How can we increase demand for essential health services?

Shifting behaviors across the cascade of care for maternal and neonatal health

Caring for the health of mothers and their newborn children means getting a lot of elements right. Antenatal care, giving birth at a healthcare facility, staying for 48 hours afterward to ensure everything is OK, and providing appropriate postnatal care – these involve a network of decisions and actions by professional providers, frontline health workers, the expectant mother herself, and members of her family. What is the most effective way to make sure all the elements fall into place? And how can this be done in a complex environment where individuals are driven by differing attitudes and motivations?

The Reproductive, Maternal, Neonatal, and Child Health (RMNCH) program of Uttar Pradesh state in India has worked hard to improve the supply and quality of services for pregnant women, but even so, too few are registered for services early in their pregnancy, and rates of delivery at healthcare facilities vary widely by area. The majority of women who do give birth at facilities return home within 12 hours, and progress has been slow in improving uptake of important postnatal behaviors such as early initiation of breastfeeding, exclusive breastfeeding, and appropriate care of the umbilical stump.

Surgo Foundation believes that a more holistic approach is needed, one that addresses the drivers of behavior across the system, and helps families see maternal and newborn care as a cascade of healthy behaviors that can be anticipated and planned. We see opportunities in complementing the “push” approach – boosting the supply of care – with a “pull” approach that increases families’ demand for the best possible information and support from frontline workers and healthcare facility staff. This will enable families to understand and choose the healthiest behaviors for new mothers and their babies.

Some of these insights come from the research we’ve done to map who makes the decisions in households for each RMNCH behavior, and what influences those decisions – attitudes, beliefs, and biases, as well as external factors such as the availability of information, interactions with frontline workers, and the family’s resources.

We found that families do not understand RMNCH healthy behaviors as a cascade of predictable actions, and that they tend to wait instead for frontline workers to tell them what to do, such as when to go for their next antenatal check-up. This prevents them from engaging actively with the healthcare system and planning thoroughly for the delivery and post-delivery period. Helping families to understand the significance of the RMNCH cascade and to demand the services they need is crucial to improving outcomes.

Our research also identified that the husband and mother-in-law, more than the pregnant woman, are key decision-makers about seeking care, and they sometimes instigate behaviors that risk the health of the mother or infant, such as giving the baby unnecessary food supplements. Targeting the right individual with the right message, and at the right time, can help change this.

Our statistical analyses show that key healthy behaviors, such as registering a pregnancy in the first trimester, or having at least three antenatal visits from a frontline health worker, can predict other healthy behaviors further along the cascade. Prioritizing these interventions could have an outsized and positive effect on the overall health of mothers and babies, and further strengthen effective, demand-driven behavior change along the RMNCH cascade.