Saas, bahu, and ASHA: Information diffusion in rural Bihar

India has made significant progress in improving maternal and child health outcomes, and the contribution of ASHAs – female community health workers – in promoting healthcare-seeking behaviour is widely acknowledged. In this context, Dutta et al. discuss findings from their study in rural Bihar and highlight two key issues: mothers-in-law acting as mediators in the interaction between ASHAs and women of reproductive age, and the limited success in influencing educated women from affluent families.

The National Health Mission has resulted in substantially improved maternal and child health (MCH) outcomes in India. For instance, institutional delivery has increased from 38.7% of all births (2005-06) to 78.9% (2015-16); under-five mortality rates, too have decreased from 74 per 1,000 live births to 50 in the same period (International Institute for Population Sciences, 2016). The role of ASHA (accredited social health activists) workers¹ in this transformation has been well-documented (Bajpai et al. 2009, Paul and Pandey 2020). However, the status of MCH outcomes in some states has been historically poor. With the onset of the National Health Mission, however, there has been some progress in some of these states such as Bihar (Ghosh and Husain 2019). In recent research (Dutta et al. 2021), we examine some community- and household-level forces that have played a role in determining the MCH outcomes.

Background

At the start of the millennium, improving MCH outcomes was one of the major challenges facing South Asian countries, including India. Despite impressive economic performance, India failed to attain the Millennium Development Goals with respect to reducing maternal, infant, and child mortality, and is also lagging behind in achieving Sustainable Development Goals in this respect. Other MCH indicators, including nutritional outcomes, too, were poor. Further, there was considerable regional variation in these indicators, with states like Bihar lagging behind.

Figure 1. Maternal and child health indicators, Bihar and all-India

Maternal and child health indicators	1992-93		2005-06
	Bihar	India	Bihar	India
Infant mortality rate (per 1,000)	89.2	78.5	61	57
Under-five mortality rate (per 1,000)	127.5	109.3	84	74
Total fertility rate	4.0	3.4	4.2	3.0
Percentage of mothers with at least three antenatal care check-ups	30.7	43.8	14.5	42.8
Percentage of women adopting modern contraception methods	18.5	33.1	26.8	45.3
Percentage of institutional deliveries	12.1	25.5	18.6	31.1
Percentage of children exclusively breastfed (0-5 months)	51.6	51	27.3	48.3

Source: National Family Health Survey (NFHS)-1 (1992-93); NFHS-4 (2015-16)

In 2005, the Ministry of Health and Family Welfare announced a flagship programme called National Rural Health Mission. Now part of the National Health Mission (since 2013), this programme was successful in improving the health scenario (Nagaran et al. 2015). One of the key components responsible for the success of the programme was the introduction of ASHAs.

ASHAs are local women, recruited as community-level health workers. They are responsible for motivating behavioural change through the dissemination of information and awareness-building about MCH issues. In Bihar, the efforts of ASHAs have been supplemented by the health and nutrition strategy (HNS) of the Bihar Rural Livelihoods Project or JEEViKA². The HNS targets self-help groups under JEEViKA, with community mobilisers³undertaking efforts to spread awareness among group members through monthly meetings. These two strategies have led to an improvement in MCH outcomes (Gupta et al. 2019, World Bank, 2016).

The study

The attempts at behavioural change have created networks of information dissemination within the community, and have also generated exogenous peer effects, with the behaviour of one person being influenced by the behaviour of other community members. As part of International Growth Centre (IGC) research (Dutta, Husain and Ghosh 2021), we examine whether ASHAs have been successful in reaching out to rural households and motivating them to adopt recommended MCH practices. The study addresses the following research questions: (i) What are the adoption levels of MCH practices (for example, availing antenatal care (ANC) services, seeking protection against anaemia and neonatal tetanus, institutional delivery, utilising postnatal care (PNC) services, exclusive breastfeeding of children between 0-5 years of age, and complementary feeding of children aged 6-36 months)?; (ii) Are there any peer effects?; (iii) Who has motivated such changes?; and (iv) What are the characteristics of networks formed to disseminate information about MCH practices?

We conducted a primary survey of 2,250 women who had at least one child aged less than 36 months, across six districts of Bihar⁴ between January and March 2020. This was supplemented by focus group discussions (FGDs) among the women⁵, interviews of ASHAs, and analysis of information networks using social network analytic methods.

Mapping information networks

Analysis of our data, combined with the last two rounds of the National Family Health Survey (NFHS-4, 2015-16; NFHS-5, 2019-20), show that MCH practices have improved in Bihar in recent years (see Figure 2 below). Our analysis also reveals that there is a peer effect with village-level adoption rates being a significant determinant of the decision to adopt MCH practices by an individual, like utilising ANC and PNC services, availing institutional delivery, adopting contraception methods, exclusive breastfeeding of children below six months, supplementary feeding of children above six months, etc.

Figure 2. Maternal health practices in Bihar

Source: Authors’ primary survey; NFHS-4 and NFHS-5.

Notes: The vertical axis measure changes in maternal health practices in percentage.

Participants of FGDs reported that ASHAs were the main motivators underlying the change; and this was confirmed by our statistical analysis of the identity of the main motivator. This is in consonance with similar global studies (Reichenbach 2007) showing that women, even when briefly trained, can successfully increase the utilisation of healthcare services, particularly if they are locally recruited and made accountable to the local clients⁶.

