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Assessment of an intervention on improving the maternal and neonatal out comes in Koppal and Bagalkot districts, Karnataka: Experience from Sukshema project

Abstract

Background: To improve the MNCH outcomes in 8 districts of Karnataka, Bill & Melinda Gates Foundation (BMGF) funded a project namely Sukshema in the year 2010. The Sukshema project was taken into account the potential of increasing community engagement and demand creation through ASHA and on-site nurse mentoring. We assessed over time changes in selected MNCH indicators among women who had delivered in the past 2 months in two districts, namely Bagalkot and Koppal.

Methods: To monitor the project, we designed a rapid and routine data collection strategy, namely community behaviour tracking survey (CBTS) using mobile technology. The catchment area of an ASHA is the primary sampling unit and selected and in each district 200 ASHA areas were selected. Women from these selected ASHA areas were interviewed and collected information on various MNCH outcomes. To assess the changes in selected MNCH indicators we used multivariate logistic regression.

Results: We noticed gradual increase in institutional delivery, hospital stay for 48 or more hours, initiation of breastfeeding within one hour and continuum of care. However the increase was significant only between round-1 and round-4, and round-1 and round-5 in case of hospital stay for 48 or more hours and initiation of breastfeeding within 1 hour. In case of continuum of care we observed significant change across various rounds of CBTS.

Conclusion: The result indicates that our programme approach of increasing community engagement and demand creation through ASHA made a significant difference to the MNCH outcomes in the study districts.

Key words: Maternal, Neonatal, Continuum, Breastfeeding initiation, 48 hours stay in facility

Introduction

Evidence suggested a shortfall in reducing maternal mortality and under-5 deaths as targeted by the

Millennium Development Goals in low and middle income countries1, 2. In India, the progress over

the targets in respect of reducing under-5 mortality was moderately on track and improvement in

maternal health was either slow or off track3. As such, there is a growing interest in interventions

aimed at community and health facility levels to improve the health of women and children to

accelerate the reduction in maternal and child mortality rates. Community participation has long

been advocated to build links with improving maternal and child health and it was important in

supporting the provision of local health services and in delivering interventions at the community

level4. Moreover, community-based intervention packages in reducing maternal and neonatal

morbidities and mortality should be supplemented by developing and strengthening linkages with

the local health systems. A major concern shared was the low coverage of interventions during

delivery and postnatal care despite high utilisation of antenatal care5. Few community based

intervention trails conducted in Asian countries has provided evidence of improving the neonatal

survival 6-8. It was documented that universal coverage of 16 proven newborn health interventions

could avert up to 72 percent of all newborn deaths9. According to a study conducted in rural India,

home-based package of maternal and newborn health interventions delivered by community health

workers (CHWs) reduced neonatal mortality by 62%10. It has been estimated that 74 percent of

maternal deaths could be averted if all women had access to interventions that address

complications of pregnancy and childbirth, especially emergency obstetric care11. A systematic

review of the effectiveness of training in emergency obstetric care concluded that training

programmes may improve quality of care but strong evidence is lacking 12.

In India, the National Rural Health Mission (NRHM) was launched by the Honourable Prime Minister

on 12th Aril, 2005 to provide accessible, affordable, and accountable quality health services even to

the poorest households in the remotest rural areas. The thrust of the Mission was on establishing a

fully functional, community owned, decentralized health delivery system with inter-sectoral

convergence at all levels, to ensure simultaneous action on a wide range of determinants of health

such as water, sanitation, nutrition, social and gender equity13. One of the NRHM’s major objectives

is to reduce the number of mothers and infants who die during and immediately after birth, and the

number of children under five who die from common illnesses. Karnataka state is better placed as

far as the maternal, neonatal and child health (MNCH) indicators are concerned in comparison to the

national level14. However, within the state the MNCH indicators vary considerably across various

districts15.

