- Reducing mortality among mothers, newborns and children

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1 PAKUR - Reducing mortality among mothers, newborns and children India has been overcoming the challenge of reducing the Maternal Mortality Ratio and Infant Mortality Rate as indicators in halving the poverty by Though the daunting task of decreasing Maternal Mortality Ratio from 437 to 109 and under-5 Mortality Rate from 125 to 42 (MDG India country report 2014) seem impervious to achieve, rays of hope have been emerging in the tribal district of Pakur, in Jharkhand state. EFICOR in partnership with the Health Bridge Foundation withthe financial support of the Department of Foreign Affairs, Trade and Development, Canada implemented the Pakur Mother and Child Survival Progamme in reducing mortality among mothers and children under the age of two by strengthening and sustaining community based approaches in the past three years ( ). Working towards a just, responsible & compassionate society

2 Confronting crisis One of the important revenue-earning districts of the newly created Jharkhand State with the best black stone and coal mines, the Pakur District has a literacy rate of (2011 census) which is much lower than the national average at 74. The District has a large tribal population (49.30 %) living in remote, inaccessible villages and suffers from diseases such as malaria, TB etc. Coverage of Pakur Mother and Child Survival Project Children between months benefitted Children between 0-12 months benefitted Women between years benefitted Couples benefitted Population Villages Blocks ,877 1,03,508 78,702 1,40,333 8,99, ,000,000 When the Project was initiated in 2012 the Infant Mortality Rate was at 81 (third highest in the State), Neo-natal Mortality rate (NNMR) at 34 and Maternal Mortality Ratio at 318 (second highest in the State) as per Annual Health Survey which were comparitively very high in terms of the State and national average. Maternal, newborn and child health is confronted with issues that threaten the well being of communities in the district. Women die of pregnancy-related causes and 50 percent deaths of children under five years are in the first weeks of their lives. Interventions reaching the most needy are often inadequate, thereby leading to deaths, stunted growth, infections and diseases which are easily preventable. The coverage and quality in maternal, newborn, and child health interventions vary considerably, depending on the accessibility and awareness and care seeking behaviour of the community. The Pakur Mother and Child Survival Project has been helping to bring about better health, hygiene and nutrition with a focus on gender equity in the state which was overwhelmed with diseases and lacking adequate health services. The results of the final Knowledge, Practice and Coverage survey (KPC) undertaken in June 2014 are encouraging, indicating improvements in the district with regards to the health of both mothers between years and children below two years. Accomplishing success through joint participation EFICOR in partnership with Health Bridge Foundation, Canada with financial support from the Department of Foreign Affairs, Trade and Development, Canada worked along with the Jharkhand Government. The concerted action with diverse stakeholders including Government Ministries (Health & Family Welfare, Women & Child Development), experts in the field and other NGOs, was able to improve mother and child health. Such a combination which strengthened the partnership, had an impact which the project could not have achieved alone. A Sahiya counselling a pregnant woman with the help of the flip book

3 Eliminating obstacles The Project addressed gaps in maternal and child health, in the district particularly during pregnancy, birth, first days of life and till the age of 23 months, such as delay in seeking care, lack in awareness of danger signs that were hindrances to their survival. Through Capacity Building of the community level health personnel with four other cross cutting strategies of Community Mobilisation, Behaviour Change activities, Gender Equity and Supportive Supervision, the Project is facilitating the sustenance of maternal and child health in Pakur district. Capacity building The Pakur Mother and Child Survival Project focused on the continuum of maternal, newborn and child health care, by training 1135 Anganwadi workers and 721 Sahiyas. The project has also trained 2028 Village Health Sanitation and Nutrition Committee (VHSNC) members. The monthly meetings initiated at the 56 Health Subcenters with full cooperation of the district officials has improved the quality of health facilities provided at Anganwadi centers and at the Health Sub-centres resulting in a responsible and robust health system. Strengthening Village Health, Sanitation and Nutrition Committees (VHSNCs) e St r ng h t ening of convergence between Health and ICDS at HSC level

4 Anganwadi workers (AWWs) Training on WHO Standard Growth Monitoring Chart and Nutritional Counselling has helped the Anganwadi Workers to use them to identify undernourished children in the community. They provide counselling to parents and guardians of malnourished children and initiate prompt referrals to the Nutrition Rehabilitation Centres for the severely malnourished children. The Village Health Sanitation and Nutrition Committee oversees the Anganwadi level monitoring and support. Accredited Social Health Activist (ASHA or Sahiya) The ASHA workers (Sahiyas) trained in Time Counselling, antenatal care and post-natal care, mobilize communities for immunization, treatment and/or referral for Malaria, Diarrhoea and Acute Respiratory Infection (ARI). Families were also given orientation on gender issues during counselling. Their consistent counselling of pregnant and nursing mothers at regular intervals on reproductive and child health issues and their support in Behaviour Change Activities improved knowledge regarding danger signs during pregnancy and in accessing health services. Strengthening convergence meetings The Auxilliary Nurse Midwives (ANMs) conducted Monthly Convergence meetings with ASHA workers (Sahiyas) Anganwadi Workers (AWWs) and Village Health, Sanitation and Nutrition Committees (VHSNC) thus strengthening the Health Sub-centre. Facilitating Monthly Convergence meetings with health service providers offered a platform to review, plan and impart training on maternal and child health. Mobilising community Sustainability of positive health outcomes in the community required fortifying the capacity of the Village Health, Sanitation and Nutrition committees (VHSNCs) to take ownership and promote access to health services available to their communities. The Project staff built the capacity of 600 VHSNCs. This ensured quality services at the health facilities; providing access to appropriate care as well as promoting healthy household behaviours. Introduction of the Self-scoring tool and community growth chart helped members to assess the communities' progress in maternal, newborn and child health. A method to convey the child's nutritional status to the mother along with the Integrated Child Development Services (ICDS) team through coloured pictorial stickers was an innovative approach which was also shared in the district and state government meetings. Promoting positive behaviour change Important Health messages through street plays and dramas such as 'Saas Bahu Pati Sammelan', 'Kala Jatha' and video film shows in local dialects like Santhali, Benngali and Hindi influenced the community towards behavioural changes have been appealing to the community. These are messages on health, nutrition and gender related issues, etc., which demand for services and the referrals linked the community to the health facilities. Hoardings on MNCH practices were placed at 120 Anganwadi centers, six at community health centers and one at district hospital. The Project developed innovative approaches using the Behaviour Change Framework designed specifically for primary and influencing groups, to reach literate and non-literate people. As a result, there were marked improvements in antenatal care behaviours, consumption of iron folic acid tablets and institutional delivery. An Anganwadi Worker filling the Growth Monitoring Chart

