Improving maternal health is a global public health priority. While maternal health, essentially captured by estimates of maternal mortality showed a substantial decline during the Millennial Development Goals (MDG) period (2000-2015), desired global and country-specific goals for maternal mortality reducti
Improving maternal health is a global public health priority. While maternal health, essentially captured by estimates of maternal mortality showed a substantial decline during the Millennial Development Goals (MDG) period (2000-2015), desired global and country-specific goals for maternal mortality reduction were almost universally missed (1,2). Consequently, estimates from key studies suggested that despite the 39 per cent reduction in maternal mortality ratio (MMR) over the MDG period, almost 295,000 maternal deaths still occurred annually in 2017 with the majority disproportionately situated in Africa and South Asia (2). Moreover, the unmet gap in reducing maternal deaths from the MDG’s period has now carried over to the Sustainable Development Goals (SDG) with an ambitious target of maternal mortality ratio of 70 per 100,000 live births by 2030 for all countries (3).
Reducing maternal mortality in high burden regions requires addressing preventable causes of maternal mortality that may occur at any stage of maternity requiring high-quality person-centred care (4,5). These often manifest in pregnant women through physical signs related to underlying pregnancy-related complications, namely bleeding disorders, pregnancy-induced hypertension (eclampsia), delivery complications, post-delivery bleeding and infections (4,6). These physical signs act as an early warning or danger signs of maternal complications. Studies show that within Sub-Saharan Africa and South Asia, there is limited health system capability in providing emergency maternity care, that contributes to the overall high rates of maternal death (4,7). Therefore, achieving the maternal health SDG target would require novel strategies that complement existing country-level efforts, especially among low resource and high disease burden regions where substantial maternal deaths are avoidable (1,4).
According to the World Health Organization (2019), the majority (99 per cent) of maternal deaths still occur in low-income regions of South Asia and Sub-Saharan Africa where selected countries contribute the substantial burden (1,4,8,9). Within South Asia, India alone accounts for an estimated 10 per cent of global maternal deaths or 45,000 maternal deaths annually and 20 per cent of global under-5 child mortality with 1.04 million deaths estimated annually (1,10,11). India accelerated the rate of maternal death decline in the latter half of the MDG period (2006-2015) due to strategic health system reforms that prioritised community health care and incentivised institutional delivery, leading to a national average of 80 per cent institutional deliveries across rural and urban populations(10–12). Importantly, the rise in institutional deliveries has not been matched with adequate provision of Basic and Emergency Medical Obstetric Care (EMOC) in facilities in rural areas (13). Previous studies from India found that institutional deliveries alone, in the absence of high-quality EMOC and adequate referral system, is weakly associated with maternal mortality reduction (14–16). Studies from other countries also showed that prioritising institutional deliveries alone, without adequate investments to ensure skilled high-quality care, increases the risk of negligence in maternal health care facilities (17,18).
In India, substantial regional disparities account for select northern states traditionally reporting low development and maternal health indicators. Notably, the state of Uttar Pradesh (UP) accounts for the highest number of maternal deaths in India, which is partly attributed to the state population (200 million) (10,19,20). The Maternal Mortality Ratio (MMR) in Uttar Pradesh stands at 188 per 100,000 live births compared to the national MMR of 130 per 100,000 live births (21). Institutional delivery in rural regions in UP is substantially lower at 66 per cent as compared to the national rural average of 75 per cent (22,23). Importantly, UP reported 34 per cent home deliveries in 2016, among which only four per cent were attended by a skilled birth attendant (23).
Studies from rural Uttar Pradesh showed that delays in care-seeking were exacerbated by health system gaps in the provision of adequate pre- and post-natal care, gaps that disproportionately impact poor families with low literacy (24–27). Additionally, among the 22 per cent of pregnant women in rural UP who reported receiving the minimum required three Antenatal care (ANC) visits (now the minimum required ANC visits are revised to four), only 10 per cent consumed the recommended iron-folic acid (IFA) for 100 days or more when they were pregnant (23).
It was reported that less than 28 per cent of women received basic post-natal care (PNC) in rural UP among which a meagre 17 per cent received PNC within the first week of post-delivery where most complications are likely to occur (13). Inadequate ANC and PNC compromise the quality of health literacy related to maternal complications recognition in women. Women having knowledge of danger sign are likely to support earlier identification of maternal complications when they occur and prompt families to seek early health care. Studies in many settings found that low knowledge levels predispose women and households to either miss out potential maternal complications or seek delayed care to the detriment of the mother (16,24,27,28,29).
