Progress Report Establishing a sustainable support service to improve mother and child health in Khorda, West Bengal July 2006 - June 2008 (Two year interim report for three year project )

Project objectives

Khorda in West Bengal, India, has a population of around 16,800, spread over seventeen villages, all with poor health and nutrition indicators. The objectives of the Guernsey Overseas Aid Commission Funded project are:

• To build the capacity of the key stakeholders to undertake dialogue and action, by coordinating mechanisms on reproductive and child health issues, services, rights and entitlements
• To ensure safe motherhood
• To ensure child survival and growth

• 73% have had at least three ante-natal checkups or more (the state average is 56%), helping identify potential problems and ensure women were fully informed about measures they could take to protect their own health and the health of their unborn children.
• There have been eight miscarriages. In each case, the health worker sought to investigate contributing factors and provided appropriate support to the women affected.
• 100% of women have had a haemoglobin test, indicating that more than half were anaemic. The health-workers are now explaining simple steps that can be taken, such as eating nutritious food more regularly.
• 73% have received two tetanus toxoid injections; as is recommended for pregnant women in India
• 73% have received 100 or more iron folic acid tablets (more than three times the state average which is 21%), reducing the risk of dangerous bleeding during childbirth, or abnormalities in the children.
• Out of 220 births, 212 were live (96%). Verbal autopsies investigated the cause of still-births, and health workers continued home visits to provide emotional support to family members.
• 100% of deliveries have had a trained person present at the birth.
• 80% of infants were delivered in hospital, with full access to medical support in the case of complications, compared to the average for rural West Bengal of 34%.
• The remaining 20% of deliveries were conducted at home. All had a person present trained in hygiene during childbirth, spotting potential complications and the need to report these to medical personnel as soon as possible. This compares extremely favourably to an average proportion of home births attended by a trained person in rural West Bengal of just 37%.

Progress towards improved child health and nutrition

98% of newborns were weighed within 48 hours of birth. Of the newborn babies, 80% weighed at least 2.5kg or 5.5 lbs (World Health Organisation recommended minimum weight). Because many of the mothers have been chronically malnourished since childhood, many are unable to fully nourish the baby in their womb, and many babies are born before reaching full-term. Five of the infants born died after birth. Verbal autopsies have been carried out, and health workers continued home visits to provide emotional support to family members. Following advice on the value of breastfeeding, 89% of infants were exclusively breastfed for the initial three months; 77% were exclusively breastfed for the first six months. There was continued monitoring of the nutritional status of the child through regular weighing, and advice given accordingly to the parents of children that were underweight. 97% of children have received complete primary immunisation.

• 14 adolescent groups have been formed (15-17 members in each group) in four villages, each with two leaders. Thirty-two meetings have been conducted, where adolescent issues such as the need for addressing adolescent reproductive and sexual health, good nutrition and effective parenting have been openly shared. Meetings are particularly helpful for adolescent girls from sheltered homes, as meeting with peers helps them gain greater knowledge and confidence, enabling them to make more informed decisions.
• 14 meetings for adolescent group leaders were held with personnel from CINI and local government officials to discuss health and nutrition issues, and enable the group leaders to understand the importance of ownership, ensuring that activities are undertaken by themselves, with support from their respective local government bodies. Group leaders were also able to share their experiences and learn from one another.
• 20 adolescent peer sessions informed adolescents about adolescent reproductive and sexual health issues (which are not otherwise openly discussed).
• 24 meetings for adolescents were held as a forum to openly discuss problems, enabling adolescents to improve their knowledge of health issues and take greater responsibility.

• Meetings with service providers: Five meetings with government health service providers and key community leaders were held to help improve the delivery of local government health services. Issues discussed included: registration of pregnant women; spacing and supply of contraceptives; supply of iron tablets for pregnant women and adolescents; and the roles of different service providers to ensure quality health services to the poor. After, panchayat members and service providers were more receptive to the adolescent programme, and continued to extend support to the project. Outcomes of these meetings include: the purchase of iron tablets to hold for times of inadequate supply, a new health centre was built, and the local village health centres are now equipped with essential medical instruments.
• Meetings for mothers: 90 meetings across the 17 villages were organised. Key information disseminated included: the causes and consequences of early marriage and early pregnancy, ante and post-natal care, healthy growth of children under the age of one, and contraceptives.
• Orientation of self-help groups: Thirteen one-day orientation days were held for women's self help groups. 195 women and 42 leaders were informed about safe motherhood and child survival, empowering them to share this information with their groups. Later on, follow up training was provided to improve their knowledge of ante- and post-natal care, childcare, sexually transmitted diseases and infections, and aimed to break down myths about HIV/AIDS.
• Meetings with women's groups: 42 women's groups have been formed and monthly meetings are held with group leaders. Issues covered were: health, nutrition, and concerns requiring immediate attention. Other women are turning to these women for support on health related issues, and are adopting positive health practices. Events, attended by these women's groups, health functionaries and panchayat leaders, were organised to raise awareness of health issues within the wider community, thereby encouraging community ownership.