5 Nurturing gender equity In order to identify and assess the levels of acceptance in shared decision making in families on maternal, neonatal and child health practices the Project conducted a study on participatory gender engagement. The data was used in developing Behaviour Change Communication /Information Education & Communication (IEC) materials incorporating the need for husband's support during the pregnancy and neonatal care wherever required. The IEC/Booklet was also used by ASHA workers (Sahiyas) and project staff in providing appropriate household counselling. Providing Supportive Supervision The Project provided supportive supervision to the Auxilliary Nurse Midwives, ASHA workers (Sahiyas) and Anganwadi workers on Village Health and Nutrition Days (VHND). Encouraging outcomes The End line Knowledge Practices and Coverage (KPC) survey conducted in June 2014 showed encouraging progress with respect to key indicators of Maternal and Child Health among the population covered by the Project. The project's unique thrust on gender issues was clearly reflected in the finding. Maternal and Newborn Care the promotion of breastfeeding and practice of exclusive breastfeeding have been reinforced by the project. Diarrhoea and Pneumonia (ARI) / Sanitation The decreased levels of childhood illness and sanitation point to the effectiveness of the project strategies. Improvements have been noticed when the number of children with diarrhoea or pneumonia were taken for treatment to a qualified provider on the same day. Malaria Treatment and Prevention The project has facilitated an increase in awareness and improved access to bed nets, which reflects the effectiveness of 'behaviour change communication'. The Project's mission in supporting strong health systems for women and children using community based approaches by working along with the government structure has brought services closer to such rural and hard to reach communities. Building village capacity and engaging community members to work out local solutions have paved a way to save the lives of women and children. Indicators of Maternal and Newborn care are higher towards the end line as compared to baseline. Elevation in the levels of institutional delivery and consumption of iron and folic acid tablets has been attributed to the bridging of awareness gaps and access to health services facilitated by ASHA workers (Sahiyas) and Anganwadi Workers. Behaviour change through communication, i.e., activities like group discussion and theatre shows increased the knowledge regarding danger signs and access to antenatal care among the pregnant women. Childhood and Adult Nutrition The indicators of Childhood nutrition with regard to breastfeeding are higher than the baseline survey representing enhancement in nutrition. Therefore,

6 Maternal & Newborn Care Breastfeeding & Nutrition Pregnant mothers made 3 Antenatal visits Pregnant mothers received 2 doses of Tetanus immunization Pregnant mothers had consumed iron supplements for 100 days *Early initiation of breast feeding for the newborn Exclusive breast feeding 0-5 months Maternal Body Mass Index (BMI) Mothers received Postnatal visits Pregnant mothers had institutional delivery and attended by skilled birth attendant Pregnant mothers know 3 danger signs during pregnancy Complementary feeds in 6-23 months **Infants received Vit A supplements Child underweight 0-23 months NFHS 3 (2005-6) % Baseline 2012 % Endline 2014 % Childhood Immunization Malaria Treatment & Prevention Children between months fully immunized Children between months accessed DPT1 vaccine Children months received the DPT3 vaccine *Mothers' ill health and cultural beliefs strongly opposing early initiation of breast feeding showing a decline. **There was Vit A stock out in the entire state thus showing a decline. Possess Bednet 77.6 Use Bednet Immediate treatment of fever Photos courtesy: Christy Sasi About EFICOR EFICOR is a National Christian Organisation engaged in Disaster Response, Development and Training. It serves the poor, socially excluded and the marginalised in situations of poverty, injustice and disaster irrespective of caste, creed or ethnicity. EFICOR is registered under the Karnataka Societies Registration Act, 1960 (Karnataka Act No.17 of 1960) on 30 April, The registration number is 70/ EFICOR is also registered under the Foreign Contribution Regulation Act, 1976 and the registration number is All donations sent to EFICOR are exempted under section 80 (G) of the IT Act of Regd No.DIT (E) /DEL EE /4 dated 6/6/2010 valid from onwards. About Health Bridge Foundation Health Bridge Foundation works with partners worldwide to improve Health and Health equity through Research, Policy and Action. Health Bridge has been working since 1982 in Asia, Africa and the Americas to improve the heatlh of vulnerable populations. Working towards a just, responsible & compassionate society THE EVANGELICAL FELLOWSHIP OF INDIA COMMISSION ON RELIEF (EFICOR) 308, Mahatta Tower, B- Block Community Centre, Janakpuri, New Delhi Telefax : , , hq@eficor.org Website : Improving health and health equity Printed on 100% Recycled Paper