In order to improve the MNCH outcomes in the Karnataka state, Bill & Melinda Gates Foundation

(BMGF) funded a project namely Sukshema in the year 2010 to the University of

Manitoba/Karnataka Health Promotion Trust. The Sukshema intervention project is focused on 8

districts in the northern Karnataka namely, Bagalkot, Koppal, Bellary, Raichur, Bijapur, Yadgir,

Gulbarga and Bidar among the rural population. After a detailed situational assessments and a

thorough deliberation with different stake holders including government of Karnataka, the project

has prioritized technical interventions at health facility and community levels. Both the interventions

were field tested in two districts separately and subsequently scaled up into other six districts. At the

facility level in 2012, the project introduced an innovative strategy of providing on-site mentoring for

PHC staff including both clinical and delivery issues through a dedicated cadre of nurse mentors. This

intervention strategy was first tested in Gulbarga and Bellary districts on a pilot basis and then

scaled up into other six districts. Similarly, the community intervention was first introduced in

Bagalkot and Koppal districts in 2012 and then scaled up into other six districts. The community

intervention include enumeration tracking tool (ETT), home based maternal and newborn care tool

(HBMNC), family focused communication (FFC), supportive community monitoring tool (SCMT) and

sub-centre forum (Arogya Mantapa). The front line workers (FLW) such as ASHAs, Anganwadi

workers (AWW) and Junior Health Assistants (JHA) were provided with training for using and

maintaining these tools and activities. The interventions envisaged to increase the frequency and

quality of interactions of FLWs with families, improve the community’s knowledge and practice

regarding MNCH care, improve the quality of care at birth and immediate postpartum care at health

facilities, and improve the community participation in planning and monitoring of MNCH

programme. The intervention has been in operation for the past two years and consequently

believed to bring about changes in MNCH outcomes in the project districts. Hence, evidence for

dissemination of Sukshema intervention learning at the community level is important.

In this context, the objective of the paper was to examine the overtime changes in the selected

MNCH indicators as compared to first round of data in two districts, namely Bagalkot and Koppal, in

which the community intervention was introduced first and subsequently adopted the on-site nurse

mentoring. These two districts are selected for the analysis because the exposure to community

level activities was longer in these two districts as compared to other districts.

Methods

Data

As a part of monitoring the project, we designed a rapid and routine data collection strategy, namely

community behaviour tracking survey (CBTS), in these 8 districts every 4 months. Mobile phones

were used to collect the information from the eligible mothers. The data collected using the mobiles

were transferred to the server immediately after the interview was completed. As such, this

provided a real time feedback data to the intervention, reducing the lag between data collection,

data entry and analysis of the data for monitoring the project objectives. We collected information

on selected background characteristics of the women; knowledge on danger signs during pregnancy,

delivery and postpartum, anemia among pregnant and delivered mothers, birth planning,

government schemes for mother and children; and utilisation of antenatal care (ANC), delivery care

and postnatal care (PNC) services.

Study design

In this survey, the catchment area covered by an ASHA is the primary sampling unit. In each district,

we prepared a sampling frame consisting of all the ASHA catchment areas, irrespective of whether

ASHA position is presently filled or vacant. Thus, we ensured that the sampling frame represents all

the rural areas in the district. We regularly update the sample frame of ASHA list prior to each round

of CBTS. In each district, 200 ASHA areas were selected from the sampling frame using systematic

sampling method, with Taluka and PHC as intrinsic stratifications. Within each selected ASHA areas,

households (HHs) were enumerated using a house listing form in a clockwise fashion with a random

start. The investigators listed all the eligible women, who had delivered in the past 2 months prior to

the survey – either a usual resident or a visitor in the HH and interviewed them. The enumeration

and interviews were halted when a maximum of 5 completed interviews was achieved or 200 HHs in

the ASHA area were enumerated or if less than 200 HHs, all the HHs in the ASHA areas were

enumerated.

Data collection

In round-1 of CBTS in Koppal and Bagalkot districts, we used paper based questionnaires instead of

mobile application to collect the data. Also, the data was collected by the resource persons who

were involved in the community intervention in these districts. However, after the round-1 of CBTS

in Koppal and Bagalkot districts, in order to accelerate the data collection, it was decided to recruit

and train field investigators solely for the purpose of data collection. We recruited and trained 20

field investigators for conducting the CBTS using the mobile phone application. In each district, the

data collection was carried out by 10 field investigators and completed within one month. Data

collection for round-1 was carried out during June-July, 2012; round-2 was carried out during March-

April, 2013; round-3 was carried out during July-August, 2013; round-4 was carried out during

November-December 2013, and round-5 was carried out during April-May, 2014.

