What does behavior have to do with it?


The science around what to deliver in maternal and newborn health is well-established, but the science on how to do it, effectively and efficiently, is not. 

Insights from behavioral and social science could help us move from what to do, to how best to do it. 

Imagine that you are a pregnant in woman in the highlands of Peru. You are deciding whether or not to go to a health facility to deliver your baby, what kinds of things are you thinking about, what might influence your decision? 

CARE embarked on a program in Ayacucho, Peru to encourage mothers to go to the health facility for childbirth in an effort to reduce maternal deaths. We worked closely with the government and partners to upgrade maternal health facilities, train health workers, facilitate emergency transport, and conduct birth preparedness education with the community. But, despite these improvements, women were still not going to the facility to deliver their babies. 

We talked to women in the community, to see what the real barriers to care were. Several issues emerged. The health providers all spoke Spanish so the Quechua-speaking women could not understand them. Further, women were required to give birth lying down and they were not allowed to bring a companion into the delivery room with them—practices that many found unfamiliar and frightening. 

With these insights in hand, CARE facilitated discussions at the health facility and, working together, community members and health care providers identified solutions. Signs were posted in the facility in the local language informing women of their rights and translators were made available. And culturally appropriate maternal health practices such as having a companion with the mother during labor and delivery--were adopted by the health facility. These changes contributed to significantly increased rates and timeliness of maternal health care-seeking. The result? Within four years, maternal deaths had decreased by 39 percent across the entire region from the baseline. (Kayongo et al, 2006).

When we think of health care in this more holistic way, we recognize that it is a dynamic system of relationships and behaviors. Behaviors of policy makers who allocate resources to support health care delivery, of local health officials who train and deploy the workforce, of frontline health workers who deliver care, of community and household members who support women in accessing services, and of women and girls themselves who may, or may not, be aware of their rights to services, and feel empowered and equipped to protect and maintain their health. 

Our approach at CARE incorporates these key social and behavioral principles and focuses on three main areas: 

  1. Empowering women and communities, by encouraging and supporting their voice and participation in the decisions that affect them. For example, in Bangladesh, communities we work with commit to zero tolerance of maternal deaths and then implement a community support system to achieve that goal. This support system empowers community members to undertake actions that facilitate access to needed services - such as, consulting with providers to set service delivery rates, identifying and referring pregnant women to a health facility for delivery and mobilizing resources for poor households to ensure timely transport when needed. As a result, skilled birth attendance increased by 34% in our project area. 
  2. Empowering and equipping health workers with the tools and support they need to provide respectful, responsive and effective care. Health workers are on the frontline of this fight to save women and children’s lives—and yet they are often poorly or inconsistently paid, lack equipment, supplies and supervision, and have little ability to influence their work environment and secure their own rights to training, equipment and support. CARE has developed a number of innovative approaches to empower and motivate health workers, such as team-based goals and incentives, and mobile phone-based counseling and data collection tools that help frontline workers use data to make decisions about care in real time.
  3. Creating spaces for dialogue and negotiation between the community and the health system to build understanding, trust and a sense of mutual responsibility for health outcomes. Tools such as CARE’s Community Score Card help community members, health providers and local officials work together to identify barriers, jointly develop locally relevant solutions, and hold each other mutually accountable for implementing those solutions. 

Social and behavioral science tells us that behavior is initially shaped in thought and driven by a complex system of beliefs, norms and expectations—and while this may require us to think differently about how to accelerate progress to reduce maternal and child deaths, it also offers new ways to craft effective programs. The results from Peru and as well as more recent programs and experiences in Bangladesh, India, Malawi and many other places around the world demonstrate the power of social and behavioral science methods and insights to improve programs and achieve results. 

About CARE's approach:

CARE believes that all women, men and young people should have equitable access to the information and services they need to realize their right to the highest possible attainable standard of sexual and reproductive health – free of discrimination, stigma, coercion and violence. CARE’s Sexual, Reproductive and Maternal Health and Rights team works to reduce maternal and newborn mortality and improve health outcomes by increasing the quality, responsiveness and equity of health services. CARE works to generate and build evidence, measure impact, and share learning globally, as well as advocate for stronger SRMH policies and encourage scale-up and replication of successful approaches in order to increase global impact.