Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India

Abstract

Background: The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.

Methods: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.

Results: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.

Conclusions: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.

Study registration: ClinicalTrials.gov number NCT02726230.

Figure 1

Sampling methodology of the Community-based Household Surveys (CHS), Bihar, 2012-2017.

Figure 2

Trends in antenatal care and birth preparedness indicators in the first, transition and second phases of the Bihar program by delivery platform in focus and non-focus districts in Bihar, India, Community-based Household Surveys, 2012-2017. Panel A. Trends in the first phase – 8 focus districts. Panel B. Change in indicator levels between the end of the first phase and beginning of the second phase – 8 focus districts. Panel C. Trends in the second phase – 8 formerly focus districts. Panel D. Trends in the second phase – 30 non-focus districts. ANC – antenatal care, FDR – false discovery date, FLW – frontline worker, F/OSD – facility care and outreach service delivery, IFA – iron and folic acid, M – mother’s behaviour. Percentages in the y-axis labels are adjusted initial levels for each indicator in each phase. Odds ratios per year are presented on the x-axis. Indicator definitions can be found in Table S2 in the Online Supplementary Document.

Figure 3

Trends in delivery (childbirth) care indicators in the first, transition and second phases of the Bihar program by facility vs home births and by delivery platform in focus and non-focus districts in Bihar, India, Community-based Household Surveys, 2012-2017. Panel A. Trends in the first phase – 8 focus districts. Panel B. Change in indicator levels between the end of the first phase and beginning of the second phase – 8 focus districts. Panel C. Trends in the second phase – 8 formerly focus districts. Panel D. Trends in the second phase – 30 non-focus districts. FDR – false discovery rate, FLW – frontline worker, F/OSD – facility care and outreach service delivery, M – mother’s behaviour,). Percentages in the y-axis labels are adjusted initial levels for each indicator in each phase. Odds ratios per year are presented on the x-axis. Indicator definitions can be found in Table S2 in the Online Supplementary Document.

Figure 4

Trends in postnatal care and nutrition indicators in the first, transition and second phases of the Bihar program by delivery platform in focus and non-focus districts in Bihar, India, Community-based Household Surveys, 2012-2017. Panel A. Trends in the first phase – 8 focus districts. Panel B. Change in indicator levels between the end of the first phase and beginning of the second phase – 8 focus districts. Panel C. Trends in the second phase – 8 formerly focus districts. Panel D. Trends in the second phase – 30 non-focus districts. FDR – false discovery rate, FLW – frontline worker, F/OSD – facility care and outreach service delivery, M – mother’s behaviour. Percentages in the y-axis labels are adjusted initial levels for each indicator in each phase. Odds ratios per year are presented on the x-axis. Indicator definitions can be found in Table S2 in the Online Supplementary Document.

Figure 5

Trends in immunisation and family planning in the first, transition and second phases of the Bihar program by delivery platform in focus and non-focus districts in Bihar, India, Community-based Household Surveys, 2012-2017. Panel A. Trends in the first phase – 8 focus districts. Panel B. Change in indicator levels between the end of the first phase and beginning of the second phase – 8 focus districts. Panel C. Trends in the second phase – 8 formerly focus districts. Panel D. Trends in the second phase – 30 non-focus districts. FDR – false discovery rate, FLW – frontline worker, F/OSD – facility care and outreach service delivery, IPV – inactivated polio vaccine, M – mother’s behaviour, OPV3 – oral polio vaccine, 3 doses, PPIUD – post-partum Intrauterine Device. Percentages in the y-axis labels are adjusted initial levels for each indicator in each phase. Odds ratios per year are presented on the x-axis. Indicator definitions can be found in Table S2 in the Online Supplementary Document.