Progress Report Establishing a sustainable support service to improve mother and child health in Khorda, West Bengal July 2006 – June 2009 Final project report

Achievements included:

• 97% of deliveries had a trained person present at the birth. This compares extremely favourably to an average proportion of births attended by a trained person in rural West Bengal of just 37%.
• 90% of newborn babies weighed at least 5.5 lbs (2.5 kgs) - the World Health Organisation recommended minimum birth weight. In India, because many 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.
• 99% of children have received complete primary immunisation.
  

Project objectives

The objectives of the Guernsey Overseas Aid Commission Funded project are:

• To make pregnancy and birth less dangerous
• To lay a strong foundation for a healthy life for children born in the area over the project period
• To improve the health and nutrition status of adolescents, who will be the parents of the future
• To raise awareness and access to services through community mobilisation activities

1) To make pregnancy and birth less dangerous: support for pregnant women and progress towards safe childbirth

Pregnant women living in Khorda were identified within their first 16 weeks of pregnancy and were then regularly visited at home and monitored by health workers and women's self help group members, who recorded their progress on health record cards and provided advice on the importance of a nutritious diet, good hygiene, adequate rest, a reduced workload, and regular check ups during pregnancy.   Expectant mothers identified as 'at risk' cases (more than three pregnancies, under 18 years or above 30 years, weigh less that 40 kgs or are less than 140 cms, or have had an earlier incident(s) of miscarriage) were referred for specialist maternal health support. Fathers and mothers-in-law were also involved in this process to ensure that expectant mothers received adequate care and support in the home environment.

Health worker provides a health check to an expectant mother

Of the 317 pregnant women identified over the three year project period:

• 316 women were identified within 16 weeks of pregnancy.
• Mother's groups were formed to act as support networks for pregnant women.
• Regular meetings with pregnant and lactating women were held. Discussions included: the various 'do's and don'ts' during pregnancy, registration at local health centres within 16 weeks of pregnancy, regular ante natal care checkups (at least 3 checkups), consumption of adequate amounts of nutritious food, rest, intake of at least 100 iron folic acid tablets and the importance of delivering with a trained person present.
• 93% received 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.
• 93% of women had a haemoglobin test, indicating that more than half were anaemic. Health-workers explained simple steps that could be taken to improve this, such as eating nutritious food more regularly.
• 93% received two tetanus toxoide injections, as is recommended for pregnant women in India.
• 93% 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.
• There were eight miscarriages. In each case, the health worker sought to investigate contributing factors and provided appropriate support to the women affected. In addition, there was one phantom pregnancy.
• There were no maternal deaths. However on average, women in India are 80 times more likely to die of a maternity related cause than women in the UK.
• Out of 308 births, 298 were live births (97%). Verbal autopsies were conducted to investigate the cause of still-births, and health workers continued to offer support to family members through home visits.
• 97% of deliveries had a trained person present at the birth. This compares extremely favourably to an average proportion of births attended by a trained person in rural West Bengal of just 37%.
• 82% of infants were delivered in hospital, with full access to medical support in the case of complications, more than double the average for rural West Bengal of 34%.
• 15% of deliveries were conducted at home and 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.
• 3% gave birth at home with an untrained person present at the birth.

2) To lay a strong foundation for a healthy life for children born in the area over the project period: progress towards improved child health and nutrition

Of the 298 infants born over the project period:

• 85% of newborns were weighed within 48 hours of birth.
• Of the newborn babies, 90% weighed at least 5.5 lbs (2.5 kgs) - the World Health Organisation recommended minimum birth 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 infants born died after birth. Verbal autopsies were carried out and health workers continued to visit mothers and family at home to provide the necessary emotional support.

Health workers regularly met with both mothers and fathers to explain good childcare practices. This included exclusive breastfeeding of the infant for the first six months, followed by the introduction of semi-solid food, and ensuring timely complete primary immunisation. Following advice on the value of breastfeeding, 95% of infants were exclusively breastfed for the initial three months; and 91% were exclusively breastfed for the first six months (compared to 57% in rural West Bengal). Home visits ensured that the nutritional status of children was monitored and recorded on health cards. In this way, malnourished children were identified quickly, and those identified as 'at risk' received regular follow up health visits. If required, 'at risk' children were referred for more specialised support. 99% of children have received complete primary immunisation.

A health worker visits a mother and her child at home in the Khorda area to record their progress

3) To improve the health and nutrition status of adolescents, who will be the parents of the future: improving adolescent health

Adolescence (between the ages of ten and 19 years) is a key phase in any individual's life. By influencing attitudes and behaviour during these formative years, we hoped to lay the foundations for a healthy adulthood and the seeds of a healthy start for the next generation. During the project period, 364 adolescents benefited. Parents and community members were also involved, as they often influence the decisions of adolescents.