Male involvement meetings: 1,226 men participated in 102 meetings which were held on a regular basis to stress the roles, responsibilities and the importance of male involvement within the family, to ensure safe motherhood and child health. As men tend to be the key decision makers in the family, it is important that they are involved in this process. Meetings with parents of children under two: Meetings aimed to develop a greater sense of responsibility amongst parents. 41 meetings were organised, reaching 416 mothers and fathers, to discuss child health, such as: feeding practices, immunisation, hygiene, prevention of common childhood diseases, as well as the importance of love and care during a baby's development. Newly wed ceremonies: These are a traditional practice welcoming newly wed couples into the community. Five ceremonies were organised and used as a platform to inform couples and others attending about family planning, contraception and local services available.

Key challenges

• It has been difficult to organise the male involvement meetings, as most men work as agricultural daily wage earners. Missing one day of work would imply loss of income. Therefore, times and locations of meetings were chosen accordingly.
• In parallel, most adolescents go to school, therefore, it is difficult to arrange adolescent meetings and peer sessions during the day. To accommodate this, meetings have been arranged so that they do not clash with school hours.
• With a recent election, the newly elected panchayat members had to be oriented about the programme, therefore slowing down the intervention process.

Key lessons for sharing:

• Women's self-help group leaders act as very effective links between the health system and community.
• The newly wed ceremonies are very effective. They present an opportunity to inform young couples about family planning before they start their family.
• Involving the local government members is essential for the project's implementation and also its sustainability.
• Self-help groups enable more people to benefit from the project, as they reach out to others within the community. This contributes towards a greater sense of community ownership, and helps to make the outcomes more sustainable.

The plan ahead for the final year of the project

• Conduct sessions with pregnant and lactating mothers on pregnancy care and childcare
• Organise male involvement meetings and training for male peer educators
• Organise community linkage activities with multiple stakeholders
• Organise training of adolescent peer group leaders
• Organise a health fair
• Conduct meetings with parents of children under the age of two
• Continue monthly adolescent group leader meetings
• Organise further training for women's self help group members
• Preparations for phasing the project out of the area in such a way that work can continue through local government and the work of community groups in a sustainable way.
• Final report and assessment of progress over the fully three years of the project.
  

Poornima's story: Safe motherhood Poornima, 26, lives in a small village in Khorda with her husband, Raju, 30, and her son Manek, 6. Raju is a daily wage labourer and barely earns enough for his family. Poornima was identified by a CINI health worker during her second pregnancy. Through regular home visits, the health worker advised Poornima on the various dos and don'ts of pregnancy. The importance of increased food and rest as well as regular medical checkups was emphasised. The health worker also interacted with Raju. Poornima gave birth to a healthy baby boy with a birth weight of 2.5 kgs (5.5 lbs), whom she named Kamal. Kamal, however, was unable to suck breast milk, which started affecting his health. Within the first six months, Kamal was severely malnourished (third grade malnutrition). CINI's health worker continued her home visits and advised Poornima to collect breast milk and feed Kamal with it. In addition, the couple was advised to take the child to a qualified doctor. Poornima and Raju never gave up hope and followed the advice given. The child has received regular immunisation. Slow but steady improvement of Kamal's health can now be seen. His nutritional status has improved. Both the health worker and the couple are positive that if they continue feeding adequate amounts of nutritious food, Kamal will soon be well nourished and healthy. On being asked what she feels about CINI's intervention, Poornima says: "My child is alive only because of CINI's health worker."

Sitangshu

Sitangshu's story: Improved health services through community mobilisation Sitangshu Bhusan, a resident of Khorda, has been a member of the panchayat (local self government) for five years. Sitangshu was initially sceptical about the project, due to the lack of resources, and he wondered how an overall improvement in health and standard of living could be accomplished. Sitangshu was involved in organizing the community meetings, to be attended by members of the community, CINI health workers and other local government members. Some issues discussed at these meetings were: improving the provisions of the government health services through the panchayat, the increased supply of contraceptives, the increased supply of iron tablets for pregnant women and adolescents and a better understanding of the role of the service providers for the poor. Over time, the attendance at meetings grew considerably and community members have become more aware of the health services available to them. Sitangshu feels that through CINI's work, the governing bodies and the community members have become closer and the panchayat now have a better understanding of the needs and expectations of their community. Sitangshu commented, "CINI effectively supported and added value to various ongoing maternal and child health initiatives as well as started its own programmes. From our side too, we wanted to support CINI." Sitangshu is no longer a panchayat member but wishes to remain associated with CINI and its activities as a volunteer. He said, "I have been personally enriched through my experience of working with CINI and am willing to be associated with the organisation as long as I can".

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