Community health workers and the improvement of antenatal care and institutional births in Bihar, India

Community health workers (CHWs) are widely recognised for their association with care-seeking behaviours; however, their role in explaining variation in maternal health has not been quantitatively examined. Evidence highlights early ANC initiation and skilled ANC as key factors associated with safe motherhood, but limited empirical work has examined how these aspects are linked with changes in maternal healthcare utilisation in Bihar over time. The study addresses this gap by examining the associations between CHW engagement, early ANC initiation, skilled ANC and changes in maternal healthcare utilisation between 2016 and 2021. We analysed data from NFHS-4 (2015–16) and NFHS-5 (2019–21) for Bihar. Outcomes included ≥ 4 ANC visits and institutional delivery. Survey-adjusted bivariate analyses, survey-adjusted multivariable logistic regression models, and Fairlie nonlinear decomposition were used to examine associated factors and to assess the extent to which early ANC, skilled providers, and CHW contact explained observed differences between survey rounds. Women, who initiated ANC in the first trimester had higher odds of receiving ≥ 4 ANC visits (OR = 2.96) and institutional delivery (OR = 1.38). Receipt of skilled ANC was associated with higher odds of ≥ 4 ANC visits and institutional delivery (OR = 3.57 and OR = 1.43), while CHW engagement was also associated with higher odds of both outcomes (OR = 1.39 and OR = 1.35). Fairlie decomposition showed that 75% of the observed difference in ≥ 4 ANC and 48% of the difference in institutional delivery between survey rounds were explained by changes in measured characteristics, including early ANC initiation, skilled providers, and CHW contact. Strengthening early ANC registration, expanding skilled ANC services, and enhancing CHW engagement may support continued improvements in maternal healthcare utilisation. Policy efforts may prioritise CHW support and early ANC uptake to address inequities and support progress toward SDG 3.1 targets.