Institute for Global Public Health, University of Manitoba, R070 Medical Rehabilitation Building, 771 McDermot Avenue, Winnipeg, R3E 0T6, Canada.
India Health Action Trust, 404, 4th Floor Ratan Square, Vidhan Sabha Marg, Lucknow, 226001, India.
Int J Equity Health. 2021 Feb 23;20(1):63. doi: 10.1186/s12939-021-01406-5.
Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India.
We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach.
Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss.
The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.
尽管围产期死亡（死产和早期新生儿死亡）大幅减少，但印度的围产儿死亡率仍然很高，无论是在全国范围内还是在个别邦。在弱势社会经济群体中，这一比率最高。为了解决这个问题，印度国家卫生使命培训了社区卫生工作者，称为认证社会卫生活动家（ASHAs），通过在分娩前后家访，为妇女提供咨询和支持。我们进行了一项定性研究，探索在印度北方邦（UP）农村地区，ASHAs 的家访如何改善社会经济地位群体之间围产期健康的公平性。
我们在 UP 的两个区的四个村庄进行了社会测绘，然后在每个村庄进行了三次焦点小组讨论（共 12 次），参与者包括 ASHAs 和最近分娩的属于“较高”和“较低”社会经济地位群体的妇女（共 134 名参与者）。我们使用主题框架方法在 NVivo 和 Dedoose 中分析数据。
家访使 ASHAs 能够与妇女建立信任关系，提供有关卫生服务、计划和预防保健的信息，并为获得产妇保健提供实际支持。这帮助了许多妇女和家庭为分娩做准备，并促使她们在卫生设施分娩。特别是，ASHAs 鼓励那些更贫穷、受教育程度更低或来自较低种姓群体的妇女在公共社区保健中心（CHC）分娩。然而，在 CHC 分娩的妇女经常经历不足的紧急产科护理、工作人员的虐待、间接费用、缺乏药物以及在出现并发症时转诊到更高一级的设施。转诊往往导致延误和更高的费用，这对被认为社会经济地位较低或居住在偏远地区的家庭造成了最大的负担，并增加了他们经历围产期损失的风险。
该研究发现，ASHAs 与许多社会经济地位较低的孕妇建立了关系，为她们提供了咨询和支持。卫生设施分娩和围产儿死亡率方面持续存在的不平等现象，是 ASHAs 职权范围之外的重叠背景问题造成的。需要支持 ASHAs 与社区组织和更广泛的卫生系统战略的整合，以解决这些问题，并优化干预覆盖、过程和围产儿健康结果之间的公平性途径。
