Blanchard, Andrea Katryn; (2019) A mixed-methods study to understand the influence of community health workers’ home visits on equity in perinatal health in Uttar Pradesh, India. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Introduction: The state of Uttar Pradesh has the highest perinatal mortality rate in India, with substantially more deaths among disadvantaged socio-economic groups. India’s National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit women during pregnancy and the postnatal period. I conducted a mixed-methods study to understand to what extent, how, and in what circumstances ASHAs’ home visits have reduced perinatal health inequities in Uttar Pradesh. Methods: I used generalised linear modelling on a cross-sectional survey of a representative sample of 52,615 women who gave birth within the last two months in 25 districts of Uttar Pradesh in 2014/15. I carried out qualitative social mapping in four purposively-selected villages in two districts, followed by three focus group discussions in each village with ASHAs and mothers from ‘higher’ and ‘lower’ socio-economic position groups (n=134). I analysed these using a thematic framework approach. Results: ASHAs’ home visits had more equitable effects on birth preparedness and institutional delivery, but less on essential newborn care practices and perinatal mortality. These effects may be attributed to the ASHAs’ ability to build relationships and promote affordable care for deliveries in public facilities. Where public services were inaccessible or of lower quality, families of low socio-economic positions delivered more at home and families of higher socio-economic positions relied on private facilities. ASHAs appeared to be less able to assist mothers who had complicated pregnancies or infants with illnesses in the early neonatal period, which were often cases with the highest and most inequitable perinatal mortality rates. Conclusions: ASHAs' home visits contributed to greater equity in birth preparedness and institutional delivery between women of lower and higher socio-economic positions. Inequities in perinatal mortality remained highest in contexts where health system, geographical, political, and socio-economic issues were too insurmountable for ASHAs to overcome.

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