experiences and lessons-learned from the integrated...

Experiences and lessons-learned from the integrated program for maternal anemia reduction in two states of

Utt P d h d Jh kh d I diUttar Pradesh and Jharkhand, India

Prakash KotechaArun Gupta Syed Iqbal Versha MathurArun Gupta, Syed Iqbal, Versha Mathur,

Chandra Mishra, Praveen Sharma, Vishwajeet Pankaj, Mini Rozario&

Nadra Franklin, Linda Tawfik, Lidan Du, Zo Rambeloson, Rolf Klemm,Nadra Franklin, Linda Tawfik, Lidan Du, Zo Rambeloson, Rolf Klemm, Omar Dary, Phillis Kim, Morgan Hillenbrand,

A2Z Project, India

2

Why Anemia and Why Uttar P d h & Jh kh d I di ?

UP Jharkhand

5058

52

71 70

60

80

Pradesh & Jharkhand, India?Population (2011)

199million

32million

Districts 73 24

A i i 52% 70%5046

0

20

40Anemia in pregnancyAmong highest SES group

52%

46%

70%

67%

Th A t t l 36 %0

NFHS II NFHS III NFHS II NFHS III NFHS II NFHS III

India UP Jharkhand

• One in five maternal death is Source: NFHS II 1998-99 NFHS III 2005-06

Three Antenatal checkups

36 % 36%

Mothers who consumed IFA for 90 days

9% 11%

attributed to iron def anemia. • In UP MMR 440/100,000• Jharkhand MMR 312/100,000

days

Source: NFHS III

• In the two states alone 77 maternal deaths every day

• 15 of them due to anemia…• 30 times these figures are

facing serious morbidities Prakash KotechaJune 13, 2011

Jharkhand & UP State:

3

A2Z Districts for Maternal Anemia

Prakash KotechaJune 13, 2011

High Prevalence of Anemia and STH Infection in UP & Jh kh d d t St t

4

UP & Jharkhand as compared to State

Anemia in UP & Jharkhand STH Infection in UP and Jharkhand

7363

72 70

60

80

100

nt w

omen

in th

e 3r

d im

este

r

49

65

5060

80

100

UP Jharkhand

0

20

40

UP A2Z 2008 NFHS UP 2006 Jharkhand A2Z 2007NFHS Jharkhand 2006

% o

f Pre

gnan tri

11 9

31

6 30

20

40

Ascariasis Trichuris Hook worm Any Infection

N = 220N = 942N = 285 N = 398Trichirura

Jharkhand n=146 UP n=150

June 13, 2011 Prakash Kotecha

Source: Awasthi S et al, 2007

5

A2Z APPROACH FOR MATERNAL ANEMIA CONTROL

Technical Assistance for Maternal Anemia Reduction

6

Technical Assistance for Maternal Anemia Reduction• Policies & Guidelines:; RCH/ICDS roles and liaison,

HMIS use, resources. (state level)• Capacity Building of front line workers and MO with the

tools to support them and providing technical assistance• Systems Strengthening: Supplies, planning y g g pp p g

denominators, provider skills, records, use of data. (state and selected districts)

• Community & BCC: Village Health & Nutrition Days, h i it i t d b d t di ithome visits, print and broadcast media, community groups and leaders, local events, folk and street plays.

• M&E: Baselines, routine data, Mid Project Surveys and E d liEnd-line surveys

• District and Block Level Consultant + Mentors

Partners: Medical Colleges, NGOs, UNICEF, MI


Three Districts Each of Uttar Pradesh & Jharkhand: A i C t l P k i P

7

Anemia Control Package in Pregnancy

1. Complete and early registration for ANC2. Provide 100 IFA to ALL pregnant women with complete

package of counseling to ensure comsumption (BCC as the focus)

3. Advice to provide and ensure the consumption of one extra meal

4. Deworming medicine after first trimester ALL pregnant mothers (ensure consumption)

5. Advice for Malaria control: IPT/Mosquito bednet/EDPTq

Prakash Kotecha

June 13, 2011

Studies8

Studies• Baseline (2007 Jharkhand 2008 UP)

