Health impact of self-help groups scaled-up statewide in Bihar, India

Abstract

Background: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017.

Methods: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age.

Results: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children.

Conclusions: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care.

Study registration: ClinicalTrials.gov number NCT02726230.

Figure 1

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators by continuum-of-care domain for self-help group members compared to non-members as measured by the Community-based Household Surveys rounds 6-9 during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 1 – Out of those who received 90+ IFA during pregnancy. 2 – 3+ times for 9-11 month-old children. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, OPV – oral polio vaccine, PPIUD – postpartum intrauterine device.

Figure 2

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators for self-help group members compared to non-members by delivery platform as measured by the Community-based Household Surveys rounds 6-9 during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 2 – Out of those who received 90+ IFA during pregnancy. 3 – 3+ times for 9-11 month-old children. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, OPV – oral polio vaccine, PPIUD – postpartum intrauterine device.

Figure 3

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators for increased time spent in months in self-help groups as measured by rounds 6-9 of the Community-based Household Surveys during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 2 – Out of those who received 90+ IFA during pregnancy. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, PPIUD – postpartum intrauterine device.

Figure 4

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators for self-help group members sub-categorised into those who were younger (<25 years old, 1) or older (≥25 years old, 0) compared to age-comparable non-members as measured by Community-based Household Surveys rounds 6-9 during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 2 – Out of those who received 90+ IFA during pregnancy. 3 – 3+ times for 9-11 month-old children. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, OPV – oral polio vaccine, PPIUD – postpartum intrauterine device.

Figure 5

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators for self-help group members with 0-1 child, 2 children, or 3 or more children compared to parity-comparable non-SHG-members as measured by Community-based Household Surveys rounds 6-9 during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 2 – Out of those who received 90+ IFA during pregnancy. 3 – 3+ times for 9-11 month-old children. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, OPV – oral polio vaccine, PPIUD – postpartum intrauterine device.

Figure 6

Forest plot of odds ratios and 95% confidence intervals of health, nutrition and sanitation indicators for one increased frontline worker visit stratified by non-self-help group (SHG)-members and SHG members as measured by Community-based Household Surveys rounds 6-9 during scale-up (2014-2017) statewide in Bihar, India. All models presented were adjusted for age of the mother and sex of the focal child. These models also accounted for the study’s complex design by applying study weights. 2 – Out of those who received 90+ IFA during pregnancy. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus, FLW – frontline worker, IFA – iron-folic acid, IPV – inactivated polio vaccine, PPIUD – postpartum intrauterine device.