Changing Behavioral Patterns Related to Maternity and Childbirth in Rural and Poor Populations: A Critical Review

Abstract

While life expectancy has increased worldwide in recent decades, dramatic health inequalities persist across and within countries and between different population groups. Maternal mortality in low-and middle-income countries is almost fifty times that of high-income countries, while neonatal mortality is nine times higher, and both are consistently higher in rural, poor, and indigenous populations. Despite important efforts to expand the supply of health services to disadvantaged populations, these inequalities have not fallen as expected. As a result, more emphasis is now being placed on demand strategies in an effort to change behavioral patterns related to maternity and childbirth. This review surveys the experimental and quasi-experimental literature in the area of maternal and neonatal health in rural and poor areas of developing countries to identify strategies that are capable of modifying demand behavior and thereby impacting key indicators. We analyze three kinds of strategies: those covering direct costs, promotion of social and cultural changes, and introduction of incentives. We find significant results from the combination of individual counselling and women groups in the community, as well as from the introduction of small incentives as opposed to more expensive Cash Conditional Transfers (CCTs). We conclude with lessons for impact evaluation and policy-making.

Testing a Practitioner-Friendly Behavior Model in Pakistan, India, and Nigeria

“…Strategies to improve maternal and child health primarily through extending the supply of health services are no longer considered su cient [1]. To reduce global maternal and child mortality and morbidity, for example, research that identi es barriers to the utilization of health services is a high priority [2]. Effective health services utilization can only occur when individuals seek appropriate care and when the health system has the capacity to provide that care [3].…”

“…There is increasing recognition of the need to take on the challenge of changing behavior related to women's seeking of maternal and child health services, in conjunction with strategies to improve the quality of services [2]. A key theme that emerges from systematic reviews is the inconsistent effectiveness of clinical behavior change efforts.…”

Public Health Insurance and Maternal Health Care Utilization in India: Evidence from a 2005-2012 Mothers’ Cohort Study

“…A socio-cultural preference for home-based childbirth and viewing childbirth as a natural occurrence not needing professional assistance have been prevalent in India [14]. Garcia-Prado (p.96) [58] notes that "With respect to demand, the biggest challenge is to change behavioral patterns related to maternity and childbirth and promote the use of health services that can reduce maternal and neonatal deaths". There is evidence that Accredited Social Health Activists (ASHAs), who provide counselling to pregnant women and arrange for their care, have helped to change the society's attitude towards maternity care.…”

Implementation of the ‘Optimising the Health Extension Program’ Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

“…12 This activity was not planned to be implemented in eight districts where no budget was allocated for this activity. 13 This activity was not planned to be implemented in eight districts where no budget was allocated for this activity. 14 This activity was not planned to be implemented in eight districts where no budget was allocated for this activity.…”

“…Research suggests that interventions to improve care-seeking at the community level will be most successful if they are linked to the health system and target both supply-and demand-side issues [11][12][13][14]. Guided by these principles, the Ethiopian Ministry of Health, in partnership with four non-governmental organisations (NGOs), initiated a complex intervention to improve the utilisation of community-based child health services.…”