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Posts Tagged ‘American India Foundation’

This is the third post in a series on maternal health in rural Jharkhand, India. 

At 4am, Radha’s body became completely stiff. Then came the convulsions.

Radha, a newly married young woman in a small village in rural Jharkhand, was pregnant with her first child and her due date was just one week away.

Radha’s story paints a personal picture of the issues that pregnant women face in rural Jharkhand–and it points to conceptual questions and unforeseen consequences of Janani Suraksha Yojana (JSY), a national program that aims to increase institutional deliveries across India. Her story raises big picture questions that merit further investigation, especially given the scope, cost, and potential of JSY, the largest conditional cash transfer program of its kind in the world. Radha’s story also sheds light on some of the implementation challenges and the pockets of the population that seem to be left out, beyond the reach of JSY.

Radha wears dramatic sindor along the part of her hair, the unmistakable red powder that makes clear she is a married woman. Photo by: Kate Mitchell

Against the wishes of her in-laws, Radha had left her husband’s village and returned to her parents’ home in a small village in the Seraikela block of Jharkhand. She was planning to deliver her baby in her parents’ community and at home, just as her mother, Prema, had given birth to her at home 18 years earlier.

Radha’s decisions to return to her parents village and to deliver at home are not uncommon practices in India.

Returning to the parental village

In India, women are often married at a very young age. In rural Jharkhand, 73.4% (National Family Health Survey of India, NFHS-3) of women are married before the age of 18. Once they are married, they go to live with their husband’s families where they take on the often demanding role of daughter-in-law that traditionally involves cooking, cleaning, and collecting water and firewood for the entire family. It is an age-old tradition that once women reach the 8th or 9th month of pregnancy with their first child, they return to their parents’ community where they spend the final month(s) of pregnancy and deliver the baby. This tradition is often cherished by women as it offers them some much-needed respite from their daughter-in-law duties, and a chance to reconnect and spend time with their families.

Home delivery

According to the National Family Health Survey of India, only 40.8% of deliveries in India occur in an institution–and in rural Jharkhand, where Radha lives, significantly fewer women opt for institutional care with only 11% of babies born within health facilities.

Prema, Radha's mother, is the mother of six children--Radha was the fourth, but the first to survive beyond one year of life. Photo by: Karl Gruschow.

According to Prema, Radha’s in-laws had recently learned about a government program that is providing a cash payment of 1650 rupees (approximately 40 US dollars) to women who opt for institutional delivery over the traditional practice of home delivery. Prema said that the decision of where Radha would deliver caused a conflict between the two families. She said that Radha’s in-laws wanted Radha to deliver in an institution in their district—and Prema did not seem to believe that their motive was entirely about a safe delivery.

It is unclear what motivated Radha’s in-laws to push for her to remain in their district for the delivery. Did they believe that institutional delivery was a safer option and want to keep her close to ensure that she delivered in an institution?

Or, were they pushing Radha to deliver within their district so that they would have access to the cash payment?

Was it a combination of the two—a promise that Radha and the new baby would receive care in the event of a complication, sweetened with a little cash?

Whatever their motives were, the conflict that arose between the two families is one unforeseen consequence of Janani Suraksha Yojana.

While a little tension between in-laws might not seem like such a big deal, it points to  bigger questions about the unanticipated repercussions of providing women, who may or may not have the autonomy within their families to command how and when to use the money, with cash on a conditional basis linked to a new behavior, institutional delivery,  that they may or may not want to adopt. The idea that JSY might be becoming a source of conflict among other families, as it is in Radha’s family, and influencing in-laws to try to keep daughters-in law in their districts for delivery, leaves me with several questions:

  • To what extent might JSY be creating barriers for women hoping to follow the cherished tradition of returning to their parents’ community for the last month of pregnancy and delivery of their first child?
  • What ethical considerations does cash introduce to women’s decisions about where to give birth? The money is obviously aimed at encouraging women to pursue a safe delivery, but the women involved are often younger than 18 and often have only limited capacity within their husband’s families to influence decisions about new behaviors.
  • Who actually controls the money?
  • Whom is actually incentivised by it?

If it is the parents and the in-laws who are most concerned with and/or motivated by the cash payment (and will have the most control over how the cash is used), how can JSY be modified to ensure that the wants and needs of rural women are not overlooked? How might policy makers ensure that JSY does not interfere with the tradition of going to the parental village for delivery or further restrict the autonomy of young newly married women to make decisions, while still promoting institutional delivery?

