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Previous research on sex ratio at birth (SRB) in India has largely relied on macro‐analysis of census data that do not contain the breadth of factors needed to explain patterns in SRB. Additionally, no previous research has examined the differentiation of factors associated with SRB across birth orders, a key determinant in societies affected by son preference. This study aims to fill these gaps using micro‐data related to 553,461 births occurring between 2005 and 2016 collected as part of the 2015–2016 National Family Health Survey. Analyses used multivariable logistic regressions stratified by birth order to examine associations with SRB at the national level. The SRB at birth order 1 was outside the biological normal limit, and generally increased with birth order. First births in households with wealth in the middle and richest quintiles, with mothers who desired a higher ideal number of sons than daughters, and in lower fertility communities had a higher probability of being male. Most SRB correlates were visible at birth orders 3 or higher. Programs and policies designed to address India's male‐skewed SRB must consider the diverse factors that influence SRB, particularly for higher order births.

Background This study aims to explore the potential association between unintended pregnancy and maternal health complications. Secondarily, we test whether antenatal care (ANC) and community health worker (CHW) visits moderate the observed association between unintended pregnancy and maternal health complications. Methods Cross sectional data were collected using a multistage sampling design to identify women who had a live birth in the last 12 months across 25 highest risk districts of Uttar Pradesh (N = 3659). Participants were surveyed on demographics, unintendedness of last pregnancy, receipt of ANC clinical visits and community outreach during pregnancy, and maternal complications. Regression models described the relations between unintended pregnancy and maternal complications. To determine if receipt of ANC and CHW visits in pregnancy moderated associations between unintended pregnancy and maternal complications, we used the Mantel-Haenzel risk estimation test and stratified logistic models testing interactions of unintended pregnancy and receipt of health services to predict maternal complications. Results Around one-fifth of the women (16.9%) reported that their previous pregnancy was unintended. Logistic regression analyses revealed that unintended pregnancy was significantly associated with maternal complications- pre-eclampsia (AOR:2.06; 95% CI:1.57–2.72), postpartum hemorrhage (AOR:1.46; 95% CI: 1.01–2.13) and postpartum pre-eclampsia (AOR:2.34; 95% CI:1.47–3.72). Results from the Mantel Haenszel test indicated that both ANC and CHW home visit in pregnancy significantly affect the association between unintended pregnancy and postpartum hemorrhage (p Conclusion Unintended pregnancy is associated with increased risk for maternal health complications, but provision of ANC clinical visits and CHW home visits in pregnancy may be able to reduce potential effects of unintended pregnancy on maternal health.

Background Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors. Methods The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups. Results Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76–13.7, p p p Conclusions The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach’s sustainability needs to be further examined.

Background The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0–2, 3–7, and 8–27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. Methods Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. Results The NMR 0–2-day, 3–7-day, and 8–27-day mortality estimates in 2016 were 24.7 (95% CI 21.8–28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0–2-day mortality. In the final regression model, the highest odds for mortality in 0–2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9–22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3–7- and 8–27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31–16.90, and OR 4.88, 95% CI 3.13–7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39–11.10, and OR 11.77, 95% CI 6.43–21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0–2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3–7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8–27 days. Conclusions To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0–2 days versus the rest of the neonatal period. Monitoring mortality at 0–2 and 3–7 days separately in the traditional early neonatal period of 0–7 days would enable more effective programming to reduce neonatal mortality. Electronic supplementary material The online version of this article (10.1186/s12916-019-1372-z) contains supplementary material, which is available to authorized users.

Summary Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Objective To assess the effects of new-born care intervention through self-help groups in improving new-born healthcare practices in rural India. Methods A quasi-experimental design was used to evaluate behavioral change intervention integrated in >25,000 microfinance-based self-help groups in rural Bihar. Three rounds of cross-sectional surveys were conducted to understand the impact of intervention on new-born healthcare practices by talking to women who delivered a baby in the last 6 months. Results Intervention groups showed greater improvement than control groups in the timely initiation of breastfeeding (adjusted odds ratio (AOR) = 6.3, 95% CI: 2.8, 14.3), exclusive breastfeeding on day 1 (AOR = 4.3, 95% CI: 1.9, 9.9), initiation of skin-to-skin care (AOR = 1.9, CI: 1.0, 3.8), and delayed bathing (AOR = 2.8, 95% CI: 1.4, 5.9) with greater effect of on home deliveries where clinical care is often absent. Conclusion Sharing messages on appropriate new-born practices through self-help groups improve new-born care practices.