• 14 adolescent groups were formed (15-17 members in each group) in four villages, each with two leaders.
• 42 meetings were conducted, where adolescent issues such as the need to address adolescent reproductive and sexual health, good nutrition and effective parenting were openly shared. Meetings were particularly helpful for adolescent girls, as meeting with their peers helped them gain greater knowledge and confidence, enabling them to make more informed decisions.
• 19 meetings with adolescent group leaders were held with CINI's project team and local government officials to discuss health and nutrition issues, and enable group leaders to understand the importance of ownership, and that activities were to be undertaken by themselves with support from their respective local government bodies. Group leaders were also able to share their experiences and learn from each other. They received training on: the importance of good nutrition during adolescence, the prevalence of anaemia amongst adolescent girls, ill effects of early marriage and early pregnancy, use of contraceptives, reproductive and sexual health issues, and HIV and AIDS.
• 25 adolescent peer sessions informed adolescents about adolescent reproductive and sexual health issues (which were not otherwise openly discussed).
• 27 meetings were organised for adolescents to openly discuss problems, enabling them to improve their knowledge of health issues and take greater responsibility for their own health.
• 25 issue-based meetings were held with adolescents in the community, led by the peer educators.
• 12 meetings were carried out with parents (reaching 165 parents) to gain their support for the work, and to generate greater understanding between adolescents and their parents.

Improved capacity of local service providers and local government

• Seven meetings were held with government health service providers (health workers, doctors, nurses, rural medical practitioners, and traditional birth attendants) and key community leaders to discuss how the delivery of local government health services could be improved. These reached 458 individuals. Issues covered included: registration of pregnant women at government health centres; health and nutrition services available; birth spacing, and the supply and use of contraceptives; supply of iron tablets; and the roles of service providers to ensure quality health services to the poor. Afterwards, panchayat members and service providers were more receptive to the adolescent part of the programme, and continued to extend their support. Outcomes included: the purchase of iron tablets to hold for times of inadequate supply; a new health centre was built; and local village health centres were equipped with essential medical instruments.
• Orientation of panchayat members on HIV and AIDS: Local government representatives were informed about HIV and AIDS issues (how it is and is not spread, how it can be prevented, and the referral services available).

Improved community awareness

• 135 meetings across the 17 villages were organised in collaboration with local government representatives reaching 2,125 mothers. Self-help group members also participated in these meetings. 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.
• 13 one-day orientation days of women from local self-help groups were held reaching 195 women and 42 leaders, and informing them 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 HIV/AIDS.
• 42 women's groups were formed (made up of 504 women) and these met 25 times over the project period. The group leaders met a further 19 times. Issues covered were: maternal and child health, nutrition, and concerns requiring immediate attention. These meetings also facilitated discussion on how during women's group meetings, women could discuss their problems and arrive at solutions collectively. Other women were turning to these women for support on health related issues, and were 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.

Involving men within the family is important to ensuring safe motherhood and child health

As men tend to be the key decision makers within the family, 1,226 men participated in 118 meetings. These stressed the roles, responsibilities and importance of male involvement, to ensure safe motherhood and child health. Meetings with parents of children under two aimed to develop a greater sense of responsibility amongst parents. 45 meetings were organised, reaching 489 mothers and fathers to discuss child health. Topics included: feeding practices, immunisation, hygiene, prevention of common childhood diseases, as well as the importance of love and care during a baby's development. Two health fairs were organised within the community providing an opportunity to raise community awareness of mother and child health and nutrition related issues.

• Newly wed ceremonies are a traditional practice welcoming newly wed couples into the community.   Seven ceremonies were organised and used as a platform to inform couples and others attending about family planning, contraception and locally available services.

Key challenges

• Initially, parents of the adolescents were hesitant about the involvement of their children in the project, particularly because reproductive and sexual health issues had never been openly discussed at the community level. However, by involving parents from the beginning of the project, their support for the work was gained.
• With an election in the second year of the project, the newly elected panchayat members had to be brought up to speed on the progress being made, therefore slowing down the intervention process.

Key lessons for sharing

• Through regular interaction with parents, the importance of discussing adolescent health issues was explained.
• Traditional customs ought to be handled carefully without offending the religious/social sentiments. In order to change behaviour patterns, it is important to clearly explain facts and myths.
• The newly wed ceremonies were very effective. They presented an opportunity to inform young couples about family planning before they started their family.
• Involving the local government members was essential for the project's implementation and sustainability.
• Self-help groups enabled more people to benefit from the project, as they reached out to other members of the community. Self-help group leaders acted as very effective links between the health system and community. This contributed towards a greater sense of community ownership, and helped to make the outcomes more sustainable.

Reflections from Ishani, one of CINI's project workers "The project was initiated with the aim of establishing a proper system involving local self-government system and health service providers to break the cycle of poverty, malnutrition and ill health. Through this intervention the panchayats have been strengthened to act effectively. Now the panchayats and local service providers are in a position to ensure quality health care services. The project hence has ensured that the various programmes started by CINI will continue even when CINI withdraws, beyond the intervention period. We have built the capacity of the various stakeholders. The programme has hence been a success. However, traditional and cultural beliefs and practices at the community level have been and still are a major stumbling block. Various practices such as feeding honey to the newborn, discontinuation of exclusive breastfeeding of the child before he/she crosses six months and traditional healers or religious leaders being given the first preference over qualified medical doctors are still followed, and have a negative impact on the health practices of the people. Through the project interventions, there has been greater awareness of healthy behavior and health at an individual, household and community level."

Ishani

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