health Childrens health Drinking water Family planning Female Global health Health Behavior Health disparities Health Promotion Health services Health surveys Healthcare Disparities Households Humans India Infant Infant Health Infant, Newborn Intersectionality Male Maternal & child health Maternal Health Maternal Health Services Newborn babies Nutrition Nutritional Status Population Pregnancy Prenatal care Quality control Reproductive Health Research Theme 6: Learning from Ananya Program in Bihar Skin care Social exclusion Socioeconomic factors Womens health India Bihar India
ISSN:	2047-2978, 2047-2986, 2047-2986
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Abstract	Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India. Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India. At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), < 0.01) and skin-to-skin care (+14.8% vs +20.4%, < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64). Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all. ClinicalTrials.gov number NCT02726230.
AbstractList	Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India. Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India. At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), < 0.01) and skin-to-skin care (+14.8% vs +20.4%, < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64). Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all. ClinicalTrials.gov number NCT02726230. BackgroundDespite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.MethodsUtilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India.ResultsAt baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P < 0.01) and skin-to-skin care (+14.8% vs +20.4%, P < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).ConclusionsDisparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.Study registrationClinicalTrials.gov number NCT02726230 Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.BACKGROUNDDespite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India.METHODSUtilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India.At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P < 0.01) and skin-to-skin care (+14.8% vs +20.4%, P < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).RESULTSAt baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P < 0.01) and skin-to-skin care (+14.8% vs +20.4%, P < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.CONCLUSIONSDisparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.ClinicalTrials.gov number NCT02726230.STUDY REGISTRATIONClinicalTrials.gov number NCT02726230.
Author	Mahmood, Wajeeha Tarigopula, Usha Kiran Abdalla, Safa Sridharan, Swetha Rotz, Dana Nanda, Priya Pepper, Kevin T Rangarajan, Anu Weng, Yingjie Srikantiah, Sridhar Mahapatra, Tanmay Mehta, Kala M Atmavilas, Yamini Darmstadt, Gary L Carmichael, Suzan L Bhattacharya, Debarshi Shah, Hemant Bentley, Jason Borkum, Evan Ward, Victoria C
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Contributor	Munar, Wolfgang A Tarigopula, Usha Kiran Irani, Laili Creanga, Andreea Chaudhuri, Indrajit Nanda, Priya Weng, Yingjie Walker, Dilys Wilhelm, Jess Atmavilas, Yamini Darmstadt, Gary L Bentley, Jason Borkum, Evan Carmichael, Suzan Sastry, Padmapriya Mitra, Radharani Saggurti, Niranjan Raheel, Hina Pepper, Kevin T Rangarajan, Anu Srikantiah, Sridhar Mahapatra, Tanmay Ward, Victoria Mehta, Kala M Bhattacharya, Debarshi Dutt, Priyanka Shah, Hemant
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Snippet	Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal... BackgroundDespite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a...
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SubjectTerms	Behavior Breast feeding Breastfeeding & lactation Child Health Childrens health Drinking water Family planning Female Global health Health Behavior Health disparities Health Promotion Health services Health surveys Healthcare Disparities Households Humans India Infant Infant Health Infant, Newborn Intersectionality Male Maternal & child health Maternal Health Maternal Health Services Newborn babies Nutrition Nutritional Status Population Pregnancy Prenatal care Quality control Reproductive Health Research Theme 6: Learning from Ananya Program in Bihar Skin care Social exclusion Socioeconomic factors Womens health
Title	Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens
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