Pervasive cultural beliefs about the nature of the complications indicated that many women in rural settings lacked awareness of danger signs of maternal illness, which influences the decision-making process to seek care (16,24). Studies in rural UP showed that families with low access to maternal services were more likely to follow cultural traditions around the timing and place of childbirth (16,24). These traditions and social norms restrict women’s mobility and access to treatment during maternal complications (24,29).
Community-based Health Literacy and Microfinance Program
In rural India and similar regions, community-based health literacy interventions are used to supplement formal health system efforts to promote routine maternal health service utilisation related to antenatal visits, institutional deliveries and skilled attendance at birth (7,29,30). Studies highlighted the positive effect of health literacy on improving maternal health utilisation despite low levels of education in communities (31). Community health programs are increasingly providing evidence for reducing maternal and newborn health inequities in rural areas through women’s empowerment and support greater female economic participation (32–34). Additionally, community mobilisation advocates progressively push for layering multiple interventions, including financial mechanisms in developmental packages for low resource regions seeking to impact maternal mortality (35-37). Women only microfinance-based Self-help groups (SHG) program is a novel intervention to address informational and financial barriers to maternal care-seeking by improving maternal health literacy and providing access to credit (33,38). The provision of health knowledge through peer-network of SHGs is also postulated to shift social norms about maternal health outcomes by providing an enabling environment for discussion and change (39–41). Moreover, SHGs have now been placed under India’s rural health programs facilitating coordination of health services with community health workers in villages (12,42). SHGs as a developmental model, permits the scaling of an added health intervention and allows the diffusion of new knowledge and skills through program channels over time in a social system (39,43).
The SHG platform is the underlying developmental model of the IMFHL program evaluated in this paper. The IMFHL program aimed to empower marginalised women by organising them in self-help groups comprising 10-15 households to adopt desired health behaviours and provide access credit for poverty reduction (44,45). Studies have shown that SHG membership fosters social capital and cohesion among member through group collectivisation, with membership influencing social norms and behaviours (39,40,41). Previous studies in rural India suggested that SHG membership may increase access to social and health advice networks for mothers, including increased linkages to the health system (39,40). However, the potential of SHGs as a community network to reach non-members with new knowledge has not been studied.
While most studies attribute the change in health behaviours due to the influence of program input, limited studies have explored the phenomenon of diffusion of health literacy from program members to non-members (44,39,46). Diffusion in this paper adopts a definition that explains the process by which an innovation - in this case, the knowledge of maternal danger signs, is communicated through programmatic channels over time from members to non-members of a social system (43). Moreover, in this study, diffusion is contrasted with dissemination which entails active planned efforts to reach an intended outcome (47). For example, the layering of a health literacy component on the SHG platform is indicative of a planned approach for the dissemination of health information among members; whereas the assumed natural transfer of knowledge from SHG members to neighbouring non-members without planned programmatic input reflects the phenomenon of diffusion.
The commonly adopted Roger’s model of diffusion has been used in public health programs to describe the pattern of behaviour change adoption across communities using selected interventions such as contraceptive use, child marriage and intimate partner violence (47-50). Moreover, while previous diffusion studies have shown the key role of interpersonal connection in promoting health information, the application of the model to evaluate the spread of microfinance has not yet been done (32,39,44,50). Particularly, no study elsewhere, to the best of our knowledge, has evaluated the diffusion of the knowledge of maternal danger signs from microfinance members to non-members in a rural setting with low literacy and high poverty- populations.
The IMFHL program provided health literacy to women on recognising key pregnancy-related danger signs, and adoption of birth preparedness complication readiness (BPCR) plans to reduce delays in seeking health care during maternal complications. While studies evaluating SHGs and embedded health programs have demonstrated the gain in knowledge of routine maternal services such as antenatal care and institutional delivery (32,36,44,51), no study till date examined the incremental impact of program participation on knowledge of maternal danger signs among women or the women’s likelihood of identifying the risks of complications during the pregnancy, delivery and post-partum period. Moreover, there is limited evidence about the effects of broader individual, household, community, and area-level confounders on knowledge of danger signs among members and non-members of integrated microfinance and health literacy (IMFHL) program in rural settings.
This research aims to evaluate if membership in an IMFHL program improves the knowledge levels of maternal danger signs associated with high-risk pregnancies among women in rural Uttar Pradesh while adjusting for other individual, households and community or area-level characteristics. This research also seeks to investigate the impact of exposure to each of the different levels of the integrated program and the presence of a diffusion effect of knowledge from member to non-member households in program villages in Uttar Pradesh. The study hypothesises that providing health literacy to women through the SHG program is likely to increase knowledge of maternal danger signs leading to early recognition of danger signs at home and fewer delays in seeking health treatment, and thereby improving maternal health.
