Coexisting traditional and biomedical healthcare systems: a mixed-methods analysis of community health workers and traditional birth attendants' contributions to perinatal health behaviors in rural India

In many rural communities, traditional and biomedical health systems operate side by side, yet the comparative roles of traditional birth attendants and community health workers in perinatal care remain poorly understood. This study examines the variations in the influence of Accredited Social Health Activists (ASHAs) and traditional birth attendants (locally known as Dais) on maternal and newborn health behaviors in rural Bihar, India. We employed a mixed-methods design. Qualitative data included 40 focus group discussions, 50 key informant interviews, and six weeks of focused ethnographic observation of both ASHAs and Dais guided by rapid ethnography principles. Quantitative data were collected through a multi-stage cluster random survey of 1,166 recent mothers and 400 ASHAs, designed to ensure representation across Bihar's major linguistic regions. Logistic regression with backward selection (validated through sensitivity analyses and alternate specifications) estimated the influence of each provider on perinatal behaviors, with multicollinearity assessed using variance inflation factors. Findings revealed distinct temporal and functional roles: ASHAs were most active during pregnancy and labor, significantly increasing the odds of antenatal visits and institutional delivery, while Dais exerted greater influence postpartum, promoting traditional practices such as newborn massage. Synergistic effects emerged in breastfeeding initiation when both providers were involved, while conflicting guidance appeared in cord care. Families often created hybrid care models that blended biomedical recommendations with ritual practices. Overall, the coexistence of ASHAs and Dais suggests complementarity rather than simple competition, though patterns varied across settings. The study focuses on behaviors rather than health outcomes, and we acknowledge that this scope, along with ethical considerations of working with overlapping provider systems, shapes interpretation. Tailored strategies that foster respectful collaboration-such as joint training and coordinated outreach-may improve the uptake and cultural acceptability of maternal and newborn health programs in rural contexts.