Background Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. Methods A model for health layering of SHGs – Parivartan – was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. Results In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. Conclusions Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. Study registration ClinicalTrials.gov number NCT02726230

BackgroundIndia suffers some of the highest maternal and neonatal mortality rates in the world. Intimate partner violence (IPV) can be a barrier to utilization of perinatal care, and has been associated with poor maternal and neonatal health outcomes. However, studies that assess the relationship between IPV and perinatal health care often focus solely on receipt of services, and not the quality of the services received.Methods and findingsData were collected in 2016-2017 from a representative sample of women (15-49yrs) in Uttar Pradesh, India who had given birth within the previous 12 months (N = 5020), including use of perinatal health services and past 12 months experiences of physical and sexual IPV. Multivariate logistic regression models assessed whether physical or sexual IPV were associated with perinatal health service utilization and quality. Reports of IPV were not associated with odds of receiving antenatal care or a health worker home visit during the third trimester, but physical IPV was associated with fewer diagnostic tests during antenatal visits (beta = -0.30), and fewer health topics covered during home visits (beta = -0.44). Recent physical and recent sexual IPV were both associated with decreased odds of institutional delivery (physical IPV AOR 0.65; sexual IPV AOR 0.61), and recent sexual IPV was associated with leaving a delivery facility earlier than recommended (AOR = 1.87). Neither form of IPV was associated with receipt of a postnatal home visit, but recent physical IPV was associated with fewer health topics discussed during such visits (beta = -0.26).ConclusionsIn this study, reduced quantity and quality of perinatal health care were associated with recent IPV experiences. In cases where IPV was not related to care receipt, IPV remained associated with diminished care quality. Additional study to understand the mechanisms underlying associations between IPV and care qualities is required to inform health services.

Increasing modern contraceptive use and gender equity are major foci of the recently ratified Sustainable Development Goals for 2030 and the Government of India. Coercion and sabotage by husbands and in-laws to inhibit women's access, initiation, continuation, and successful use of modern contraception methods (i.e., reproductive coercion) may contribute to low usage rates and unintended pregnancy in India; however, little is known about the extent of this problem. The current study assesses the prevalence of reproductive coercion, both husband and in-law perpetrated, among a large population-based sample. Data were collected from currently married women of reproductive age (15–49 years; N = 1770) across 49 districts of Uttar Pradesh as part of an evaluation of a broad effort to improve the public health system in the state. Dependent variables included modern contraceptive use in the past 12 months, unintended pregnancy, and pregnancy termination. Independent variables included ever experiencing reproductive coercion (RC) by a current husband or in-laws and lifetime experience of physical and sexual intimate partner violence (IPV) by a current husband. Approximately 1 in 8 (12%) women reported ever experiencing RC from their current husbands or in-laws; 42% of these women reported RC by husbands only, 48% reported RC by in-laws only, and 10% reported RC by both husbands and in-laws. Among women experiencing RC, more than one-third (36%) reported that their most recent pregnancy was unintended; these women had 4 to 5 times greater odds of unintended pregnancy and a more than 5 times decreased likelihood of recent use of modern contraceptives than women not experiencing RC, after accounting for effects of demographics and physical and sexual IPV. Scalable and sustainable interventions in both clinical and community settings are needed to reduce RC, a potentially key factor in effective strategies for improving women's reproductive autonomy and health in India and globally., Highlights • 1 in 8 women in Uttar Pradesh report reproductive coercion from husbands or in-laws. • Husbands and in-laws were responsible for RC in similar measure (42% and 48%). • Experiencing RC related to 4–5x greater odds of recent unintended pregnancy. • Experiencing RC related to 5x decreased odds of recent contraceptive use. • Reducing RC is key to improving women's reproductive autonomy and health.

Background mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes. Methods The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups. Results The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P

IntroductionWe evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.MethodsThis study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.ResultsThe TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial’s goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.ConclusionResults suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW–beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.Trial registration numberNCT03406221

Introduction Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India. Data and methods This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment. Results There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5-4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs. Conclusions Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.

Background: Low availability of women physicians in rural areas can compromise women's health care seeking, where need can be greatest. We examined the associations between availability of women physicians and maternal and child health service utilization in India. Methods: We analyzed cross-sectional district-level data from all 256 districts in 18 states, from India's District-Level Household and Facility Survey (2012–13) and the National Family Health Survey (2015–16). Assessed measures included lady medical officers (LMOs) availability at Primary Health Centers (PHCs, which are largely rural serving), modern contraceptive use, antenatal care (ANC), skilled birth attendance (SBA), maternal postnatal care (PNC), infant PNC, and child immunization. Multilevel regression models nesting districts in states examined associations between LMO availability and health service utilization, adjusting for district-level socioeconomic status (SES) indicators (e.g., women's education, household water access), urbanicity, health insurance coverage and sampled PHCs (15 on average) within districts. Findings: Only 72 of 256 districts (28.1%) reported >50% of PHCs with LMOs. In multivariable models, LMO availability in PHCs was associated with higher district prevalence (%) of modern contraceptive use [β=0.04 (95% CI: 0.007, 0.08)], 4+ ANC [β =0.07 (95% CI: 0.008, 0.13)], skilled birth attendance [β=0.09 (0.03, 0.14) and maternal PNC [β=0.08 (95% CI: 0.03, 0.12)], but not infant PNC or child immunization. Interpretation: Higher district availability of women physicians is associated with higher maternal health care utilization but not child health care utilization. Improving gender parity in the physician workforce and rural women physician access may improve maternal health care use in India. Keywords: Female physicians, Women doctors, Maternal and child health services, Health workforce, Gender equity

Highlights • Ownership of a bank account is associated with improved reproductive and maternal health services utilization and behaviour. • Observed associations are strongest in states where the utilization of studied services is far below the national average. • No association is found between women's ownership of a bank account and institutional delivery.