Figure 1 provides a conceptual framework showing the program’s input on eligible woman’s knowledge of maternal danger signs and hypothesized improvement in care-seeking practises.
on were almost universally missed (1,2). Consequently, estimates from key studies suggested that despite the 39 per cent reduction in maternal mortality ratio (MMR) over the MDG period, almost 295,000 maternal deaths still occurred annually in 2017 with the majority disproportionately situated in Africa and South Asia (2). Moreover, the unmet gap in reducing maternal deaths from the MDG’s period has now carried over to the Sustainable Development Goals (SDG) with an ambitious target of maternal mortality ratio of 70 per 100,000 live births by 2030 for
all countries (3).
Reducing maternal mortality in high burden regions requires addressing preventable causes of maternal mortality that may occur at any stage of maternity requiring high-quality person-centred care (4,5). These often manifest in pregnant women through physical signs related to underlying pregnancy-related complications, namely bleeding disorders, pregnancy-induced hypertension (eclampsia), delivery complications, post-delivery bleeding and infections (4,6). These physical signs act as an early warning or danger signs of maternal complications. Studies show that within Sub-Saharan Africa and South Asia, there is limited health system capability in providing emergency maternity care, that contributes to the overall high rates of maternal death (4,7). Therefore, achieving the maternal health SDG target would require novel strategies that complement existing country-level efforts, especially among low resource and high disease burden regions where substantial maternal deaths are avoidable (1,4).
According to the World Health Organization (2019), the majority (99 per cent) of maternal deaths still occur in low-income regions of South Asia and Sub-Saharan Africa where selected countries contribute the substantial burden (1,4,8,9). Within South Asia, India alone accounts for an estimated 10 per cent of global maternal deaths or 45,000 maternal deaths annually and 20 per cent of global under-5 child mortality with 1.04 million deaths estimated annually (1,10,11). India accelerated the rate of maternal death decline in the latter half of the MDG period (2006-2015) due to strategic health system reforms that prioritised community health care and incentivised institutional delivery, leading to a national average of 80 per cent institutional deliveries across rural and urban populations(10–12). Importantly, the rise in institutional deliveries has not been matched with adequate provision of Basic and Emergency Medical Obstetric Care (EMOC) in facilities in rural areas (13). Previous studies from India found that institutional deliveries alone, in the absence of high-quality EMOC and adequate referral system, is weakly associated with maternal mortality reduction (14–16). Studies from other countries also showed that prioritising institutional deliveries alone, without adequate investments to ensure skilled high-quality care, increases the risk of negligence in maternal health care facilities (17,18).
In India, substantial regional disparities account for select northern states traditionally reporting low development and maternal health indicators. Notably, the state of Uttar Pradesh (UP) accounts for the highest number of maternal deaths in India, which is partly attributed to the state population (200 million) (10,19,20). The Maternal Mortality Ratio (MMR) in Uttar Pradesh stands at 188 per 100,000 live births compared to the national MMR of 130 per 100,000 live births (21). Institutional delivery in rural regions in UP is substantially lower at 66 per cent as compared to the national rural average of 75 per cent (22,23). Importantly, UP reported 34 per cent home deliveries in 2016, among which only four per cent were attended by a skilled birth attendant (23).
Studies from rural Uttar Pradesh showed that delays in care-seeking were exacerbated by health system gaps in the provision of adequate pre- and post-natal care, gaps that disproportionately impact poor families with low literacy (24–27). Additionally, among the 22 per cent of pregnant women in rural UP who reported receiving the minimum required three Antenatal care (ANC) visits (now the minimum required ANC visits are revised to four), only 10 per cent consumed the recommended iron-folic acid (IFA) for 100 days or more when they were pregnant (23).
It was reported that less than 28 per cent of women received basic post-natal care (PNC) in rural UP among which a meagre 17 per cent received PNC within the first week of post-delivery where most complications are likely to occur (13). Inadequate ANC and PNC compromise the quality of health literacy related to maternal complications recognition in women. Women having knowledge of danger sign are likely to support earlier identification of maternal complications when they occur and prompt families to seek early health care. Studies in many settings found that low knowledge levels predispose women and households to either miss out potential maternal complications or seek delayed care to the detriment of the mother (16,24,27,28,29).
Pervasive cultural beliefs about the nature of the complications indicated that many women in rural settings lacked awareness of danger signs of maternal illness, which influences the decision-making process to seek care (16,24). Studies in rural UP showed that families with low access to maternal services were more likely to follow cultural traditions around the timing and place of childbirth (16,24). These traditions and social norms restrict women’s mobility and access to treatment during maternal complications (24,29).