Statistical analysis

We compared the selected background characteristics of the women between the five CBTS rounds.

Further, we observed the changes in the selected MNCH outcome indicators between the five CBTS

rounds. We also applied a nonparametric test for trend across five rounds of CBTS for the selected

MNCH indicators. To identify overtime changes in selected MNCH indicators between first round and

other subsequent rounds, we performed multivariate logistic regression model. In the logistic model,

we used institutional delivery, mother stayed in the health facility for 48 hours or more, continuum

of maternal and neonatal care and breastfed within one hour as the outcome variables and used

round as an independent variable. In order to identify statistically significant changes in the outcome

variables between first round and subsequent rounds, we applied four separate logistic models for

each of the outcome variables. Since, our main interest is to study the difference in the selected

MNCH indicators across various rounds as compared to first round, the model considered round as

an independent variable. The other independent variables entered into the model were age of the

women, caste of the women, HH has below poverty line (BPL) card, residential status of the women

and district. The continuum of maternal and neonatal care is defined as the women who received at

least three ANC visits in a health facility, who delivered in a health facility, who stayed in the facility

for at least 48 hours and who received PNC visit by ASHA at home. All the statistical analyses were

conducted using Stata version 12.0 (StataCorp LP, College Station, TX, USA).

Results

Table 1 presents the distribution of recently delivered women between different rounds of CBTS.

Since, the aim of the survey was to monitor the Sukeshama programme, we collected only few

background characteristics of the women. Overall, no difference was observed in the distribution of

women according to age, caste/tribe and district across various rounds of CBTS. However,

substantial difference in the distribution of women was observed for the possession of BPL card in

the household in the subsequent rounds as compared to first round. In round-1, around 40 percent

of the women reported to have the BPL card and in the subsequent rounds around 70 or more

percent of the women reported so. We also found difference in the distribution of women across

survey rounds according to residential status. For instance, the percentage of women who are

visitors increased from 73% in round-1 to 83% in round-5.

Trends in selected maternal and neonatal care indicators for recently delivered women across CBTS

rounds were provided in table 2. Three or more ANC visits to a health facility were also increased

from 73% in round-1 to 92% in round-5. We also found more women delivering in an institution and

staying 48 or more hours in the health facility after the delivery across various CBTS rounds. PNC visit

by ASHA in the home within one month of delivery did not show any improvement across various

rounds of CBTS. However, we identified a gradual increment in the continuum of maternal and

neonatal care over the time period in the study area. Initiation of breast feeding within one hour of

delivery was also improved over the time period. The test for trends across various rounds of CBTS

was also showed significant difference over time for all the outcome variables studied, excluding

PNC visit by ASHA in the home within one month of delivery.

Table 3 provides the results of logistic model showing the changes in the institutional delivery across

various rounds of CBTS as compared to first round of CBTS. Institutional delivery is an important

opportunity to reduce maternal and neonatal deaths because intrapartum care is more easily

provided in a health centre. The results indicated that institutional delivery was increased

significantly in round-5 as compared to first round of CBTS. Though women from BPL households

likely to have higher institutional deliveries its effect was not significant. Non-scheduled caste and

non-scheduled tribe mothers were more likely to delivery in a health facility than scheduled caste or

scheduled tribe mothers. More than three times visit by ASHA during the pregnancy also significantly

improves the likelihood of delivering in a health facility.

Table 4 provides the results of the 48 or more hours of hospital stay by the women after delivery.

Though, we noticed gradual increase in the likelihood of staying in the hospital for 48 or more hours

across the CBTS, the increase was significant only between round-1 and round-4, and round-1 and

round-5. The results also suggest that staying of 48 or more hours in the health facility was

comparatively higher for women who were visited by ASHA more than three times during the

pregnancy. Evidently, increasing the number of ASHA visits in the home during the pregnancy would

improve the hospital stay by the women after delivery.