During our time talking with women in the Seraikela block of Jharkhand, it seemed to me that women were far more motivated by an awareness of potential complications and an assurance that they and their babies would be cared for than they were by the promise of a one time cash payment.

A few weeks back, we met a woman named Sita who had just delivered her second baby. Her first child is now four years old. Sita initially planned to deliver at home but when her labor seemed to go on for too long, she chose to go to an institution. In her case, this was a feasible and reasonably safe plan—as the institution was only a half an hour away from her home and her family had access to a vehicle that could be used to reach the facility. Sita explained that the reason she went to the institution was because she was afraid; “If I die, what will happen to my son?” To Sita, the cash seemed like a nice bonus—but far from a deciding factor.

Sita, mother of a four-year old, chose to deliver her most recent baby in an institution due to her fears about who would care for her four-year old if she did not survive the delivery. Photo by: Kate Mitchell

This idea that women are motivated to seek care when they believe institutions will provide them with high quality care is illustrated by the three delays framework for understanding maternal mortality. The framework shows a direct arrow between the quality of care within the facility (perceived or actual) and a woman’s decision to seek care. This means that her perception of the quality will play a big role in whether she seeks care for the first time, but it also means that if the woman seeks care, and it turns out to be poor quality, she might not ever choose to seek care again and her experience might also influence the behavior of other women.

Through the National Rural Health Mission, the government has hired an extensive system of community health workers who are working to increase awareness and identification of maternal and newborn danger signs, and encourage women to seek care. Through JSY, the government is providing women with a cash payment that sometimes serves as an incentive and other times as a partial reimbursement for costs associated with seeking care. But, what happens when the women reach the institution? It is important to remember that the type of care they find will play a role in whether they (and their sisters, sisters-in-law, and friends) continue to seek care.

Just a few days ago, the Times of India ran a story about this issue:

“…The NRHM hired over 8.5 lakh* women as Accredited Social Health Activists (ASHAs), mostly village women with minimum Class VIII education, to provide preventive health services in villages including taking pregnant women for antenatal check ups, organising immunization camps, dispensing basic drugs and educating people about hygiene practices. About 6.5 lakh have completed their training and have started work. Though ASHAs have boosted the utilisation of public health facilities in many places, the facilities themselves have not been upgraded to take the increased load.”

Sita’s story combined with an understanding of the three delays framework makes me wonder what would happen if the government, who aims to increase institutional deliveries, took on the challenge of dramatically improving the quality of care within institutions as one of their strategies for increasing the number of women who deliver within health facilities.

In Radha’s case, it seemed that tradition, Radha’s parents’ wishes, and Radha’s own wishes would trump Janani Suraksha Yojana, the cash provided by the program, and the wishes of the in-laws. It also seemed that, for Radha and her parents, cash was not enough to persuade them to choose institutional delivery over home delivery. For she was home with her parents when the convulsions began, and she had no plans to go to an institution.

But when Radha’s family was awakened by her uncontrollable shaking, the trajectory of events changed course.

Radha’s story will continue in upcoming posts…

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*One lakh, part of the Indian numbering system, is equal to 100,000. 

Note: We have changed the names in this series, in order to provide a level of privacy to the families who shared their stories.

Tata Steel Rural Development Society, my host organization for my fellowship, provided us with transportation and interpreter services. Many thanks to Shabnam Khalid for her help with translation. 

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This post is the first in a series on maternal health in the Seraikela block of Jharkhand, India. 

In 2009, Sarah Blake and I worked together at the Maternal Health Task Force, a Gates Foundation funded maternal health initiative based at EngenderHealth in New York City. Since then, Sarah went on to work as a consultant with several non-profit organizations, including UNFPA and Women Deliver.  I took off for India as a Clinton Fellow with the American India Foundation where I have been working for the past nine months on a maternal and newborn health project in Jharkhand, a state with high levels of maternal and newborn deaths.

A new mom holds her newborn in a small community called Sini, in the Seraikela block, as community members look on.

Sarah and I recently teamed up again (this time, in India) to explore our common interest in maternal health. Over the past two weeks, we have visited hospitals, health centers, government offices, rural villages, and homes in the Seraikela block, a rural area with rugged terrain and limited infrastructure outside the industrial city of Jamshedpur, in the state of Jharkhand.  We conducted a series of interviews with women, families, health workers, and government health officials. We asked questions about pregnancy, childbirth and the postpartum period. We learned about the women’s experiences with home and institutional deliveries–and the factors that influence their decision to deliver at home or in an institution. We explored the implementation of and attitudes toward Janani Suraksha Yojana, a conditional cash transfer program that aims to increase institutional deliveries across India.

