Case study

Improving Maternal Health Outcomes: The effects of decentralisation on prenatal health preferences in India and Indonesia

Principal Investigator: Dr Sarah Shair-Rosenfield

Co-Investigator: Dr Patrick Nolen*

Partner organisations: Aparna Shankar, Flame University (Pune, India), Qualtrics

*Dr Nolen passed away in October 2020, six months into the project. His contribution to its initial development cannot be overemphasised and his ideas continue to help shape aspects of this broader research agenda.

What is your research about?

A key millennium goal is to reduce Maternal Mortality Rates (MMR). Between 1992 and 2006, nearly 20% of the world’s maternal deaths occurred in India. In the past 15 years, India’s national government has substantially reduced the country’s maternal mortality ratio but remains well shy of achieving the 2030 Sustainable Development Goal in this area. A primary contributing factor to persistently high MMR is that pre- and post-natal care services are underutilised. Though political and fiscal decentralisation have helped to improve maternal health and institutionalised delivery services, there are many aspects of Indian politics, society, and culture that remain as barriers to women’s take-up of these services. In the long-term, this project aims to: (i) determine barriers to women’s prenatal service access; (ii) determine why women are not taking up more prenatal services that are available; and (iii) provide recommendations on how to increase uptake of prenatal services – especially in the rural areas – so that, ultimately, the MMR will decrease over time.

Dr Sarah Shair-Rosenfield
"Our project aims to understand constraints on access to maternal healthcare in South/Southeast Asia, how this curtails women's pursuit of health, wellbeing and equality and to provide policymakers with the tools to overcome those restraints."
Dr Sarah Shair-Rosenfield department of government

What activities did your GCRF@Essex funding support and how do your GCRF funded projects support your wider research plans?

To achieve these aims in the context of India, we developed a questionnaire targeted to women of childbearing age. Rather than focus on routine prenatal care, we instead asked respondents about their preferences and associated costs with different types of care providers if they were to experience pregnancy complications. We then contacted Qualtrics, an internationally recognised marketing firm with a standing online representative panel of respondents in India. After a number of delays due to Covid-19, the GCRF@Essex funding enabled us to have Qualtrics administer the survey, completing data collection of more than 1500 women respondents in the Indian states of Rajasthan and Uttar Pradesh. We also received GCRF@Essex funding to run a companion survey in Indonesia, with a 2200-respondent national sample.

How is your project benefitting the countries involved and which Sustainable Development Goals (SDGs) are being addressed?

The key SDG addressed is SDG 1 ‘good health and well-being.’ Our aim is to increase take-up of prenatal services – especially in rural areas – as an intermediate step leading to, hopefully, a decrease in the MMR in India. Our preliminary findings from India suggest ways that policymakers can improve the likelihood that women take advantage of available prenatal care. One key issue is that women’s perceptions of the “quality” of different types of healthcare providers (local clinics, government hospitals, and private medical facilities) conditions their preferences when facing routine prenatal complications (such as dizziness or fainting associated with high blood pressure).

When asked to specify their most preferred type of provider when facing such complications, neither rural nor urban women chose local clinics. Instead, urban women preferred to seek care from private providers and rural women preferred attending government hospitals. However, our survey also reveals that while fewer than 20% of respondents said that local clinics were their first choice for such care, more than 70% still responded that they would consider seeking care from a local clinic for all of the types of complications we asked about. This is important because while the former suggests that women do not associate local clinics with the highest quality of care, a large majority still perceive it to be of sufficient quality that they would attend for prenatal care. Furthermore, only 2% responded that they would not seek treatment for any of the complications.

As a result, we suspect that low take-up of prenatal care in these two Indian states is more due to information about accessibility rather than women’s preferences not to seek care when it is publicly and widely available. In countries like India, Indonesia, and others in South and Southeast Asia, vast inequalities in healthcare options exist depending on one’s location (urban vs. rural) and means (ability to afford private care). A clear benefit is that our project highlights that women in this context do not appear to be resistant to prenatal care, and so it is imperative that governments and bureaucrats tailor their messaging regarding both the importance and availability of prenatal care access.

What are the outputs (academic and non-academic) and what are the follow up plans?

We have already applied for three grants using the questionnaire and methodology outlined in our proposal. We have applied for two grants from the British Academy and one from the Wellcome Trust. We have also used the methodology in a companion study in Indonesia. We hope to pursue a large, cross-country study that looks at these issues more broadly in South and Southeast Asia.

There are plans to continue work on this project by extending the research benefits to many countries in South and Southeast Asia. The COVID-19 situation in India and Indonesia presented significant complications in establishing and nurturing partnerships with local academics and stakeholders, especially given extended lockdowns and drains on local resources. However, other contacts of mine in the Philippines have been more able to continue their work throughout the past 18 months. The results from this study are likely to influence how the “Safe Motherhood” week run by the health department in the Philippines advertises prenatal service availability in the country’s highly urbanised cities. I plan to continue building more extensive networks of stakeholders in the region to encourage the impact of the surveys on service delivery and accessibility.

With respect to network and partnership building, which will help to ensure further impact and grant applications, I have established four new working relationships on the surveys and proposals. First, noted public health scholar Dr Aparna Shankar (Flame University in Pune, India) joined the survey project in April 2020 and has provided input into the substance and translation (both language and cultural in nature) before deployment. She and I are working on a paper which we hope to submit for peer review later this year, and we expect this survey work will produce a beneficial working relationship for longer-term scholarly output and within-country impact. Second, three collaborators joined the longer-term project for which we have been developing proposals. Another collaborator here at Essex, Professor Susan McPherson (Health and Social Care), brings a maternal mental health perspective to the project and has been involved in the development of the application to the Wellcome Trust. Additionally, noted sociologist Dr Iim Halimatusa’diyah (Syarif Hidayatullah State Islamic University in Jakarta, Indonesia) and Ms Zenaida Dy Recidoro (Chief Programme Officer, Department of Health, Government of the Philippines) joined the longer-term project as collaborators on the Wellcome Trust application. I expect that these relationships will lead to further direct links with both healthcare providers and stakeholders undertaking policy reform on maternal health in each of these countries at both national and local levels.

Dr Shankar and I are currently writing an academic paper on our results from India, and a second paper on the results from Indonesia will follow shortly thereafter. I am also writing a policy-oriented report on how the cost and perceptions of prenatal services affect take-up in urban areas.

Are there any challenges when pursuing this international and collaborative project?

Engaging in evidence-based research and collaboration on a topic such as women’s health and pregnancy is already difficult in South and Southeast Asia – there is always the fear of treading too heavily on culturally sensitive issues such as gendered health. Covid-19 further altered and constrained a number of aspects about pursuing a project as international and collaboratively-oriented as this one.

An important limitation arose from our inability to travel internationally and domestically, both to conduct research and establish/strengthen partnerships. We really suffered in the early stages of project development from not being able to meet with anyone face-to-face. As most of these collaborative relationships were brand-new, we lost some of the inspiration you often get from sitting in a room together and bouncing ideas off one another for a full or half-day’s work. That type of engagement can be so meaningful and important early on in a big project. Instead, we were largely limited to 60- or 90-minute virtual meetings due to time zone differences and working-from-home environments. In fact, we (Sarah and Patrick) never met in person even though we were both at Essex; our relationships with our other collaborators were all established via “real-time” meetings over Skype, Zoom, and WhatsApp. Eventually virtual meetings proved no different than in-person interactions, such as when we were refining the survey instrument. However, the absence of in-person engagement reduced some of the excitement and motivation that comes with early partnership building.