Continuum of maternal and neonatal care was also significantly improved between CBTS rounds (see

Table 5). Continuum of care was likely to be lower among women aged 20 years and above as

compared to women aged less than 20 years. Non-scheduled caste and non-scheduled tribe women

were likely to have a higher continuum of care than scheduled caste or scheduled tribe women. The

continuum of care was found to be significantly higher among women who were visited by the ASHA

more than three times during the pregnancy.

The odds of initiating the breast feeding within one hour after delivery was lower among women

ages less than 20 years, however the effect was not significant (see table 6). We observed significant

improvement in the initiation of breast feeding within one hour after delivery between various

rounds of CBTS. As observed for other two indicators, three or more visits by ASHA during the

pregnancy improve the initiation of breast feeding within one hour.

Discussion

The purpose of the study was to assess the effect of Sukshema intervention project in Karnataka on

improving the utilisation of maternal and neonatal services in Koppal and Bagalkot districts. There

has been apprehension that traditional study designs, such as cluster randomized designs, are not

always feasible at a time when many programmes are being scaled up in virtually every district16. As

such, we adopted an observational study based on the analysis of data used for continuous

monitoring of different levels of indicators. Prior to the intervention was started we collected the

data on various indicators and this was used for comparing the changes occurred in the intervention

districts.

Lack of attention to demand creation at community level and strategies to promote changes in care

seeking and behaviour were suggested to be important factors for the failure to deliver effective

MNCH interventions at scale17. In the Sukshema project, we addressed this issue by numerous

strategies at the community level that created demand for MNCH services. The community level

intervention introduced a tool used by ASHA which tracks each pregnant women and children for

managing the delivery of outreach services throughout the continuum of care. Use of this tool

envisaged to strengthen the accountability and shape demand from the community. ASHA’s used

HBMNC tool to improve the quality of interactions with the women and as a checklist for screening

and linking the women to appropriate services required. FFC tools were used by ASHA during her

home visits to enhance community knowledge and awareness and influence practices on key MNCH

issues. The intervention facilitated the formation of SCMT committees in each village within Village

Health Sanitation and Nutrition Committees (VHSNCs) to strengthen community ownership of and

engagement in planning and monitoring availability, accessibility, quality, utilization and coverage of

MNCH services. In addition, sub-centre forums were created through front line health workers and

members of village health sanitation committees for collectively identifying issues in their individual

areas of work, outline appropriate solutions together and support each other to implement it. At the

health facility level, as a part of on-site nurse mentoring of the PHC staff we introduced

comprehensive case sheets that prompts the staff nurse of potential complications. The routine on-

site nurse mentoring of the staff nurse regarding the clinical and service delivery issues strengthen

the clinical knowledge as well as improve the skills and practices. As such, on-site mentoring

strengthens the correct referrals as well as follow-up care and improves the provider and client

satisfaction.

The discussed interventions implemented in the Sukshema districts might have created

improvements in the utilisation of MNCH care services through improved knowledge and shaping

demand from the community members. The analysis of routine monitoring data over different time

periods in Bagalkot and Koppal districts suggested improvements in the MNCH outcome indicators.

Evidence indicates that the first two days after birth are critical period of vulnerability for

postpartum mothers and their newborns. Thus a minimum of 48 hours of stay in the hospital is

important for monitoring and assessment of maternal and neonatal well being. In the study districts,

the likelihood of staying in hospital for 48 or hours was increased over the time period. Continuum

of maternal and neonatal care which includes 3 or more antenatal visits at facility, institutional

delivery, 48 or more hours of hospital stay, and post natal visit by ASHA at home was also improved

within two year period. Since the early initiation of breastfeeding provides benefits for both the

baby and the mother, the World Health Organization recommended that breastfeeding be initiated

within one hour of birth18. We identified that the breastfeeding within one hour of birth was

increased significantly over the time period in two districts were project Sukshema was

implemented. Since the Sukshema project was taken into account the potential of increasing

community engagement and demand creation through ASHA and on-site nurse mentoring, we

believe that our approach made a significant difference to the MNCH outcomes in the study districts

as indicated by recent community based studies19-21,6.

