Households and communities in India often place women in subordinate positions to men (1-4). In healthcare, girls are frequently neglected during the care-seeking process, and they experience relatively poorer nutrition, greater delays in receiving care, and lower access to preventative and curative care (3,5-7). A major reason cited for the low girl-to-boy ratio in the population of India (0.93) is the differential in healthcare-seeking behaviour between genders (3,8). Consequently, to improve the status of women and girls in India, it is important to develop interventions that reduce the gender differences in care-seeking, especially during times, such as the neonatal period, when the human body is particularly susceptible to illness and consequences of late or inappropriate health services (9-11). Yet, the organization of such interventions has been limited due, in part, to a lack of documentation on how gender differences express themselves in the care-seeking process during the neonatal period. Moreover, such data are scarce for areas, such as Uttar Pradesh, one of the poorer states of India, where the girl-to-boy ratio (0.90) is one of the world's lowest and where the neonatal mortality rate (53.0 deaths per 1,000 livebirths) is about 120% that of India's average (8,10). The importance of the neonatal period in child health is further reflected by the fact that, of all deaths that occur globally before the fifth birthday, nearly 40% take place during the neonatal period (12).
While existing literature on care-seeking for newborn infants in India has described the female disadvantage in healthcare use-rates, there is a lack of quantitative consideration of potential gender disparities in household recognition of illness, type of care used, and monetary expenditure during the use of health services (7,10). Hospital-based studies have documented that, for every two sick male newborn infants using hospital care, there may be only one sick female counterpart brought for care (10). Community-based studies have also found a significant gender differential in healthcare-use. One study in rural India found that the proportion of sick female and male newborn infants receiving any treatment was 28.8% and 63.1% respectively (7). However, such documentation is not sufficient because gender-based differences could have happened during the recognition of illnesses prior to the use of healthcare. In addition, even when households used healthcare resources for both male and female newborn infants, there may be differences in the quality of care given to each gender. Without such detailed accounts of gender disparities at various levels during the care-seeking process, policy-makers and programme managers could be limited in designing more effective gender-sensitive interventions.
Within this context, the primary objective of this study was to quantitatively assess the gender differences in the perception of any neonatal illness in rural Uttar Pradesh, India. Additional objectives were to quantitatively assess the gender differences in the type and amount of curative care used for sick neonates; describe the role of various household members in the curative care-seeking process; and document the reasons for non-use of curative care for neonates who were perceived sick in rural Uttar Pradesh, India.
MATERIALS AND METHODS
The study was nested in a cluster-randomized trial of the impact of a package of essential newborn care in Shivgarh, a rural block of Uttar Pradesh, India, with a population of 104,000. Households in this area face a pluralist healthcare system consisting of multiple levels of formal care, e.g. primary health centre, community health centre, district hospital, and various allopathy-oriented and private healthcare providers of indigenous characteristics.
Women in the area who became pregnant during the study period were tracked under the demographic surveillance system of the cluster-randomized trial. …