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Posts Tagged ‘infant health’

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

Janani Suraksha Yojana, or JSY, is a conditional cash transfer program first instituted by the government of India under the National Rural Health Mission in 2005.  A 2010 review published in The Lancet in 2010 characterized JSY as “a conditional cash transfer scheme, to incentivize women to give birth in a health facility,” and “the largest conditional cash transfer scheme in terms of number of beneficiaries” JSY is driven by two important assumptions that are shared by many development practitioners and policy makers around the world:

  1. Conditional cash transfers can be effective in reducing poverty and promoting gender equity. As with other national conditional cash transfer programs, the cash that is entailed in JSY is part of an effort to overcome barriers to service use – such as awareness and cost; and to give money directly to poor women who otherwise may have little access or control over cash.
  2.  Increasing institutional delivery will lead to a decline in maternal and newborn deaths. Therefore, according to the government’s guidelines for JSY, “the scheme’s success is determined by the increase in institutional delivery among poor families.”

While the program aims to reach poor women across India, it is not applied the same everywhere and, by design, invests the most in the states where institutional delivery is lowest, including Jharkhand. As one of the focus states for JSY, women in Jharkhand have access to greater amounts of money than in other states, and must fulfill fewer conditions to attain it. This means that, while there are restrictions on age, number of previous children and income level in many states, any woman in Jharkhand who gives birth is entitled to the full incentive if they give birth in a facility, whether public or private and government-accredited; and to a smaller amount (for “nutrition assistance”) if they give birth at home.

Among the government officials and health workers we talked to, there seemed to be a broad consensus on the fact that the program is having an effect on what women do. According to one government official, before JSY, “The government institutions were seeing zero deliveries. In four years of JSY implementation, this number jumped to 39 percent.” On a visit to one of the primary health centers, which are staffed by auxiliary nurse midwives, who are trained to perform normal deliveries, a group of ANMs showed us the labor room – which is equipped with three birthing tables, but now, they told us, is often so crowded that laboring women end up using the countertops in that room and the neighboring office instead. However, despite this consensus on the impact of JSY, we came across only one person – a doctor at the main hospital where women from Seraikela are referred for complicated deliveries – who declared “they just come for the money. Without the money, they wouldn’t be here.”

While the cash that women are entitled to under JSY is perhaps the most visible component of the program, it may not always be the most important factor in women’s decision-making – or even the most significant payment.

Sahiyas are also entitled to a payment of 600Rs (around $13) for each woman they assist. Though the implementation guidelines for JSY require that sahiyas’ work be assessed based on the number of women they accompany to the health center, their payment relies on fulfilling many more conditions – some of which they may complete successfully, but may not persuade women to deliver in public facilities. Sahiyas are responsible for completing duties well beyond the trip to the health center: they are responsible for identifying and registering pregnant women who are eligible for the scheme, and ensuring that they have the documents they need to access funds, preparing a “micro-birth plan” detailing the expected delivery date, place and possible referral institutions, to accompanying women to health facilities and providing follow-up care and arranging immunizations in the weeks after a baby is born. The JSY scheme relies on community health workers, known as Accredited Social Health Activists (ASHAs) throughout India, and known in Jharkhand as sahiyas, who are paid for the assistance they provide to women and babies. The women we asked about the cash incentive told us that they had received 1650 Rs (around $40) in exchange for delivering in the health facility, an amount which includes both the incentive and additional funds to cover transportation costs.

The role of the sahiya that is defined in the government’s guidelines seems clearly designed to motivate sahiyas to persuade women to use government health facilities. After all, when this happens, everyone gets paid. And, indeed, the scheme often seems to work this way. In Sini, a village located 20 minutes by car (a mode of transportation not always accessible to the people who live there) from a primary health center, and perhaps an hour and a half from the main hospital, a sahiya named Sudha told us simply, “Everyone goes to the institutions now—not because of the money, but because they are afraid of complications.” As we walked around her village, talking to women who had given birth recently, this seemed to be the case. In fact, as we sat with a group of the village’s women, one introduced a newcomer to the group as a woman who had given birth at home a few years ago – “back before we knew about the risks.” The things we learned in Sini suggested that both the sahiyas and the women they serve are following the script written by the government: the sahiya raises awareness, touched with a little bit of fear, and the women absorb the information, and proceed to delivery in the government facilities. At the end of the day, everyone gets paid, and institutional delivery increases.

