DIPA SINHA

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DIPA SINHA

• INVESTING IN COMMUNITIES
• FOR
• RIGHT TO SAFE MOTHERHOOD

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Maternal Health - India

• Despite unprecedented economic growth in India
  over the last decade, maternal mortality and
  morbidity continue to be unacceptably high.
• More than 100,000 mothers in the country die each
  year as a result of pregnancy-related causes
• Poor access to institutions especially in poorer
  areas
• Low rates of institutional delivery (40.7)
• Low public investments on health in general, in
  spite of newly launched National Rural Health
  Mission

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At the Community Level

• The issue of pregnancy and child birth is an
  extremely private issue not to be talked about
• Women are the care-providers they dont need
  others to take care of their needs
• The existing norm is one where pregnancy is just
  a routine event in every womans life something
  that does not require any special care
• A need therefore to create a norm where pregnancy
  becomes a public issue, that concerns the entire
  family and the village as a whole.

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The state of public health institutions

• General apathy towards the poor
• Ill-equipped, malfunctioning public health
  provision
• Only interest in women seems to be in meeting
  sterilisation/family planning targets
• A need to make the public institutions more
  accountable to the communities they serve

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The current project

• An intervention in one mandal (Mominpet) in rural
  Andhra Pradesh, India (covering a population of
  40,000)
• Intervention activities focused on three levels
  that of the community, the family and pregnant
  women.
• Activities were conducted by local field-level
  staff, known as community organisers. The
  community organisers were identified from within
  the communities where we were working and were
  given appropriate training
• Through these organisers, the project established
  a link between pregnant women, families and the
  community, pregnant women and the health system,
  and the community and the health system.
• A baseline conducted before the start of the
  project followed up with another survey after
  almost two years

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Initiatives at the Community Level

• Work with the entire community to create an
  environment that respects women and their needs,
  especially when they are pregnant.
• Orient the community to look at pregnancy and
  safe motherhood as an issue of public concern
• Build community pressure on the health system
  making them more effective and accountable
• For this,
• Awareness campaigns, posters, marches, rallies
  and street theatre/cultural programmes held
• Health committees formed with local groups
• In all the above activities community organisers
  play a key role

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Gram Panchayats

• The Gram Panchayat holds regular review meetings
  with the representatives of public health
  services (anganwadi teacher and Auxiliary
  Nurse-Midwife), school headmasters, youth and
  womens group leaders
• In these meetings the work of each of the
  institutions is reviewed and their problems also
  discussed
• GP contributed to resolve some of the issues
  raised locally, like finding a place for ANC,
  contributing for BP apparatus, speaking to auto
  drivers about taking women to the hospital during
  labour and so on
• The GP members also presented these issues at
  meetings at the district and block level

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Youth

• Local youth (men and women) mobilised to form
  committees for protection of right to health
  (with a focus on maternal health)
• Federation of the committees formed
• They put pressure as a group on health care
  providers and even district officials
• At the same time, provided support such as
  cleaning health centre premises, collecting funds
  for improving facilities and so on

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Initiatives as the Family Level

• To ensure proper care for pregnant women, it was
  realised that the entire family, especially
  husbands, must be involved and made to take
  responsibility
• Other than talking to the husbands during home
  visits, group meetings are held once a month with
  all husbands of pregnant women in the village
• In these meetings issues related to support for
  the pregnant women and planning for an
  institutional delivery was discussed
• As a result, many husbands took on more
  responsibility at home spending on nutrition,
  bringing water, firewood and also accompanying
  women for ante-natal check ups

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Follow up of Pregnant Women

• Every pregnant women followed up by the community
  organisers to ensure registration, 2 doses of TT
  injections, IFA tablets, ANC check-ups,
  nutrition, rest and safe delivery.
• Each woman visited in her house at least twice a
  month
• Plans made along with the entire family for
  institutional delivery
• Group meetings of pregnant women, mothers-in-law
  also held. In these meetings local health
  functionaries such as ANM and anganwadi workers
  also involved.

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Changes Observed

• Study findings show that the intervention did
  result in changes in pregnancy and delivery
  related practices at the community, family and
  individual level.
• Most notable was the increased use of government
  health facilities following the intervention,
  there were more institutional deliveries, and
  more women reported accessing full antenatal
  care.

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• Women reported improved practices during
  pregnancy including reducing their domestic
  workload and consuming a more nutritious diet.
• Women also reported receiving more support from
  their husbands during pregnancy (figure below)

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Concerns

• No control site
• Two years too short a period to measure some of
  the changes
• However some conclusions made based on the
  experience of the project and the survey results
  which are quite positive in spite of the
  shortcomings

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Lessons Learnt

• Once maternal and child health becomes a concern
  of the entire community, there is pressure on the
  public health system to be accountable for
  service delivery.
• Activities need to focus on empowering
  communities to make health service providers
  demand-responsive
• At the same time, it is important to foster a
  change in the attitude of the family, notably
  husbands and mothers-in-law, to make them more
  supportive of pregnant women and to involve them
  in assisting pregnant women to access health
  services.
• There is also a need to address deep-rooted
  traditional gender norms that underscore that
  pregnancy is a womans issue, and that
  husbands/men are not required to participate in
  pregnancy care.

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Community Health Workers

• The intervention clearly highlights the need for
  a group of community level workers to act as
  motivators at the grassroots level and as a link
  between women and the health system.
• For outcomes to be sustainable, the activities of
  community workers need to go beyond providing
  only a link to pregnant women and programmes need
  to work towards building support within the
  family and the community as well.
• The intervention was based on a rights approach,
  and made safe motherhood a public issue by
  mobilising local institutions to take on the
  responsibility to demand accountability and
  better services from the health system. The
  community workers played the key role in bringing
  about this change.

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Is this scalable?

• In the present context where the need for
  community health workers has been recognised at
  the national level, as reflected in the
  formulation of the ASHA (Accredited Social Health
  Activist) programme, it is felt that this model
  is indeed scalable.
• With training, the network of ASHAs can play a
  larger role, linking the community, the family
  and women themselves, to ensure improved health
  outcomes.
• The bottleneck was not so much within the
  communities but from the level of provision of
  health care facilities that are adequate,
  sensitive and responsive