A collapsed road on the way from Jamshedpur to the Seraikela Block of Jharkhand.

Conditional cash transfers are trendy. Various governments, non-governmental organizations, and private enterprises across the globe are supporting cash transfer initiatives in efforts to improve school attendance, reduce child under-nutrition, improve maternal and newborn health, and to address other development goals.

What is a conditional cash transfer program? According to the World Bank, “conditional cash transfer programs provide cash payments to poor households that meet certain behavioral requirements, generally related to children’s health care and education”.

Janani Suraksha Yojana (JSY) is a widely discussed (mostly within the global health community but to some extent in mainstream media) and frequently praised cash transfer program. JSY was launched by the Indian government as part of the National Rural Health Mission in 2005, in an effort to reduce maternal and newborn deaths by increasing institutional deliveries.

JSY provides cash incentives to women who deliver in government health institutions as well as accredited private health centers. The program also provides a cash incentive to the health worker who supports the woman throughout her pregnancy and accompanies her to the facility. (For details and FAQs on JSY, click here.)

A community health worker accompanies a pregnant woman to Mahatma Gandhi Memorial Hospital in Jamshedpur, the main referral hospital for the surrounding rural communities.

Maternal and newborn death rates have gradually been declining across India (and the world), but the problem has yet to be resolved. Both maternal and newborn deaths in India continue to make up an extremely large percentage of the overall global burden. According to a study published in the Lancet last year, 20% of global maternal deaths and 31% of global newborn deaths in 2005 occurred in India.

JSY is a big program (the biggest of its kind in the world) that aims to deal with a big problem. The lessons that are drawn from it have the potential to influence global health policy in a big way. The 2010 evaluation of JSY published in the Lancet suggested that the program is having a significant impact on perinatal and neonatal health, but the paper asserted that the verdict was still out in terms of any impact on maternal mortality.

The lesson that has emerged from JSY for newborn health is that giving women money increases institutional deliveries and reduces perinatal and neonatal mortality.  It is likely that the same message will emerge in terms of reducing maternal mortality—and there is a good chance that this approach will be picked up in national health programs in numerous other countries that also have high levels of maternal and newborn mortality.

Our concern is that JSY is far more complex than providing women with money—and reducing maternal mortality is far more complex than increasing institutional delivery.

Given the scope, cost, and potential of JSY; it is incredibly important that we ask questions about the nuances of JSY—the role of money as an incentive for women, families and health workers; the readiness of institutions;  the challenges with transportation; the human rights implications of the program; and a variety of other related factors.

Over the next week (or couple of weeks), Sarah and I will share our experiences and insights from our time with the women, families, health workers, and government health officials of the Seraikela block of Jharkhand, a focus state for JSY. We will highlight stories from the people most impacted by and involved in Janani Suraksha Yojana.

We believe that we have scratched the surface of some interesting issues related to JSY, but our time in Seraikela certainly left us with more questions than answers, and we will be sharing those questions in upcoming posts.

We will also be asking our colleagues working in maternal and newborn health to share their thoughts through guest blog posts. If you are interested in submitting a guest post, contact us at katemitch@gmail.com and sarahcblake@gmail.com.

Tata Steel Rural Development Society, my host organization for my fellowship, provided us with transportation and interpreter services. Many thanks to Shabnam Khaled for her help with translation. 

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On Wednesday, September 29th, nearly 300 community health workers from 174 villages in the rural Seraikela block of Jharkhand, India came together for an interesting event that involved plenty of art supplies, a flurry of creative ideas, a tangible passion for and dedication to improving rural maternal and newborn health, and a little bit of healthy competition.

The gathering, part of the Maternal and Newborn Survival Initiative (MANSI), was an effort to develop effective behavior change communication tools for four maternal health interventions being implemented through MANSI– by tapping into the vast knowledge, experiences, and creative capacity of the newly identified community health workers.

Holding the belief that there is no better source of ideas for effective slogans and images than the community itself, MANSI staff coordinated a contest that called on community health workers to develop slogans and images to explain the importance of the MANSI health interventions. The thinking behind the contest was that if the artistic representations of the health interventions and the key messages come from within the communities, then the images and messages will be more likely to resonate with the community members—and ultimately the health practices will be more likely to be widely understood and adopted.

Before the contest began, the MANSI team provided an overview of the four maternal health interventions that the health workers would be developing images and slogans for: Misoprostol for post-partum hemorrhage, intermittent preventive treatment for Malaria, Vitamin A supplementation, and deworming. (In-depth training on these interventions will take place in the coming months.) Craft supplies were distributed and the nearly 300 health workers spent one hour competing to develop the most creative, compelling, and scientifically accurate slogans and images to be used as behavior change communication tools throughout the MANSI project.