If our interviews ended there, we would have walked away with an idea that JSY is working according to the guidelines, even if this is slightly different from how it is frequently discussed.

In another village, which was located around half an hour from the nearest private hospital, we found a very different story. Sita, who had given birth to her daughter a month earlier, told us that she had originally planned to deliver at home, as she had her son, who is now four. But, after being in labor for more than a day, she started to worry, “If I stay here, if something will happen, then what will I do?” At that point, she called her mother, who arrived in a borrowed car from her own village, half an hour a away, and took her, her husband and sister-in-law to the private hospital, which she had heard was better – and closer – than any public facilities.  Her daughter was born a few hours later, with no complications, and the two were discharged the next day. The village’s sahiya, Radha, who was looking on as we interviewed Sita, explained that she had not gone with the family because she had broken her arm – and because there was no room in the car. As she beamed with pride at Sita, “one of the finest ladies in the village,” Radha told us that she had filed the paperwork for Sita’s payment a few days before. Though this meant that Sita’s payment would be late, and, in all likelihood, Radha would not get paid at all, the matter seemed almost an afterthought: the money would come, sure, because Sita was entitled to it. It was not enough to cover the cost of the private hospital, which was 2500Rs, but Sita had saved some money in case she needed to pay for hospital fees, and she now plans to set the money from JSY aside for her daughter.

Where JSY – and other cash transfer programs – are often presented along the narrow lines of cash in exchange for a pre-defined healthy behaviour – in this case, institutional delivery in a public facility, in action, things are much more complicated. It is possible that people do not always want to talk about the way that cash influences the choices they make about something so momentous as childbirth, even from the few people we talked to, it seemed pretty clear that their choices, though often health-seeking, did not necessarily conform to the conditions defined by JSY–and were not necessarily strongly motivated by cash. There seemed to be no shortage of knowledge about the risks that go with having a baby, or of the ability for some health institutions to provide some help, whether for a normal delivery or as for Sita, a place to go when things seemed to be going wrong.

The more we talked to sahiyas and new mothers, the more questions followed. For a program that is so reliant on community health workers, discussions of JSY rarely address the ways in which different sahiyas may influence women and what factors are influencing them.

Does it matter that some sahiyas live in communities where the private facilities have better reputations, even if they are more expensive and there is no financial incentive for the sahiya? Is it possible that the payments sahiyas receive throughout the year ultimately influence women’s choices more than the one payment that the women receive on giving birth?

If we follow the government guidelines for assessing sahiyas, it is clear that the sahiyas in Sini are more successful, but if we also consider Sita’s ability to make and act on a plan to seek care in a nearby facility in an emergency, we are left with a different possible definition of success. It might be worth asking how JSY might allow for a broader view of what women want and need. This seems especially important in a community like Seraikela where some health facilities are reasonably accessible, but where private facilities may be too expensive and public facilities are not yet equipped to meet the demands that would come with 100 percent institutional delivery, the current goal of JSY.

Note: All names used in this post are pseudonyms.

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

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On Monday, I traveled with my colleague, Anupam Sarkar, a nutrition and newborn health expert and Project Advisor for the Maternal and Newborn Survival Initiative (MANSI), to Hudu, a small, hard-to-reach village amidst forest, steel plants, and roaming wild elephants. It took us nearly 2 hours from Jamshedpur, weaving around and cutting through steel plants and villages along bumpy and muddy roads–the same roads that pregnant women must travel on if they opt for institutional delivery. We were heading to Hudu to observe a Seraikela Chhau peformance.

