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Fivian E, Parida M, Harris-Fry H, Mohanty S, Padhan S, Pradhan R, Das P, Odhiambo G, Prost A, Roopnaraine T, Behera S, James P, Mishra NK, Rath S, Nair N, Rath S, Koniz-Booher P, Danton H, Allen E, Kadiyala S. Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003206. [PMID: 38743726 DOI: 10.1371/journal.pgph.0003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/14/2024] [Indexed: 05/16/2024]
Abstract
Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.
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Affiliation(s)
- Emily Fivian
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | - Pranay Das
- DCOR Consulting Pvt. Ltd., Bhubaneswar, India
| | - Gladys Odhiambo
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Philip James
- Emergency Nutrition Network (ENN), Oxford, United Kingdom
| | - Naba Kishor Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | | | | | - Peggy Koniz-Booher
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Heather Danton
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mishra S, Horton S, Bhutta ZA, Essue BM. Association between the use of Accredited Social Health Activist (ASHA) services and uptake of institutional deliveries in India. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002651. [PMID: 38227565 PMCID: PMC10790990 DOI: 10.1371/journal.pgph.0002651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
This study examines the impact of accredited social health activists (ASHAs), on increasing rates of institution-based deliveries among Indian women with a specific focus on the nine low-performing, empowered action group states and Assam (EAGA) in India. Using the latest round of the National Family Health Survey-V (2019-21), we first investigate the association between the use of ASHA services and socio-demographic attributes of women using a multivariate logistic regression. We then use propensity-score matching (PSM) to address observable selection bias in the data and assess the impact of ASHA services on the likelihood of institution-based deliveries using a generalized estimating equations model. Of the 232,920 women in our sample, 55.5% lived in EAGA states. Overall, 63.3% of women (70.6% in EAGA states) reported utilizing ASHA services, and 88.6% had an institution-based delivery (84.0% in EAGA states). Younger women from the poorest wealth index were more likely to use ASHA services and women in rural areas had a two-fold likelihood. Conversely, women with health insurance were less likely to use ASHA services compared to those without. Using PSM, the average treatment effect of using ASHA services on institution-based deliveries was 5.1% for all India (EAGA = 7.4%). The generalized estimating equations model indicated that the use of ASHA services significantly increased the likelihood of institution-based delivery by 1.6 times (95%CI = 1.5-1.7) for all India (EAGA = 1.8; 95%CI = 1.7-1.9). Our study finds that ASHAs are effective in enhancing the uptake of maternal services particularly institution-based deliveries. These findings underscore the necessity for continual, systematic investments to strengthen the ASHA program and to optimize the program's effectiveness in varied settings that rely on the community health worker model, thereby advancing child and maternal health outcomes.
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Affiliation(s)
- Sujata Mishra
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Susan Horton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Zulfiqar A. Bhutta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Institute for Global Health & Development, The Aga Khan University, Karachi, Pakistan
| | - Beverley M. Essue
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Blanchard AK, Ansari S, Rajput R, Colbourn T, Houweling TAJ, Lorway R, Isac S, Prost A, Anthony J. 'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India. Glob Public Health 2024; 19:2348640. [PMID: 38716491 DOI: 10.1080/17441692.2024.2348640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/22/2024] [Indexed: 05/15/2024]
Abstract
This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.
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Affiliation(s)
- Andrea K Blanchard
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | | | | | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | | | - Robert Lorway
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Shajy Isac
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- India Health Action Trust, Lucknow, India
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - John Anthony
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- India Health Action Trust, Lucknow, India
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Van Iseghem T, Jacobs I, Vanden Bossche D, Delobelle P, Willems S, Masquillier C, Decat P. The role of community health workers in primary healthcare in the WHO-EU region: a scoping review. Int J Equity Health 2023; 22:134. [PMID: 37474937 PMCID: PMC10357780 DOI: 10.1186/s12939-023-01944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/26/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Existing evidence on the role of community health workers (CHWs) in primary healthcare originates primarily from the United States, Canada and Australia, and from low- and middle-income countries. Little is known about the role of CHWs in primary healthcare in European countries. This scoping review aimed to contribute to filling this gap by providing an overview of literature reporting on the involvement of CHWs in primary healthcare in WHO-EU countries since 2001 with a focus on the role, training, recruitment and remuneration. METHODS This systematic scoping review followed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, extension for Scoping Reviews. All published peer-reviewed literature indexed in PubMed, Web of Science, and Embase databases from Jan 2001 to Feb 2023 were reviewed for inclusion. Included studies were screened on title, abstract and full text according to predetermined eligibility criteria. Studies were included if they were conducted in the WHO-EU region and provided information regarding the role, training, recruitment or remuneration of CHWs. RESULTS Forty studies were included in this review, originating from eight countries. The involvement of CHWs in the WHO-EU regions was usually project-based, except in the United Kingdom. A substantial amount of literature with variability in the terminology used to describe CHWs, the areas of involvement, recruitment, training, and remuneration strategies was found. The included studies reported a trend towards recruitment from within the communities with some form of training and payment of CHWs. A salient finding was the social embeddedness of CHWs in the communities they served. Their roles can be classified into one or a combination of the following: educational; navigational and supportive. CONCLUSION Future research projects involving CHWs should detail their involvement and elaborate on CHWs' role, training and recruitment procedures. In addition, further research on CHW programmes in the WHO-EU region is necessary to prepare for their integration into the broader national health systems.