Community-based Health Literacy and Microfinance Program
In rural India and similar regions, community-based health literacy interventions are used to supplement formal health system efforts to promote routine maternal health service utilisation related to antenatal visits, institutional deliveries and skilled attendance at birth (7,29,30). Studies highlighted the positive effect of health literacy on improving maternal health utilisation despite low levels of education in communities (31). Community health programs are increasingly providing evidence for reducing maternal and newborn health inequities in rural areas through women’s empowerment and support greater female economic participation (32–34). Additionally, community mobilisation advocates progressively push for layering multiple interventions, including financial mechanisms in developmental packages for low resource regions seeking to impact maternal mortality (35-37). Women only microfinance-based Self-help groups (SHG) program is a novel intervention to address informational and financial barriers to maternal care-seeking by improving maternal health literacy and providing access to credit (33,38). The provision of health knowledge through peer-network of SHGs is also postulated to shift social norms about maternal health outcomes by providing an enabling environment for discussion and change (39–41). Moreover, SHGs have now been placed under India’s rural health programs facilitating coordination of health services with community health workers in villages (12,42). SHGs as a developmental model, permits the scaling of an added health intervention and allows the diffusion of new knowledge and skills through program channels over time in a social system (39,43).
The SHG platform is the underlying developmental model of the IMFHL program evaluated in this paper. The IMFHL program aimed to empower marginalised women by organising them in self-help groups comprising 10-15 households to adopt desired health behaviours and provide access credit for poverty reduction (44,45). Studies have shown that SHG membership fosters social capital and cohesion among member through group collectivisation, with membership influencing social norms and behaviours (39,40,41). Previous studies in rural India suggested that SHG membership may increase access to social and health advice networks for mothers, including increased linkages to the health system (39,40). However, the potential of SHGs as a community network to reach non-members with new knowledge has not been studied.
While most studies attribute the change in health behaviours due to the influence of program input, limited studies have explored the phenomenon of diffusion of health literacy from program members to non-members (44,39,46). Diffusion in this paper adopts a definition that explains the process by which an innovation - in this case, the knowledge of maternal danger signs, is communicated through programmatic channels over time from members to non-members of a social system (43). Moreover, in this study, diffusion is contrasted with dissemination which entails active planned efforts to reach an intended outcome (47). For example, the layering of a health literacy component on the SHG platform is indicative of a planned approach for the dissemination of health information among members; whereas the assumed natural transfer of knowledge from SHG members to neighbouring non-members without planned programmatic input reflects the phenomenon of diffusion.
The commonly adopted Roger’s model of diffusion has been used in public health programs to describe the pattern of behaviour change adoption across communities using selected interventions such as contraceptive use, child marriage and intimate partner violence (47-50). Moreover, while previous diffusion studies have shown the key role of interpersonal connection in promoting health information, the application of the model to evaluate the spread of microfinance has not yet been done (32,39,44,50). Particularly, no study elsewhere, to the best of our knowledge, has evaluated the diffusion of the knowledge of maternal danger signs from microfinance members to non-members in a rural setting with low literacy and high poverty- populations.
The IMFHL program provided health literacy to women on recognising key pregnancy-related danger signs, and adoption of birth preparedness complication readiness (BPCR) plans to reduce delays in seeking health care during maternal complications. While studies evaluating SHGs and embedded health programs have demonstrated the gain in knowledge of routine maternal services such as antenatal care and institutional delivery (32,36,44,51), no study till date examined the incremental impact of program participation on knowledge of maternal danger signs among women or the women’s likelihood of identifying the risks of complications during the pregnancy, delivery and post-partum period. Moreover, there is limited evidence about the effects of broader individual, household, community, and area-level confounders on knowledge of danger signs among members and non-members of integrated microfinance and health literacy (IMFHL) program in rural settings.
This research aims to evaluate if membership in an IMFHL program improves the knowledge levels of maternal danger signs associated with high-risk pregnancies among women in rural Uttar Pradesh while adjusting for other individual, households and community or area-level characteristics. This research also seeks to investigate the impact of exposure to each of the different levels of the integrated program and the presence of a diffusion effect of knowledge from member to non-member households in program villages in Uttar Pradesh. The study hypothesises that providing health literacy to women through the SHG program is likely to increase knowledge of maternal danger signs leading to early recognition of danger signs at home and fewer delays in seeking health treatment, and thereby improving maternal health.
Figure 1 provides a conceptual framework showing the program’s input on eligible woman’s knowledge of maternal danger signs and hypothesized improvement in care-seeking practises.