Seraikela Chhau is a traditional form of dance that originates in the Seraikela block of Jharkhand, part of the eastern steel belt of India. Over the past six months, I have been working as a Clinton Fellow with the Maternal and Newborn Survival Initiative in the Seraikela block. MANSI is a partnership between the American India Foundation, Tata Steel Rural Development Society, and the local government—with technical support from SEARCH. As part of our project activities, our team has recently coordinated a series of Seraikela Chhau performances that will combine the native dance form with key maternal and newborn health messages throughout the 174 villages of our project area.

When Anupam and I arrived in Hudu, we learned that a pair of twins had recently passed away in the village and we decided to visit the family before the performance began. We are conducting similar home visits for every maternal and newborn death that has been reported in our project area (spanning 174 villages) since the baseline survey was completed in 2009. The goal of the home visits is to gain a better understanding of the ground realities and knowledge gaps so that we can shape and inform the messages of the MANSI health communication campaigns in a way that meets the needs of the communities.

The local health worker guided us to the home where the twins had passed away. The parents were not at home–but we were able to meet with the paternal grandparents, Asha and Ganesh Sardar.

 

They shared their story…

The mother of the twins, Vilasi, is 28 years old. She and her husband, Ragdu, already had four children, all girls, and the family was  eager to have a boy. Soon they became pregnant with twins, one girl and one boy. All four of the previous children were delivered at home without complication–and the family assumed that this delivery would also be free of complications. They explained that they were unaware of the benefits of institutional delivery. When the twins were born, they seemed very small. Immediately following delivery, the mother put the babies to her breasts to feed them. They were weak and unable to suckle. Initially the family thought about giving them goat’s milk–but eventually decided to give sugar water (locally called Misri Pani). When it became clear that the babies were extremely weak and in critical condition, the family wanted to take the infants to the hospital but they had not anticipated the emergency. They were not prepared. They did not have a transportation plan or money set aside. One baby died the very same day–and the other died the following day.

We thanked the grandparents for sharing their story and asked them if it would be OK if we also shared their story with other communities. The grandparents agreed and the grandfather said, “After losing the twins, I have come to know about the importance of institutional delivery. Why not share our story and let others also come to know?”

It is tough to know precisely what led to the death of the twins—and if giving birth in a facility would have made a difference. But it is clear that many factors were stacked against them. The family was faced with poor roads, long distances to health centers, limited resources, combined with a lack of information at the community level about birth spacing and planning, care of low birth weight babies, danger signs, institutional delivery, and information on how to tap into government schemes that offer cash incentives for institutional delivery—all potential topics for future Chhau performances.

With the story of the twins on our minds, we returned to the center of the village to observe the performance.

With no electricity in the village, the performers rigged their loud speaker system to their vehicle battery. They began beating their drums and singing loudly, calling on community members to gather in the village center.

It did not take long for community members to gather, all curious to know what the commotion was about. They formed a crowd of boys and girls, and men and women of all ages. Soon the drumming and singing picked up pace, a performer dressed in a traditional colorful costume with a big mask jumped out from behind the vehicle, and the show began!

The performers acted out various situations, using dance and drama to cover several critical maternal and newborn health topics—with a focus on the importance of institutional delivery, birth planning/preparedness, and the five cleans of safe delivery. The audience watched with great enthusiasm.

As we traveled the bumpy roads away from Hudu, a jagged rock punctured our tire–delaying our return to Jamshedpur and reminding me of the numerous barriers that women face in accessing care. While we waited for the tire to get repaired, I thought of the twins and the grandparents who we interviewed. I also thought of the Chhau dance and all of the community members in attendance. That day, I witnessed the consequences of the various factors that were stacked against the twins. I also witnessed one strategy for building community awareness of critical maternal and newborn health information. I left feeling confident that the Chhau performance that we observed will help to equip the community of Hudu with key information about maternal and newborn health—and will serve as one of many important steps toward the overall goal of protecting the health of women and infants in the Seraikela block.

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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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On July 1st, the Women Deliver team announced the top five highlights from the 2010 conference (June 7-9). See below for a summary of the conference highlights–with links to publications, videos, photos, and additional information that came out of the conference.