Mid P j M i i S (2009)• Mid Project Monitoring Survey (2009)• Endline ( 2011)

Districts with Blocks for UP Districts with Blocks for Jharkhand

DistrictIntervention Blocks

Non‐intervention Blocks District

Intervention Block

Non‐intervention Blocks

Kaushambi 1 Sarsawan Manjhanpur Dumka 1 Raneshwar Gopikandar2 Mooratganj Kanaili 2 Saraiyahat Jama3 Sirathu Chayal 3 Kathikund Jarmundi3 Sirathu Chayal 3 Kathikund Jarmundi

Newada MasaliaKada Ramgarh

Varansi 1 Araji Lane Kashi Vidyapeeth Latehar 1 Balumath Barwadih2 Cholapur Chirai Gaon 2 Chandwa Garu2 Cholapur Chirai Gaon 2 Chandwa Garu3 Sewapuri Harahua 3 Latehar

Bada GaonPindara

S.R.Nagar 1 Gyanpur Deegh Ramgarh 1 Mandu Patratu

Prakash Kotecha

2 Bhadoi Aurai 2 Gola3 Suryawan 3 Ramgarh

June 13, 2011

Field Surveys Measuring Anemia

9

Field Surveys Measuring Anemia • For each state 31 cluster sampled PPS and then 10 mothers

from each cluster (n=310 for CPW and RDW total n=620) was planned with expected design effect of 2 reduction of anemiaplanned with expected design effect of 2 reduction of anemia 15%. (Baseline and Endline)

• Ethical Committee approved : US and India• HemoCue Machine (301) was used for measuring hemoglobin

level with lancet needle.• Qualitative Study (FGD for ANM, AWW and beneficiariesQualitative Study (FGD for ANM, AWW and beneficiaries

mothers with high and low compliance)


10

Results for Process Indicators

Maternal Anemia ANC Coverage

11

Maternal Anemia ANC Coverage

Jharkhand UPImproved ANC I d ANCJharkhand UPImproved ANC over 1.5 times

to 85%

ANC Coverage

Improved ANC over 2.2 times to 86%

54

9285

60

80

100 9286

60

80

100

0

20

40 36

20

40

60

Baseline (Dec 2007) Mid Project Survey(April 2009)

Endline (April 2011) 0B aseline

(M arch 2008)M id P ro ject

Survey II(F ebruary 2009)

End o r P ro ject(A pril 2011)


Maternal Anemia IFA R i d d C d

12

IFA Received and Consumed

Jharkhand UPJharkhand UP

Any IFA Received 100 IFA Received 100 IFA Consumed Any IFA Received 100 IFA Received 100 IFA ConsumedFocus on this Focus on this

8371

60

80

10085

78

52 5460

80

100

43

23

4134

821 25

20

40

60

24

8

52

7

27 27

20

40

60

8

0

20

Baseline (Dec 2007 ) Mid Project Survey (April2009)

Endline (April 2011)

0Baseline (March 2008) Mid Project Survey II

(February 2009) End or Project (April 2011)


D i M di i R i d

13

Deworming Medicine Received

40

50

Jharkhand UP

16 1620

30

3

10

4

10

0

10

0Basel ine (2007/2008) ) Mid Project Survey (Apri l

2009)Endl ine (Apri l 2011)


Maternal Anemia

14

ICDS Food Received

90100

Jharkhand UP

59

81

52

90

60

80

100

15

39

52

40

60

15

0

20

Baseline (Dec 2007 Mid Project Survey (April Endline (April 2011)Jhakhand 2008 UP ) 2009)


15

Results forImpact on Anemia Prevalence

M t l A i P l UP

16

Maternal Anemia Prevalence UPAnemia Prevalence Severe Anemia

73 7880

100 23% reduction achieved

5650

40

60

80

8 102 1

0

20

40

0B aseline

(M arch 2008)M id P ro ject

Survey I(A ugust

2008)

M id P ro ject Survey II(F ebruary

2009)

End o rP ro ject

(A pril 2011)2008) 2009)

