The objective of the current study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives and explanations of health-related beliefs and behaviours during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practises including taboos, superstitions and rituals used to mitigate them. Second, we describe the extent to which these practises are explained as risk-preventing versus health-promoting behaviour. Third, we discuss the extent to which these practises are consistent, inconsistent or unrelated to biomedical health practises and describe the extent to which traditional and biomedical health practises compete, conflict and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practises in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practises can improve the efficacy of health interventions and improve outcomes. This article is part of the theme issue ‘Ritual renaissance: new insights into the most human of behaviours’.

BackgroundMaternal malnutrition is a major source of regional health inequity and contributes to maternal and infant morbidity and mortality. Bihar, a state in eastern India adjacent to Jharkhand and West Bengal, has relatively high neonatal mortality rates because a large portion of infants are born to young mothers. Bihar has the second-highest proportion of underweight children under 3 in India, with infant mortality rates of 48 per 1000 live births. Maternal malnutrition remains a major threat to perinatal health in Bihar, where 58.3% of pregnant women are anaemic.MethodsWe examined dietary beliefs and practices among mothers, mothers-in-law and community members, including Accredited Social Health Activists (ASHAs), using focus group discussions (n=40 groups, 213 participants), key informant interviews (n=50 participants) and quantitative surveys (n=1200 recent mothers and 400 community health workers). We report foods that are added/avoided during the perinatal period, along with stated reasons underlying food choice. We summarise the content of the diet based on responses to the quantitative survey and identify influencers of food choice and stated explanations for adding and avoiding foods.Key findingsAnalyses for all methodologies included gathering frequency counts and running descriptive statistics by food item, recommendation to eat or avoid, pregnancy or post partum, food group and health promoting or risk avoiding. During pregnancy, commonly added foods were generally nutritious (milk, pulses) with explanations for consuming these foods related to promoting health. Commonly avoided foods during pregnancy were also nutritious (wood apples, eggplant) with explanations for avoiding these foods related to miscarriage, newborn appearance and issues with digestion. Post partum, commonly added foods included sweets because they ease digestion whereas commonly avoided foods included eggplants and oily or spicy foods. Family, friends, relatives or neighbours influenced food choice for both mothers and ASHAs more than ASHAs and other health workers.Perinatal dietary beliefs and behaviours are shaped by local gastroecologies or systems of knowledge and practice that surround and inform dietary choices, as well as how those choices are explained and influenced. Our data provide novel insight into how health influencers operating within traditional and biomedical health systems shape the perinatal dietary beliefs of both mothers and community health workers.

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA’s overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.