This post was originally posted on the Women Deliver website and is reposted on MMD with permission from Women Deliver.
conference-participants.jpg

Women Deliver 2010 Conference participants

Thank you to everyone who contributed to the success of the second Women Deliver global conference. To put world leaders on notice that the time for action on maternal health is now, 3,400 advocates, policymakers, development leaders, health care professionals, youth, and media from 146 countries converged on Washington, DC on June 7-9 at Women Deliver 2010. More than 800 speeches and presentations were given at the six plenaries and 120 breakout sessions.  The heads of five UN agencies, plus the Secretary-General of the United Nations, attended. Thirty countries, UN agencies, the World Bank, corporations, and foundations helped support Women Deliver. Please see below for highlights and recaps of the conference.

1. Key Statements. Read the outcome statements from the:

2. Webcasts. Watch the videos from our plenary sessions and our press conferences, and watch Hillary Clinton’s address to the Women Deliver 2010 attendees.

3. Photos. Take a look at photos from the plenary sessions, breakout sessions and other conference events, and download them at no cost.

4. Programme. Review the plenary and breakout sessions that were held at Women Deliver 2010.

5. Publications and Advocacy Tools. Visit our Knowledge Center to download publications and advocacy tools, including:

Stay tuned for our summary report on breakout sessions by theme.

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Join Dr. Harry Strulovici, Founder and President of Life for Mothers, Director of  the International Maternal Health Initiative within the Division of Reproductive Global Health and  Clinical Assistant Professor in the Department of Obstetrics & Gynaecology at NYU School of Medicine; Julie McLaughlin, the Sector Manager for Health, Nutrition and Population in the South Asia Region of the World Bank; and Samuel Mills MD DrPH, a consultant in the Health, Nutrition and Population Unit of the Human Development Network for a presentation and Q&A  at the World Bank on reducing maternal and neonatal mortality in Uganda through a holistic approach.

Life for Mothers

When: Jun 15, 2010, 12:30-2pm

Where: World Bank: 1818 H Street NW, Washington, DC 20433

What : Presentation on a Holistic Strategy To Reduce Maternal/Neonatal Mortality in Uganda

Who:

  • Dr. Harry Strulovici, director of  the International Maternal Health Initiative within the Division of Reproductive Global Health and  Clinical Assistant Professor in the Department of Obstetrics & Gynaecology at NYU School of Medicine
  • Julie McLaughlin,the Sector Manager for Health, Nutrition and Population in the South Asia Region of the World Bank
  • Samuel Mills MD DrPH, a consultant in the Health, Nutrition and Population Unit of the Human Development Network at the World Bank

Schedule of events: Lecture with Q&A

RSVP: Contact Victor Arias at varias@worldbank.org

Click here for more details.

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A new report by Save the Children, “State of the World’s Mothers 2010,” identifies Norway as the best place in the world to be a mother–and Afghanistan as the worst.

Save the Children

The focus of the report is on the shortage of front line health workers in developing countries–and the critical need to train more female health workers in order to save the lives of women, children and newborns living in the most marginalized communities.

“Mothers in Norway and Australia are living in the best places in the world, according to Save the Children’s 11th annual “Mothers’ Index”, which ranks the best and worst places to be a mother.  Afghanistan ranked at the bottom of the list of 160 countries, which included 43 developed nations and 117 in the developing world.

The “Mothers’ Index” is highlighted in Save the Children’s State of the World’s Mothers 2010 report, which examines the many ways women working on the front lines of health care are helping to save the lives of mothers, newborns and young children, and makes an urgent call to increase the number of front-line health workers in the world’s poorest nations….”

Read the full post on the Save the Children site for an overview of the report with a list of the top ten (and bottom ten) places to be a mother–and several very interesting country comparisons across maternal and child health indicators.

UNFPA and the International Confederation of Midwives are also speaking out about the urgent need to train more front line health workers in difficult to reach communities. I posted an excerpt of their statement a couple hours ago.

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