Progress Report Improving health and nutrition through increased community involvement in Khagramuri, West Bengal, India April 2007 - March 2009 (final report)

• Health workers identified and tracked 380 pregnant women. Of these, 92% were identified within 16 weeks of pregnancy, and 85% were registered within 16 weeks of pregnancy.
• 97% of pregnant women received blood tests, revealing that most were anaemic. Except for one case of severe anaemia, the expecting mothers suffered from either mild or moderate anaemia. With regular intake of nutritious food, along with rest and medical checkups, CINI was able to help them manage this problem. Further, 81% of pregnant women consumed 100 or more iron folic acid tablets.
• 97% of pregnant women were administered tetanus toxide inoculations and 91% received at least three or more ante natal checkups (the average for rural West Bengal is 56%).
• 87% of deliveries had a trained person present, either in hospital, private nursing home, or at home. This is more than double the average for rural West Bengal which is 37%. The remaining 13% of women gave birth at home with an untrained traditional birth attendant present.

• 380 women delivered and there were 382 births (with two cases of twins).
• 91% of newborns were weighed within 48 hours. Of these, 85% weighed at least 5.5 lbs (2.5 kg) or more. It is not possible to completely eradicate babies being born underweight, as so many mothers are chronically malnourished.
• Through continued home visits and community events, mothers and family members were advised on the importance of exclusively breastfeeding for the first three to six months, followed by the introduction of complementary feeding. 88% of babies were exclusively breastfed for the initial three months, and 59% of babies were exclusively breastfed for the initial six-month period. 92% of eligible children (age 1) received complete primary immunisation (state average is 63%).
• Fathers were encouraged to be involved in their children's upbringing, and the family were encouraged to take the child for regular check ups by a qualified doctor.
• Unfortunately, 5 babies and 1 infant died. In each case, representatives from CINI's Women's Health division and the Child Health and Development division, along with doctors, visited the families to assess the causative factors. Visits also provided much-required counselling support to the family.
• At the end of the project, 85% of children under the age of three were of a normal weight.
• The Government's 'Anganwadi Workers' who work to initiate early childhood education amongst infants and young children were involved at every stage of the project. They played a crucial role in ensuring that the children received qualitative health and education inputs. With their increased interaction with parents of children, service providers were brought much closer to the community. This had an overall effect on making services more accessible to local people. Regular meetings created an effect much deeper than merely improving awareness; they opened a forum for government workers to address various community concerns, and establish a two way dialogue.

16 meetings with 20 peer educators (with 10-12 in each) focused on the project aims and objectives, the importance of the adolescent health programme, and the expected roles and responsibilities of peer educators. In addition, discussion focused on physical and psychological changes during adolescence, good nutrition, personal hygiene and sexual and reproductive health issues, including HIV/AIDS and contraception. 62 issue based meetings were conducted with 50 adolescents (10-12 in each meeting) to discuss adolescent health issues, and generate greater awareness. They explained the importance of nutrition in adolescence, various physical and psychological changes that occur, the prevalence of anaemia, contraception, and family planning.

Meetings with small groups of adolescents provided a forum to share experiences, and learn about health issues that they may otherwise not talk about at home

• 16 stakeholders meetings (10-12 in each meeting) were conducted involving various decision-making heads, crucial for creating a stronger support network and a more responsive environment for adolescents.
• Four newly wed ceremonies for married adolescents were held. These highlighted the importance of family planning, contraceptives and the benefits of delaying the first pregnancy.

Local government representatives meet to discuss community needs and available local health services	11 meetings with panchayats were conducted (10-12 in each). Meetings focused on the objectives of the project and how it is enshrined in the Indian constitution that the panchayats (local government) are responsible for ensuring the delivery of improvements in mother and child health in their area. Government health schemes for pregnant women, and the need to improve greater awareness of the availability of such schemes were also discussed. As CINI has phased out of the area, sustainability of the project was also discussed. Plans were made to bring about greater convergence of various systems and institutions and to generate greater awareness and collective ownership.
98 male involvement meetings (with 25 in each) were conducted reaching approximately 400 men. These men were husbands of the women directly covered in the project, as well as other members of the community. Meetings focused on the role of male family members, as they play an integral role to ensuring safe motherhood at the family level. Husbands were encouraged to share the domestic workload with their pregnant wives, and to accompany them to the local health centre, particularly in later stages of pregnancy. With the arrival of a newborn, the responsibilities of the father to ensure that the child receives correct food, timely immunisation and love were also highlighted.		Male members of the community meet to discuss their role in safe motherhood, child survival and growth

• 15 meetings with service providers (10-12 per meeting) were organised. These discussed: the importance of working with adolescents, the need to take consideration of HIV and AIDS, and the importance of working closely with the community when planning health and nutrition initiatives. They were also informed about the latest health and nutrition related government schemes.
• 78 meetings with pregnant or lactating women (10-15 in each) discussed good mother and child health practices. These helped reach out to even greater numbers of women.
• Training and capacity building: Four of CINI's health workers have been trained on safe motherhood, child survival, growth and development and adolescent health; 12 traditional birth attendants were trained on how to deliver safer births; orientation training and quarterly updates with government health workers were organised; and health workers communicated regularly with health service providers on a one-to-one informal basis.

Exit-strategy

Service providers and local government representatives will continue to make progress to improve mother and child health after the end of the project period. CINI has facilitated the process of regular meetings to be held on the fourth Saturday of every month between the local government representatives, local service providers, along with community representatives, as prescribed by the state governance system. Earlier attendance of these meetings was erratic. These meetings will continue to function as a platform for communication and to address health and nutrition issues even after CINI has withdrawn.

Project outcomes

Increased access to government health services: During the two year project period, access to government health services has increased. In 2006, health centre records indicate that 2,000 residents in the local area accessed the health centres each year; however in 2009, this doubled to 4,000 patients. In addition, in 2006, records also show that 48% of births were delivered in hospital; however in 2009, this increased to 60%.

Improved quality of government health services: Health service delivery centres are now much better equipped with necessary medicines and equipment. Earlier, most vaccines for children were not available all year round. Also, equipment such as weighing machines and blood pressure machines were not available in most of the health centres. Through continued interaction with the service providers and local government representatives, this equipment has been sourced, and is now available for use. Furthermore, due to a lack of health staff and a pressure on health services, especially in the government hospitals, patients frequently complained of being neglected or poorly treated. Through regular meetings with service providers, a marked positive difference in attitude and behaviour has been noticed.

• Despite being informed of the benefits of hospital delivery, many pregnant women and/or their families, particularly mothers-in-law, choose a home delivery as it is perceived as being cheaper and is what has been done for generations. Delivering at home in India is a very different experience than in the UK, and can often be very unsafe as there is no blood supply on standby, no drugs and no ambulance if things go wrong.
• Some members of the community were unconvinced of the benefits of adolescent involvement the adolescent health programme. This required a sensitive approach to engage greater community participation.
• CINI's strategic decision to shift from being a service provider to a facilitator was first met with apprehension. However, with time, stakeholders understood how CINI's new approach would be more sustainable in the long run.

• Regular collective meetings, formal as well as informal, with the service providers, local legislative members and community members, helped establishing greater understanding between the three stakeholders, bringing them closer together.
• One-on-one interaction with key stakeholders proved to be effective in securing their support, particularly in cases where formal meetings could not be arranged.
• Use of behaviour change information not only strengthens the process of positive behaviour change, but also explains the various concepts of health and nutrition amongst community members. Materials that are largely pictorial enable illiterate community members to understand concepts.
   

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