Who Gets the Message – and What Is It?

The Challenge

For women in rural India, community healthcare workers provide essential reproductive, maternal, and neonatal care. But studies report mixed results on the effectiveness of those efforts with pregnant women. How can community healthcare workers be helped to navigate the complex web of decision-making in rural Indian households, where husbands and mothers-in-law are also heavily involved in pregnant women’s healthcare decisions?

Our Approach

We investigated the impact of community healthcare workers in rural parts of Uttar Pradesh in India, through questionnaires and face-to-face interviews with women who’d recently given birth, their husbands, mothers-in-law, and their assigned ASHAs (community healthcare workers).

Key Results

• We learned that the content, message, and recipient of communications all mattered in different ways. ASHAs need to target their efforts more precisely to serve pregnant women – which means the right number of visits, at the right time, targeting the right household members with the right messages.
• We identified positive outcomes associated with targeted counseling messages to specific household members.
• We found that training the workers on the most effective messages and how to deliver them to different members of the household could improve health indicators for mothers and babies.

In India, community health workers known as ASHAs (Accredited Social Health Activists) provide essential counseling and care to vulnerable women. But it’s hard to gauge the precise impact of their work, and therefore to know how ASHAs can best support their patients. 

To learn more, we gathered data on the health behaviors of pregnant women and new mothers, and the specific activities of ASHAs, through a detailed questionnaire and in-person interviews with more than 5,400 women in Uttar Pradesh state who had recently given birth, as well as their husbands, mothers-in-law, and ASHAs. We focused on outcomes known to be important for maternal and infant health, such as attending three or more antenatal checkups, taking nutritional supplements, having an institutional delivery (i.e. in a clinic or hospital), and breastfeeding. We also inquired about ASHAs’ behaviors, such as the number and timing of their prenatal and postnatal visits and whether they were present for the birth.

The most important insight from our study was that what ASHAs said and did made a difference in driving desired health behaviors among pregnant women and new mothers. Receiving at least one home visit, for example, was strongly associated with the pregnant woman attending three or more checkups and taking iron and folic acid supplements. But there are things we can do to increase the impact of ASHAs’ work. For instance, it matters who they direct their messages to. Speaking with the mother-in-law about breastfeeding had a positive relationship with the rate of exclusive breastfeeding. Encouraging institutional delivery proved most effective when the ASHA spoke with the husband, who is generally responsible for household financial decisions, and the mother-in-law, rather than the pregnant woman. 

Our in-depth, data-driven research illuminated the complexity of improving health outcomes for pregnant women and their babies, but our findings suggest specific ways to make ASHAs’ efforts more effective. Guidelines might include a home visit with a woman as soon as she learns she is pregnant, and a total of four to six visits during the pregnancy. ASHAs may also need guidance and support to overcome the cultural barriers that can make it difficult to talk to the husband and mother-in-law about maternal health and infant care. Lastly, ASHAs need training to expand their arsenal of behavior change messages so they can learn to read the situation and deploy the most effective message to address the family’s concerns.