7.7 Chapter take-aways

In the second of the quantitative chapters, we provide an overview of self-reported engagement in biomedically recommended, biomedically non-recommended, and neutral health-related behaviors for both beneficiaries (Mothers) and ASHAs. We also examine how interaction with ASHAs affects overall uptake of biomedical behaviors and we make an initial estimation of how differentials in caste, religion, and wealth between ASHAs and Mothers might limit service delivery. We find that ASHA interaction has a positive effect on the uptake of biomedically recommended behaviors and do not find strong evidence that ASHA - beneficiary differences are a major factor limiting uptake of biomedically recommended behaviors.

Lived experience

We documented the extent to which time spent as an ASHA impacted her behavior during her most recent pregnancy. We found that for each year spent as ASHA, it increased the odds that she fed colostrum to her most recent child by 10%, increased the odds that she had an institutional delivery by 16%, and increased the odds that she had a timely ANC registration by over 20%. Time spent as an ASHA also increased the odds of increasing her diet during pregnancy and postpartum. This provides compelling evidence that training and experience ASHAs receive on the job positively impacts their own perinatal behavior, and increases many biomedically-recommended behaviors.


There is substantial variation in amount of contact between ASHAs and beneficiaries. For example, of the 1172 women surveyed, 22% did not receive an ASHA visit during pregnancy and 53% did not receive a postpartum visit. ASHA are more likely to visit later in the pregnancy than earlier. A substantial number of beneficiaries reported no ASHA visits in postpartum week 1, which may have significant impacts on the care given to the mother and her newborn baby, as the neonatal period (specially the first 7 days) is a time of increased risk for health complications and mortality. Our data reveal substantial room to increase the number of visits between ASHAs and beneficiaries in general, and during times in the perinatal journey with maximum potential to improve health outcomes.

We documented the impact of interacting with ASHAs on beneficiary behavior by quantifying the effects of ASHA-beneficiary interactions using a composite score that captures the depth and breadth of how ASHAs interact with beneficiaries. This ASHA interaction score is a summation of several questions that either count a number of ASHA interactions or name the ASHA as facilitating access to a key service. We found consistent evidence that greater interaction with an ASHA has a positive influence on many key behaviors of interest. For example, beneficiaries with higher ASHA interactions scores were more likely to engage in biomedically recommended behaviors. They were ~ 22% more likely to give birth in a government hospital and slightly more likely to give birth in a private hospital (both relative to a home birth), were less likely to avoid ANC registration and less likely to register late, were more likely to take IFA tablets, were more likely to have fed their babies colostrum, were more likely to have begun breast feeding in a timely manner, were less likely to have done heavy work while pregnant, were less likely to have fasted while pregnant, and were less likely to have bathed their newborn within 24 hours of giving birth. There is also a positive association between greater beneficiary-ASHA interaction and overall health scores for beneficiaries (based on a score of engaging in biomedically recommended behaviors and not engaging in non-recommended behaviors).

Embeddedness and Liminality

Beneficiaries and ASHAs engage in some behaviors at similar rates. For example, concerning biomedically non-recommended behaviors, both beneficiaries and ASHAs report concealing pregnancy in the first trimester at nearly identical rates (~87%). Concealing early pregnancy is rooted in concerns over evil eye, and fear of miscarriage.

Beneficiaries and ASHAs also report applying ointment to the cord stump and bathing within 24 hours at similar rates. Behaviors related to fasting and food restriction are also commonplace among beneficiaries and ASHAs (fasting while pregnant and food avoidance of nutritious food after birth (cereal)).

Concerning biomedically recommended behaviors, a number of critical findings emerge. First, beneficiaries engage in some behaviors at much higher rates than ASHAs (likely due to generational differences in access, ASHAs are older than many of the beneficiaries in our study). For example, institutional delivery and early ANC registration are nearly twice as common among beneficiaries as ASHAs. Breastfeeding-related behaviors (colostrum feeding (~80%) and TIBF (~60%)) occur at similar, relatively high rates. ASHAs were more likely to engage in biomedically recommended dietary behaviors (dietary increase during pregnancy and postpartum) than beneficiaries, but notably, both beneficiaries and ASHAs increased their diets during pregnancy at low rates. ASHAs were more likely to complete the full course of IFA tablets than beneficiaries, but overall rates were still under 50%.

Concerning biomedically-neutral behaviors, mothers and beneficiaries engage at very similar rates. There are some behaviors that are more common that others in general, for example, whereas ~75% of beneficiaries and ASHAs participated in Chhathi, only a minority consulted a priest during pregnancy. One notable finding is that both beneficiaries and ASHAs consulted dais during and after birth at very high rates. The majority of beneficiaries and ASHAs had a Dai at their delivery, for example, and an even larger percentage of beneficiaries and ASHAs had a Dai visit them after birth. Both were relatively less likely to have a Dai visit during pregnancy than during or after birth. This reveals important opportunities to engage Dais as critical health-influencers in outreach campaigns. Beneficiaries and ASHAs are also equally likely to isolate themselves and their babies after birth, and to avoid markets and other public places during pregnancy (due to fears of supernatural and physical dangers).

Similarities in ASHA and beneficiary engagement with perinatal behaviors provides critical insight into the kind of information that should be provided during training. In some cases, ASHAs are asked to recommend behaviors to beneficiaries they themselves did not engage in, and thus require specialized training in order to effectively educate beneficiaries about benefits and risks. Our data also reveal that ASHAs rely on health influencers such as Dais to the same extent as their beneficiaries.

Opportunity areas include providing ASHAs with targeted training on the benefits and risks of behaviors, particularly those that are relevant to biomedical recommendations, and those that involve communicating with other health influencers, such as Dais.