A panel of judges made up of doctors, public health professionals, and government officials recently selected three winning submissions for each health intervention. The winners received prizes and their slogans and images are being incorporated into the final behavior change communication strategy for the MANSI project.

Check back soon for a short video about the the winning submissions!

To learn about another initiative that is tapping into creative energy to improve maternal health, visit MDGfive.com. MDGfive.com is a global project that is uniting artists around the world to use their collective artistic abilities to develop multimedia maternal health advocacy pieces.

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I am back to blogging after a few weeks break to get settled in India!

I arrived in Jharkhand, India  just over a month ago. I am here as a William J. Clinton Fellow with the American India Foundation. I transitioned out of my previous role at the Maternal Health Task Force at EngenderHealth just after the Global Maternal Health Conference in Delhi. (Click here to view archived videos of the conference sessions.)  I was craving on-the-ground experience in program implementation and I was looking forward to working at the community level—to put to action the knowledge I gained during my time at the MHTF as well as the program planning skills I learned while completing my MPH in International Health at Boston University.

Mother and Baby, Jharkhand, India--Photo by Kate Mitchell

The people of India face some of the highest levels of maternal and newborn mortality and morbidity in the world.  Jharkhand, a newly formed state in India, faces higher maternal and newborn mortality ratios than India as a whole. And the villages of the Seraikela block, a region of Jharkhand with difficult geographic terrain and low levels of literacy, experience even higher ratios than the state.

My fellowship placement has already offered me some remarkable experiences (I’ll be writing about those experiences in upcoming posts)–and mentors who are working together to improve maternal and newborn health in Seraikela from a number of different angles and organizations.

My assignment is with a new public-private partnership that aims to improve maternal and newborn health in Seraikela at the community and facility level. (Click here to read about recent conversations at the Global Maternal Health Conference focused around striking the right balance between community and facility based interventions.)  MANSI, the Maternal and Newborn Survival Initiative, is being implemented by Tata Steel Rural Development Society, a division of Tata Steel’s corporate social responsibility wing, and the American India Foundation in partnership with the local government. (Click here for a recent post by Alanna Shaikh on corporate players getting involved in global health.) 



MANSI is a replication of the Home Based Newborn Care (HBNC) project that was originally (and very successfully) implemented by SEARCH in Gadchiroli, Maharashtra, India. The MANSI team is working closely with SEARCH to train community health workers from 174 villages within the Seraikela block on the HBNC curriculum, a set of modules that prepares community health workers to address the leading causes of newborn mortality and morbidity in India.  The team will also be training the health workers on a number of interventions that will target the health of the mother–as well as upgrading several sub-centers within the Seraikela block to be equipped to handle normal deliveries and improving referral systems for complicated deliveries.

Mother and Infant Wait to be Seen at a MNCH Clinic Under A Banyan Tree, Jharkhand, India---Photo by Kate Mitchell

Much of what I will be doing over the next ten months is helping to develop training modules for the maternal health interventions that will be added onto the HBNC model–as well as helping to conduct the training. 

I am really excited to be a part of the MANSI team.  It is going to be an exciting and challenging ten months–and I promise to keep you posted:)

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I was recently selected as a Clinton Fellow in maternal health with the American India Foundation which means I will be moving to India in September to work on the ground on a maternal and neonatal health project! This also means that my position with the Maternal Health Task Force at EngenderHealth will be open as of September.*

So…if you have a background in public health, gender studies, or a related field, are interested in using web-based communications tools, and are passionate about improving global maternal health–take a look at this job at the Maternal Health Task Force at EngenderHealth in New York City!

Job Summary:

“The Knowledge Management (KM) unit of the Maternal Health Task Force (MHTF) requires a highly motivated KM Assistant to help coordinate and implement the MHTF KM strategy and tactics. The KM Assistant will work closely with the KM Specialist in making its online knowledge portal robust, relevant, engaging, and user-friendly. The KM Assistant will proactively identify ways to engage current members and expand our audience.  This position provides a unique opportunity for those who are interested in how technology can help advance MDG5 goals.”

For more information about the job and to apply, click here.

Please feel free to contact me with questions about the position.

*While, I will be leaving my position with the Maternal Health Task Force, I will continue to maintain Maternal Mortality Daily throughout my fellowship in India—in fact, I have  exciting plans for adding new features to the blog over the next few months so stay tuned!

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