In childbirth and infancy, who decides – and why?  

Reproductive, maternal, neonatal and child health in Uttar Pradesh 

Every year in India, more than a million children die before the age of five – over half of them within their first month of life – and nearly 50,000 women do not survive pregnancy, or die within six weeks of giving birth.

Many complex factors contribute to these avoidable deaths. The survival of mother and newborn depends on crucial decisions and behaviors within the household and in medical facilities. For example, only about two-thirds of births take place in qualified healthcare facilities. What are the cultural and family dynamics that determine this? Who makes or influences the decision that birth should take place at home, and when and how can they be influenced to choose a medical facility instead? 


Even if a woman does deliver her baby in a healthcare facility, providers need to follow the best procedures to ensure survival of mothers and newborns and to manage fragile low birth-weight babies and complications such as asphyxia. How can we ensure that providers are supported and follow the optimal medical procedures in resource-poor settings?  Finally, after the mother returns home, how can we ensure that appropriate post-natal care is provided and crucial behaviors such as exclusive breastfeeding and complimentary feeding take place?  

Surgo Foundation is helping the Reproductive, Maternal, Neonatal and Child Health and Nutrition (RMNCHN) Program in the state of Utter Pradesh – where there is a disproportionate burden of maternal and infant deaths – to identify why the best behaviors are not being adopted. The goal is to design interventions to increase their adoption, giving the program transformational and sustainable impact. 

Partnering with the significant RMNCHN program already being implemented by the state government with technical support from the Bill & Melinda Gates Foundation, we are looking for clues to the underlying drivers of these behaviors and their lack of adoption at scale. These clues will help us to systematically map the network of influences on the decisions and behaviors of women, community health workers, providers in healthcare facilities, and program managers all along the journey of reproductive health, childbirth, and caring for newborns. 


Within households, our research will seek to understand the dynamics and behaviors of the woman, her husband, and other key family members such as the mother-in-law. We will study the perspective of community health workers, and the factors that influence how and when they interact with women. And we will map the responsibilities, influences, and behaviors of staff and administrators in healthcare facilities where women give birth, to understand the information, procedures, and support they need to improve health outcomes. 

By taking a systematic approach to understanding the key people and systems in the RMNCHN journey, our research will find the levers that can have the greatest impact. Together, the insights, strategies, and resources that we and our partners develop will help the RMNCHN program in Uttar Pradesh save the lives of mothers and children, and provide insights that are applicable elsewhere in India, and beyond.