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

Abstract

Background: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Study registration: ClinicalTrials.gov number NCT02726230.

Figure 1

Study flow diagrams. Panel A. Mathematica surveys, Bihar, India, 2012 and 2014. Panel B. CHS surveys, Bihar, India, 2012-2017.

Figure 2

Comparisons of maternal respondents’ demographics by least vs most marginalised group for Mathematica (2012, 2014) and Community-based Household Surveys (CHS) data (2012-2017), Bihar, India.

Figure 3

Comparison of the disparity across Community-based Household Surveys (CHS) indicators favouring the most marginalised vs the least marginalised, by round, Bihar, India, 2012-2017. ANC – antenatal care, DPT – diphtheria-pertussis-tetanus (DPT3), FLW – frontline worker, IFA – iron-folic acid, PPIUD – postpartum intrauterine device.