Background: Maternal, newborn and child health (MNCH) interventions with women's self-help groups (SHGs) can improve its outcomes in rural communities through addressing health system barriers, and empowering women. We assessed the effect of large-scale implementation of health interventions integrated within SHGs compared with standard group settings, on group advocacy, women's self-determination, and norms around health care service delivery. Methods: Using a pre-post quasi-experimental design, 33 geographic blocks were divided into two groups: intervention and comparison. SHG women in comparison blocks received the usual microcredit program, and SHG members in intervention blocks received additional participatory training around MNCH issues through a community mobilizer who led at least one health meeting a month. Two cross-sectional surveys in 2013 (N= 2407) and 2016 (N=2974) were conducted among eligible women (i.e., 18-49 years, married, SHG member and had a live birth within 12 months). The outcomes in the study were: collective agency to negotiate with health center/workers, women's self-advocacy with health workers, self-confidence in accessing health services, and services from health workers including respectful care. Outcome effects were assessed using difference-in-differences (DID) methods. Findings: Of the 5089 women interviewed across the two-time points, the mean age was 26 (±4·7) years. The intervention improved women's collective agency to demand for services and improved key healthcare system related factors: self-advocacy with local health facility (DID: 16 percentage points[pp], p

While the health-related benefits of contraceptive use for women are well documented, potential social benefits, including enabling women’s employment, have not been well researched. We examine the relationship between contraceptive use and women’s employment in India, a country where both factors have remained relatively static over the past ten years. We use data from India’s 2015–16 National Family Health Survey to test the association between current contraceptive use (none, sterilization, IUD, condom, pill, rhythm method or withdrawal) and current employment status (none, professional, clerical or sales, agricultural, services or production) with multivariable, multinomial regression; variable selection was guided by a directed acyclic graph. More than three-quarters of women in this sample were currently using contraception; sterilization was most common. Women who were sterilized or chose traditional contraception, relative to those not using contraception, were more likely to be employed in the agricultural and production sectors, versus not being employed (sterilization adjusted relative risk ratio [aRRR] = 1.5, p

Background India has the highest rate of excess female infant deaths in the world. Studies with decade-old data suggest gender inequities in infant health care seeking, but little new large-scale research has examined this issue. We assessed differences in health care utilization by sex of the child, using 2014 data for Bihar, India. Methods This was a cross-sectional analysis of statewide representative survey data collected for a non-blinded maternal and child health evaluation study. Participants included mothers of living singleton infants (n = 11 570). Sex was the main exposure. Outcomes included neonatal illness, care seeking for neonatal illness, hospitalization, facility-based postnatal visits, immunizations, and postnatal home visits by frontline workers. Analyses were conducted via multiple logistic regression with survey weights. Findings The estimated infant sex ratio was 863 females per 1000 males. Females had lower rates of reported neonatal illness (odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.6–0.9) and hospitalization during infancy (OR = 0.4, 95% CI = 0.3–0.6). Girl neonates had a significantly lower odds of receiving care if ill (80.6% vs 89.1%; OR = 0.5; 95% CI = 0.3–0.8) and lower odds of having a postnatal checkup visit within one month of birth (5.4% vs 7.3%; OR = 0.7, 95% CI = 0.6–0.9). The gender inequity in care seeking was more profound at lower wealth and higher numbers of siblings. Gender differences in immunization and frontline worker visits were not seen. Interpretation Girls in Bihar have lower odds than boys of receiving facility–based curative and preventive care, and this inequity may partially explain the persistent sex ratio imbalance and excess female mortality. Frontline worker home visits may offer a means of helping better support care for girls.

To assess the effects of new-born care intervention through self-help groups in improving new-born healthcare practices in rural India.A quasi-experimental design was used to evaluate behavioral change intervention integrated in25,000 microfinance-based self-help groups in rural Bihar. Three rounds of cross-sectional surveys were conducted to understand the impact of intervention on new-born healthcare practices by talking to women who delivered a baby in the last 6 months.Intervention groups showed greater improvement than control groups in the timely initiation of breastfeeding (adjusted odds ratio (AOR) = 6.3, 95% CI: 2.8, 14.3), exclusive breastfeeding on day 1 (AOR = 4.3, 95% CI: 1.9, 9.9), initiation of skin-to-skin care (AOR = 1.9, CI: 1.0, 3.8), and delayed bathing (AOR = 2.8, 95% CI: 1.4, 5.9) with greater effect of on home deliveries where clinical care is often absent.Sharing messages on appropriate new-born practices through self-help groups improve new-born care practices.