The study has some limitations. Since, our study was observational, we were not able to attribute

the change that observed in the MNCH outcome indicators to the Sukshema intervention. However,

we believe that within a short span of two years the gradual change observed in the study districts

was not possible without the activities carried out in the Sukshema project. We noticed significant

changes in the distribution of women according to holding of BPL card between round-1 and other

study rounds. In the first round of CBTS, the interviewers were instructed to consider the BPL

certificate from the village panchayat office and not to consider ration card for identifying women

from the BPL household. However, in the subsequent rounds of survey, the interviewers considered

ration card for identifying women from the BPL household. The data accessed online through the

department of Food, Civil Supplies & Consumer Affairs, Government of Karnataka indicated that

around 54 and 64 percent of the HHs in Bagalkot and Koppal districts have BPL cards22. So, it may be

possible that the data from round-1 CBTS underestimated the women with BPL cards. However,

multivariate analysis did not suggest any variation in the MNCH outcomes according to status of BPL

card holding.

References

1. WHO, UNICEF, UNFPA, The World Bank. Trends in Maternal Mortality: 1990 to 2010. Geneva: The

World Health Organization; 2012.

2. You D, Jones G, Wardlaw T. Levels & Trends in Child Mortality: Report 2011. Estimates Developed

by the UN Inter-Agency Group for Child Mortality Estimation (35th edition). New York: United

Nations Children’s Fund; 2011:1–24.

http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf.

3. Social Statistics Division. Towards Achieving Millennium Development Goals India 2013, Ministry

of Statistics and Programme Implementation, Government of India

http://mospi.nic.in/mospi_new/upload/MDG_pamphlet29oct2013.pdf.

http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf

http://mospi.nic.in/mospi_new/upload/MDG_pamphlet29oct2013.pdf

4. Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, et al. Alma-Ata: Rebirth

and Revision 5. Community participation: lessons for maternal, newborn, and child health. Lancet

2008, 372: 962-71.

5. Bryce J, Daelmans B, Dwivedi A, Fauveau V, Lawn JE, Mason E, et al. Countdown to 2015 for

maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet

2008, 371: 1247–58.

6. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a

participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised

controlled trial. Lancet 2004, 364: 970–979.

7. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-

based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a

cluster-randomised controlled trial. Lancet 2008, 372:1151–1162.

8. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-

based newborn-care intervention package implemented through two service-delivery strategies in

Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008, 371:1936–1944.

9. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, et al., Evidence-based, Cost-

effective Interventions: How Many Newborn Babies Can We Save?. Lancet 2005, 365:977–88.

10. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care

and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999, 354:1955–61.

11. Adam Wagstaff and Mariam Claeson, The Millennium Development Goals for Health: Rising to

the Challenges. Washington, DC:World Bank 2004.

12. van Lonkhuijzen L, Dijkman A, van Roosmalen J, Zeeman G, Scherpbier A. A systematic review of

the effectiveness of training in emergency obstetric care in low-resource environments. BJOG 2010,

117:777–787.

13. Ministry of Health and Family Welfare (MOHFW). 2006. National Rural Health Mission (2005-2012), Mission Document. New Delhi: MOHFW.

14. International Institute for Population Sciences (IIPS) and Macro International. 2007. National

Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS

15. International Institute for Population Sciences (IIPS) 2010. District Level Household and Facility

Survey 2007-08: India, Mumbai:IIPS.

16. Victora CG,Black RE, Boerma JT, Bryce J. Measuring impact in the Millennium Development Goal

era and beyond: a new approach to large-scale effectiveness evaluations. Lancet 2011, 377:85–95.

17. Bhutta ZA, Ali S, Cousens S, Ali TM, Haider BA, Rizvi A, et al. Interventions to address maternal,

newborn, and child survival: what difference can integrated primary health care strategies make?.

Lancet 2008, 372:972–89.

18. World Health Organization and UNICEF. Global Strategy for Infant and Young Child Feeding.

Geneva; 2003.

19. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of

community-based newborn-care intervention package implemented through two service-delivery

strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008, 371:

1936–44.

20. Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and

perinatal and maternal mortality in Pakistan. N Engl J Med 2005, 352:2091–99.

21. Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J. Implementing community-based

perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ 2008, 86:452–59.

22. The Department of Food, Civil Supplies & Consumer Affairs, Government of Karnataka. Source:

http://ahara.kar.nic.in/fcsstat/#bottom accessed on: Aug 6 2014 3:00AM

Table 1: Percentage distribution of recently delivered mothers according to selected background characteristics in different rounds of CBTS

Characteristics Round-1 Round-2 Round-3 Round-4 Round-5

Age group

<20 7.5 7.6 6.6 5.8 7.6

20-24 60.2 63.0 61.5 60.4 62.4

25-29 28.6 25.8 28.8 30.1 27.3

30+ 3.7 3.6 3.0 3.8 2.7

Caste

Scheduled caste/Scheduled tribe 30.9 30.8 31.0 31.5 32.8

None 69.1 69.2 69.0 68.5 67.2

Household has BPL card

No 62.9 28.7 29.9 32.9 24.9

Yes 37.1 71.3 70.1 67.1 75.1

Residential status

Usual resident 26.6 22.5 21.4 18.9 17.0

Visitor 73.4 77.5 78.6 81.1 83.0

Name of district

Bagalkot 49.1 46.0 50.1 47.6 49.0

Koppal 50.9 54.0 49.9 52.4 51.0

Number of cases 1731 1113 1159 1171 1101

http://ahara.kar.nic.in/fcsstat/#bottom

Table 2: Trends in selected maternal and neonatal care indicators for births during the two months prior to the survey

Indicator Round-1 Round-2 Round-3 Round-4 Round-5 p-value for trend

Percent of women who received three or more ANC services in a health facility 73.3 82.8 88 93.4 92.2 <0.001

Percent of women who delivered in a health facility 86.0 89.8 87.3 89.6 91.6 <0.001

Percent of women who stayed in a health facility for 48 or more hours 46.9 47.4 47.9 53.4 52.3 <0.001

Percent of women who received PNC visit by ASHA within one month of delivery 77.2 79.2 80.0 74.0 78.5 0.616

Percent of women who received continuum of care

1 29.3 33.7 37.4 38.9 39.7 <0.001

Percent of women who initiated breastfeeding within one hour of delivery 43.2 45.7 47.3 53.6 54.1 <0.001

Number of cases 1731 1113 1159 1171 1101 1 Include, women who received three ANC visits in a health facility, who had institutional delivery, who stayed in the

health facility for 48 or more hours, and who received PNC visit by ASHA at home.

Table 3: Logistic regression results of women who delivered in a health facility

Characteristics Round-1 compared to Round-2

Round-1 compared to Round-3



AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI

Age group <20 (Ref.) 20-24 0.94 0.58 1.54 0.84 0.51 1.37 0.78 0.45 1.34 1.00 0.61 1.65

25-29 0.43 0.26 0.72 0.44 0.26 0.72 0.36 0.21 0.63 0.48 0.29 0.79

30+ 0.42 0.21 0.84 0.40 0.20 0.79 0.57 0.26 1.24 0.47 0.23 0.97 Caste

Scheduled caste/Scheduled tribe (Ref.)

None 1.86 1.47 2.35 1.73 1.38 2.17 1.73 1.37 2.18 1.61 1.26 2.05 Household has BPL card

No (Ref.) Yes 1.27 0.99 1.62 1.23 0.97 1.55 1.38 1.09 1.75 1.27 0.98 1.63

Residential status

Usual resident (Ref.) Visitor 1.09 0.84 1.41 0.82 0.63 1.07 0.93 0.71 1.22 0.84 0.63 1.12

Round

1 1.31 1.02 1.70 1.03 0.82 1.31 1.30 1.01 1.67 1.68 1.27 2.21

ASHA visited women more than three times during the pregnancy

No (Ref.) Yes 1.38 1.09 1.75 1.33 1.06 1.67 1.60 1.27 2.01 1.43 1.13 1.82

Name of district

Bagalkot (Ref.) Koppal 0.50 0.39 0.64 0.45 0.35 0.56 0.45 0.36 0.58 0.40 0.31 0.51

Model chi2 (p-value) 121.66 (<0.001) 115.09 (<0.001) 134.01 (<0.001) 139.14 (<0.001)

Pseudo R2 0.0567 0.0504 0.0611 0.0677 1

Round-1 is the reference category.