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Affiliation(s)
- Tijs Van Iseghem
- Interuniversity Centre for Health Economics Research (ICHER), Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Ilka Jacobs
- Equity Research Group, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Dorien Vanden Bossche
- Unit Family Medicine, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Peter Delobelle
- Chronic Diseases Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- MENT Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sara Willems
- Equity Research Group, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Caroline Masquillier
- 'Family Medicine and Population Health' - FAMPOP, Faculty of Medical Sciences & 'Centre for Family, Population and Health', Faculty of Social sciences, University of Antwerp, Antwerp, Belgium
| | - Peter Decat
- Unit Family Medicine, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Oh SJ, Han J. The Real Story Behind Maternal Health of North Korea. J Transcult Nurs 2022; 33:297-305. [PMID: 35238262 DOI: 10.1177/10436596221079719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite the emphasis on more systematic and high-quality health care services in the maternal period, a high maternal mortality rate in developing countries is still reported. North Korea, one of the closed countries in the world, is no exception. This study aimed to explore the maternal health experiences in North Korea. METHODOLOGY Qualitative content analysis suggested by Graneheim and Lundman was used to analyze the data of 10 female North Korean defectors. RESULTS Three categories were derived: pregnancy without self-determination rights, a huge gap between the policies on maternal protection and the reality, and discriminatory childbirth and postpartum care. The theme was "perilous existence of maternal health." DISCUSSION We highlighted the need for awareness of maternity protection led by health care professionals such as nurses to guarantee Universal Health Coverage as a human right for North Korean women.
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Affiliation(s)
- Seung Jin Oh
- Ewha Womans University, Seoul, Republic of Korea
| | - Jungjin Han
- Semyung University, Jecheon, Republic of Korea
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Rajvanshi D, Anthony J, Namasivayam V, Dehury B, Banadakoppa Manjappa R, Prakash R, Chintada DR, Khare S, Avery L, Crockett M, Isac S, Becker M, Blanchard J, Halli S. Association of identification of facility and transportation for childbirth with institutional delivery in high priority districts of Uttar Pradesh, India. BMC Pregnancy Childbirth 2021; 21:724. [PMID: 34706676 PMCID: PMC8549204 DOI: 10.1186/s12884-021-04187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India. Methods A community-based cross-sectional survey was conducted between June–October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery. Results Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06–1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46–1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04–1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46–1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07–8.08). Conclusion The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04187-5.
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Affiliation(s)
- Divya Rajvanshi
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.
| | - John Anthony
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | | | - Bidyadhar Dehury
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India
| | | | - Ravi Prakash
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Dhanunjaya Rao Chintada
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Shagun Khare
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India
| | - Lisa Avery
- Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Maryanne Crockett
- Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Shajy Isac
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Marissa Becker
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - James Blanchard
- Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Shiva Halli
- India Health Action Trust, Lucknow, Uttar Pradesh/ New Delhi, India.,Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
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Gautam S, Shukla A, Mishra N, Kohli M, Singh GP. Effectiveness of virtual training for medical officers and community health officers in the critical care management of COVID-19 patients in the intensive care unit. Indian J Anaesth 2021; 65:S168-S173. [PMID: 34908569 PMCID: PMC8613469 DOI: 10.4103/ija.ija_704_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/23/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIMS The coronavirus disease -19 has changed various aspects of education and training in all fields, and e-learning has now become the preferred mode of training and teaching. The aim of this study was to assess the impact of online training and to overcome the limitations of e-learning. METHODS A total of 176 medical officers (MOs) and 720 community health officers (CHOs) were trained in four batches by using seven training modules with online videos and lecture series. Each batch received two days of training. A pre-test and post-test were conducted which consisted of 25 multiple-choice questions of 4 marks each. There was no negative marking. Candidates obtaining >80 marks were declared as having passed. The results of the pre-test and post-tests were compared. RESULTS There was remarkable improvement in the knowledge regarding critical care management after virtual training, as evidenced by the test results. None of the MOs scored more than 80% in the pre-test; however, 153 MOs scored more than 80% in the post-test. The average score improved from 47.82 (pre-test) to 89.05 (post-test). The difference was statically significant (P < 0.0001). Similarly, 123 CHOs scored more than 80% in the pre-test, while 378 CHOs scored more than 80% in the post-test. Improvement in average marks was also seen: 90.5 in the post-test as compared to 62.76 in the pre-test. The difference was statically significant (P < 0.0001). CONCLUSION Online training is beneficial for many candidates from various locations within a short period. The interactive sessions after training are also helpful, and well-designed pre- and post-tests are adequate for assessment.
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Affiliation(s)
- Shefali Gautam
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Aparna Shukla
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Neelkamal Mishra
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Monika Kohli
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Gyan P. Singh
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
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Blanchard AK, Colbourn T, Prost A, Ramesh BM, Isac S, Anthony J, Dehury B, Houweling TAJ. 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. BMJ Open 2021; 11:e044835. [PMID: 34253660 PMCID: PMC8276308 DOI: 10.1136/bmjopen-2020-044835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/20/2021] [Indexed: 12/02/2022] Open
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.
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Affiliation(s)
- Andrea Katryn Blanchard
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tim Colbourn
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Audrey Prost
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Banadakoppa Manjappa Ramesh
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shajy Isac
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- India Health Action Trust, Lucknow, India
| | - John Anthony
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- India Health Action Trust, Lucknow, India
| | | | - Tanja A J Houweling
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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