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Are community health workers effective in retaining women in the maternity care continuum? Evidence from India
  1. Smisha Agarwal1,2,3,
  2. Sian Curtis3,4,
  3. Gusavo Angeles3,4,
  4. Ilene Speizer3,4,
  5. Kavita Singh3,4,
  6. James Thomas4,5
  1. 1Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2University of North Carolina at Chapel Hill Carolina Population Center, Chapel Hill, North Carolina, USA
  3. 3Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  4. 4MEASURE Evaluation, University of North Carolina at Chapel Hill Carolina Population Center, Chapel Hill, North Carolina, USA
  5. 5Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Smisha Agarwal; smishaa{at}


Objectives Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum.

Methods Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care—at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights.

Results Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: −10.2 to −7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum.

Conclusions While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

  • human resources
  • community health workers
  • frontline health care workers
  • primary healthcare
  • maternal health
  • antenatal care
  • skilled birth attendance
  • postnatal care
  • India
  • South Asia

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  • Handling editor Stephanie M Topp

  • Contributors SA and SC designed the research protocol. All authors reviewed and contributed to the design of the protocol. Analysis was conducted, and first draft of the manuscript was prepared by SA. All authors contributed substantially to reviewing the methods, interpreting and contextualising the study results. All authors reviewed, contributed to and approved the final manuscript.

  • Funding We are grateful to the Carolina Population Center and NIH/NICHD for training support (T32 HD007168) and for general support (P2C HD050924).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was received from the University of North Carolina, Chapel Hill Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data for this study are publicly available through the National Economic Council of Applied Economic Research.