Mapping the information diffusion network revealed a hierarchical network, with the ASHA at the top, neighbours and relatives (including the mother-in-law) at the middle, and the target recipient of the information at the bottom (see Figure 3). Interaction was mostly restricted within the family. It was observed that the saas (mother-in-law) played a very crucial role as the gatekeeper through which ASHA was able to interact with the daughter-in-law (bahu). A participant of the FGDs commented, “Before taking any decision we need to consult our guardian...Now, it is true that our husband is our guardian. But within the household domain, our guardian is the saas. We have to inform her and discuss all these issues before finalising anything…Our husbands are busy with their work, and so they do not have time to guide us or understand what we need. On the other hand, our saas mostly stays at home with us and is more aware of the details of our personal life. Further, these are women-related issues, so a female guardian, like my saas, is better placed to take care of these matters”.

Figure 3. Flow of information from ASHA to target recipient

Acknowledging the power relations existing within the families, ASHAs involved the saas in the interaction with bahus. This reduced friction, and enabled the ASHA to influence the saas, and established a channel of communication between the ASHA and bahu – their target beneficiary.

In contrast, the contribution of the HNS of JEEViKA in inducing behavioural change is less apparent. A low proportion of respondents attributed their behavioural change (higher adoption of recommended MCH practices) to the community mobilisers. As JEEViKA members and their families view the SHGs primarily as an institution enabling more efficient management of household finances, they pay subscriptions regularly⁷. However, as several JEEViKA members acknowledged, “We do not attend HNS meetings regularly”. In fact, over half of the respondents had attended only up to three HNS meetings in the six months preceding the survey. Restrictions on movement outside the household, domestic chores, and the need to look after their children, are the causes cited for the absenteeism of the female members. In such cases, the saas pays the subscription, and even attends the meetings: “I don’t generally step out of the house. Besides, my child is very young, and I have to take care of her…so my saas attends JEEViKA meetings”. Hence, unlike the three-way interaction between ASHA, bahu, and saas, the dialogue in JEEViKA meetings is only between the community mobiliser and the saas. The absence of the bahu in the deliberations implies that that the power of the saas as gatekeeper increases. The information passes through the saas who may use her role as the gatekeeper to distort information, or simply withhold it, to ensure that the bahu adheres to traditional family norms about fertility and MCH practices. A similar finding, has indicated that women residing with their mothers-in-law have fewer ties with non-family actors and this restricts access of the former to reproductive health services (Almanza et al. 2020).

Role of education and economic status

An unexpected finding relates to the association between education and economic status of the family, and MCH outcomes. Education – particularly that of women – and poverty alleviation are expected to increase awareness, acting as major drivers to improve MCH outcomes through behavioural changes. Our study found that a relatively lower proportion of women with at least 10 years of education, and women from families with high asset holdings, adhered to the recommended MCH norms. It was also observed that ASHAs were less successful in reaching out to such women. FGDs revealed antagonism between ASHAs, and educated, affluent and upper-caste women; ASHAs reported that the latter believed they knew everything and sought healthcare from private facilities (often of dubious quality): “What will we explain to people who believe they know it all? The upper caste feel that they have money, and so they need not avail of any government facilities. So we visit them just to share the check-up dates”. As a result, ASHAs visited such households only to maintain records.

Looking ahead

The observed success of the ASHA workers in generating behavioural change may be attributed to their strategy of accepting that mothers-in-law are gatekeepers and involving the latter in the discussions about adopting contraception, availing of ANC and PNC services, and institutional delivery, and motivating them to encourage their daughters-in-law to adopt such practices. This has mixed consequences. In some cases, the mother-in-law has been very supportive and assisted her daughter-in-law in availing ANC services. But there are also many instances where the message of the ASHA has clashed with traditional norms of large families, and these norms have been reinforced as the mother-in-law has precluded the communication with the daughter-in-law. Policy interventions must take into account the challenge posed by intergenerational power relations among women in the household and aim to tackle potential misalignment of preferences around MCH outcomes across generations. In case of the HNS strategy, for example, meeting attendance of women of reproductive age should be ensured through steps such as allowing them to bring their children, involving them in the discussions and encouraging them to share their experiences.

Our study highlights the fact that improvement of MCH outcomes in patriarchal societies fractured by caste identities, like that in Bihar, is not a matter of merely health and awareness; rather, it incorporates a gamut of issues like economic empowerment, agency in the household domain, access to social support systems, and capability to tap social networks. Addressing all these issues is a complex task. It calls for the introduction of a unique, multi-pronged strategy, cooperation between multiple stakeholders – including gatekeepers to the household domain, and consideration of the complex cultural realities of caste, and the patriarchal nature of society.

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Notes:

Accredited social health activists (ASHAs) are community health workers instituted by the Ministry of Health and Family Welfare as part of the National Rural Health Mission.
The Bihar Rural Livelihoods Project (BRLP), locally known as JEEViKA, is an autonomous body under the Department of Rural Development, with the objective of social and economic empowerment of the rural poor through investment in capacity-building of public/private service providers, promoting the development of microfinance and agribusiness sectors, and developing organisations of the rural poor and producers to enable them to access and better negotiate services, credit and assets from public/private sector agencies, and financial institutions.
JEEViKA staff (community mobilisers) were involved in increasing awareness of the target group of women of reproductive age.
The six districts were Begusarai, Katiahar, Muzzafarpur, Nalanda, Purba Champaran, and Saharsha.
About two-thirds of the participants were JEEViKA members.
In India, ASHAs are recruited locally, reside within the community, and are known to the villagers and this ensures monitoring of their activities by the villagers.
SHGs, such as JEEViKA, take a loan for the use of their family members. Every month JEEViKA members pay a small subscription, which is used to repay the loan. As a loan is repaid, the group applies for progressively larger loans. Such loans enable the members to purchase assets, or meet household expenditure.