Table 4: Logistic regression results of women stayed 48 hours or more in a health facility






Age group <20 (Ref.)

20-24 0.91 0.69 1.21 1.07 0.80 1.43 0.80 0.60 1.08 0.83 0.62 1.11

25-29 0.65 0.48 0.88 0.77 0.57 1.05 0.55 0.40 0.76 0.56 0.41 0.76

30+ 0.84 0.52 1.36 0.76 0.46 1.24 0.68 0.42 1.11 0.67 0.41 1.10 Caste



No (Ref.)

Yes 0.86 0.73 1.00 0.87 0.74 1.02 0.97 0.83 1.13 0.92 0.78 1.08 Residential status

Usual resident (Ref.)

Visitor 1.20 1.00 1.43 1.05 0.88 1.25 1.02 0.85 1.22 1.03 0.85 1.24 Round

1 1.06 0.90 1.25 1.07 0.91 1.25 1.30 1.11 1.52 1.26 1.07 1.49


No (Ref.)

Yes 1.07 0.92 1.25 1.17 1.01 1.37 1.22 1.05 1.42 1.18 1.02 1.38 Name of district


Model chi2 (p-value) 42.53 (<0.001) 42.65 (<0.001) 60.23 (<0.001) 54.56 (<0.001)

Pseudo R2 0.0108 0.0107 0.0150 0.0139 1


Table 5: Logistic regression results of women received continuum of care







20-24 0.97 0.72 1.33 1.06 0.77 1.44 0.77 0.56 1.05 0.89 0.66 1.21

25-29 0.76 0.54 1.06 0.81 0.58 1.13 0.59 0.43 0.83 0.62 0.45 0.86

30+ 0.72 0.42 1.23 0.72 0.41 1.25 0.52 0.30 0.88 0.56 0.32 0.97 Caste

Scheduled caste/Scheduled tribe (Ref.) None 1.23 1.02 1.47 1.31 1.09 1.56 1.14 0.96 1.36 1.26 1.05 1.50

Household has BPL card

No (Ref.)



Round

1 1.25 1.05 1.49 1.38 1.16 1.63 1.45 1.23 1.72 1.50 1.25 1.79


No (Ref.) Yes 2.05 1.73 2.43 1.97 1.67 2.33 2.11 1.78 2.49 2.16 1.83 2.56

Name of district


Model chi2 (p-value) 100.85 (<0.001) 108.24 (<0.001) 143.58 (<0.001) 145.91 (<0.001)

Pseudo R2 0.0287 0.0298 0.0391 0.0406 1


Table 6: Logistic regression results of women who breastfed the child within one hour of delivery







20-24 1.41 1.05 1.90 1.08 0.81 1.45 1.33 0.98 1.80 1.01 0.76 1.35

25-29 1.56 1.14 2.15 1.37 1.00 1.87 1.42 1.03 1.97 1.36 1.00 1.85

30+ 1.05 0.64 1.73 1.06 0.64 1.73 1.35 0.83 2.20 0.94 0.57 1.55 Caste



No (Ref.)



Round

1 1.04 0.88 1.22 1.13 0.97 1.33 1.41 1.21 1.65 1.42 1.21 1.68


No (Ref.)

Yes 1.35 1.16 1.58 1.15 0.99 1.34 1.31 1.13 1.53 1.20 1.03 1.39 Name of district

Bagalkot (Ref.)

Koppal 0.86 0.74 1.00 0.86 0.74 1.00 0.81 0.70 0.94 0.90 0.77 1.05

Model chi2 (p-value) 34.41 (0.001) 20.64 (0.0143) 50.73 (<0.001) 54.42 (<0.001)

Pseudo R2 0.0088 0.0052 0.0127 0.0139 1


assessment of an intervention on improving the maternal ... · delivery and postnatal care despite...

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