Prakash Kotecha

Mean Hb Improved from 9.8 to 10.9 g/dL

June 13, 2011

17

Maternal Anemia JharkhandAnemia PrevalenceAnemia Prevalence

87

only 2% reduction achieved

72 70

60

80

20

40

2 3 10

20

Baseline (Dec 2007 ) Mid Project Survey (April 2009) Endline (April 2011)( ) j y ( p ) ( p )

Prakash Kotecha

Mean Hb Improved from 10.14 to 10.34 g/dL

June 13, 2011

What Worked18

• Helping ANM to assist (Job Aid) how to find out unregistered pregnant woman for antenatal care, how to locate them counseling steps for pregnant woman forlocate them, counseling steps for pregnant woman for anemia control and simple check list to avoid stock out at sub-center level.

• Empowering Medical officers through (Self guide, a tool) that provided simple steps to estimate expected number of pregnant mothers and compare them withnumber of pregnant mothers and compare them with actual registration and find out the registration gap

• Hand Holding and mentoring frontline workers• Creating Demand? through print media, electronic

media and folk media improved utilization… to get data that it made an impact is difficult proposition within thethat it made an impact is difficult proposition within the framework and mandate of our work..


Challenges in Anemia Control19

Challenges in Anemia Control• Not a priority disease for health care provider, nor for

beneficiaries. It is a SILENT MORBIDITY• 100 IFA tablets are recommended for prevention of

anemia and is enough for additional requirement of iron for pregnancy for fetus placenta and increased bloodfor pregnancy for fetus, placenta and increased blood volume.

• Compliance for this 100 IFA also is a challenge.– Relative lack of importance for anemia as perception hardly

exists..(provider and clients both)– Time availability by health workers for anemia (provider)y y (p )– Priority for counseling vs other assignments (provider)– Capacity, conviction, understanding and desire to counsel

Fortification of food accepted world over needs to be• Fortification of food, accepted world over needs to be strengthened, which is a proven technology.


Challenges converted to InnovationJharkhand UP Health workers were anemic themselves…?

97% 91% 91%100%74%

50%

75%

100% N=467

0%

25%

ANM AWW Others Total

68.20% 65.70%56.10%

50.00%

61.10%60%

80%

100% N=467N=126

20%

40%

0%ANM ASHA AWW SUPERVISOR Total


Challenges beyond us21

Challenges beyond us..• Political instability

– Government ChangesGovernment Changes– Frequent Transfers of CMO/MO– Maoist and Terrorist activities

• Changes of Leaders and staff– Country Program Director and project director

changed– State Coordinator changed three times in both the

statestate– Country Director Changed– AOTR at India and Washington changeg g


22

Will Anemia Control be achieved ever?

Jharkhand State

23


24

What ever you do ymay look to be insignificant, but is very importantvery important that you do it.

The smallest drop of rain create the ocean


25

Knowing is not enough; We must applyWe must apply....

Willingness is not enough;Willingness is not enough; We must do…..

Johann Wolfgang von Goethe;Jo a o ga g o Goet e;German Writer 1749-1832


26

Let us all strive to make every mother non anemicy

Thank You

A2Z—the USAID Micronutrient and Child Blindness Project—is managed by the Academy for Educational Development(AED) and funded by the United States Agency for International Development (USAID), Health, Infectious Disease andNutrition (HIDN) Office of the Bureau of Global Health, Cooperative Agreement, Leadership with Associate Awards,GHS-A-00-05-00012-00. The information provided does not represent the views or positions of the U.S. Agency forInternational Development or the U.S. Government.

June 13, 2011 Prakash Kotecha

27

INDIA NFHS III: Anemia Vs IFAS

7580

100Percentage of Pregnant Women who took IFA for at least 90 daysPregnant women age 15-49 who are anaemic

37 38 39 39 40 41 42

6975

5260

4958 61

36

68 72

56 5863

5849

63

45

70

54

42

58

6861

37

5360 56 53

3740

60

49 10 11 12 13 13 14 16 17 18 21 23 25 26 26 27 28 28 31 34 37 3836 37

3037 33

0

20

0

Source: NFHS III (2005-06)


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