Mishra Sujata, Horton Susan, Bhutta Zulfiqar A, Essue Beverley M
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
School of Public Health Sciences, University of Waterloo, Waterloo, Canada.
PLOS Glob Public Health. 2024 Jan 16;4(1):e0002651. doi: 10.1371/journal.pgph.0002651. eCollection 2024.
This study examines the impact of accredited social health activists (ASHAs), on increasing rates of institution-based deliveries among Indian women with a specific focus on the nine low-performing, empowered action group states and Assam (EAGA) in India. Using the latest round of the National Family Health Survey-V (2019-21), we first investigate the association between the use of ASHA services and socio-demographic attributes of women using a multivariate logistic regression. We then use propensity-score matching (PSM) to address observable selection bias in the data and assess the impact of ASHA services on the likelihood of institution-based deliveries using a generalized estimating equations model. Of the 232,920 women in our sample, 55.5% lived in EAGA states. Overall, 63.3% of women (70.6% in EAGA states) reported utilizing ASHA services, and 88.6% had an institution-based delivery (84.0% in EAGA states). Younger women from the poorest wealth index were more likely to use ASHA services and women in rural areas had a two-fold likelihood. Conversely, women with health insurance were less likely to use ASHA services compared to those without. Using PSM, the average treatment effect of using ASHA services on institution-based deliveries was 5.1% for all India (EAGA = 7.4%). The generalized estimating equations model indicated that the use of ASHA services significantly increased the likelihood of institution-based delivery by 1.6 times (95%CI = 1.5-1.7) for all India (EAGA = 1.8; 95%CI = 1.7-1.9). Our study finds that ASHAs are effective in enhancing the uptake of maternal services particularly institution-based deliveries. These findings underscore the necessity for continual, systematic investments to strengthen the ASHA program and to optimize the program's effectiveness in varied settings that rely on the community health worker model, thereby advancing child and maternal health outcomes.
本研究考察了经认可的社会健康活动家（ASHAs）对提高印度妇女机构分娩率的影响，特别关注印度九个表现不佳的赋权行动小组邦和阿萨姆邦（EAGA）。利用最新一轮的全国家庭健康调查五（2019 - 2021年），我们首先使用多元逻辑回归研究了ASHAs服务的使用与妇女社会人口学特征之间的关联。然后，我们使用倾向得分匹配（PSM）来解决数据中可观察到的选择偏差，并使用广义估计方程模型评估ASHAs服务对机构分娩可能性的影响。在我们样本中的232,920名妇女中，55.5%生活在EAGA邦。总体而言，63.3%的妇女（EAGA邦为70.6%）报告使用了ASHAs服务，88.6%的妇女进行了机构分娩（EAGA邦为84.0%）。来自最贫困财富指数组的年轻妇女更有可能使用ASHAs服务，农村地区的妇女使用可能性是两倍。相反，与没有医疗保险的妇女相比，有医疗保险的妇女使用ASHAs服务的可能性较小。使用PSM，在全印度，使用ASHAs服务对机构分娩的平均治疗效果为5.1%（EAGA = 7.4%）。广义估计方程模型表明，在全印度，使用ASHAs服务显著提高了机构分娩的可能性1.6倍（95%CI = 1.5 - 1.7）（EAGA = 1.8；95%CI = 1.7 - 1.9）。我们的研究发现，ASHAs在提高孕产妇服务的利用率，特别是机构分娩方面是有效的。这些发现强调了持续、系统投资以加强ASHAs项目并在依赖社区卫生工作者模式的不同环境中优化该项目有效性的必要性，从而改善儿童和孕产妇健康结果。
