Enabling Community Action for Maternal Health

Second State Level Advisory MeetingOctober 3, 2013,

VadodaraCollaborative partners

SAHAJ, ANANDI and Tribhuvandas Foundation

A Project of MacArthur and CommonHealth

Objectives

• To enable communities to monitor access to and quality of maternal health care through use of ‘safe delivery’ indicators.

• To equip communities with skills to identify and report pregnancy related deaths and perinatal deaths.

• To build capacity of NRHM accountability mechanisms and other community based organizations to examine the social, economic and gender factors underlying maternal deaths which need to be addressed.

• To advocate with stakeholders in the health system to facilitate community monitoring of maternal health care and community participation in Maternal Death Reviews.

Monitoring the Quality of Maternal Health – the process thus far…..

Two training programs Quality of Maternal health

and Maternal Death Reviews

Draft tool testing

Orientation meetings in the community

Community level discussions on women's

perception of Safe delivery

A poster showing what women considered a

'Safe delivery'

A Tool for monitoring quality of maternal health care which incorporated

women's perception of Safe delivery

Number of tools filled (August 2013)

Anand Dahod Panchmahals Total

Anklav Umreth Devgarh Baria Gogambha All four blocks

Number of forms filled

44 30 121 108 303

Number of forms compiled into Report card

30 30 89 98 247

How were the tools filled?

• Maintaining village wise list of all pregnant women and all deaths of women between 15-49 years

• Volunteers identified and trained for filling maternal health tool who were

o Village health workers from TF

o Sangathan women and young literate girls from ANANDI

How was the Report Card made?

• Exposure visit to SATHI, MASUM and RACHNA in March 2013 – Used SATHI tool for reference

• Compiled - 117 completed maternal health tools from Dahod and Panchmahals- 60 (30 each from Anklav and 30 from Umreth respectively) from Anand

• Training conducted by Dr. Subha Sri - Data too exhaustive – which AN/PN quality indicators to keep?- Prioritized and finalized the minimum indicators emerging from 3 group

exercises.- Gujarati report card made on chart paper, field tested with volunteers and

suggestions incorporated .

The First Report Card (6 charts)

Sharing the report card with community and validating findings

• Two meetings in Anklav (Anand) and one in Devgarh Baria (Dahod) with respondents, volunteers and community leaders

• In Baria, due to low literacy levels, women found it difficult to understand the concept of colour coding based on the percentage assigned to each indicator.

• Different approach in Anklav - TF team member provided information about importance of each check up and then shared data with group and asked them to grade it

Sharing the report card with community and validating findings (contd.)

• Most grades given by women matched grades given in the report card prepared on the basis of compiled data from the tools.

• After several rounds, clubbed related information under one heading

• The finished product is a neat one page report card.

The Report Card

Poor Condition <50% Average Condition 51 -70 % Good Condition >71%

REPORT CARD ANANDI BLOCKS ANANDI BLOCKS (updated)

A ANC N=117 N=187

1 Registration (within 3 months) 33 28.2 51 27.3

2 Weight (minimum 3 times) 9 7.8 19 10.2

3 Blood pressure (minimum 3 times) 1 0.8 5 2.7

4 Abdominal checkups (minimum 3 times) 3 2.6 3 1.6

5 Hemoglobin (minimum 2 times) 10 8.5 17 9.0

6 Tetanus toxid (TT) ( 2 times in the 1st delivery and 1 when second delivery within 3 years)

87 74.3 141 75.4

7 Iron folic tablets (minimum 90 tablets regular)

6 5.1 17 9.0

8 Calcium tablets (minimum 90 tablets regular)

33 28.2 5 2.7

B INFORMATION

1 High Risk symptoms(Yes)

20 17.0 53 28.3

ANANDI’S REPORT CARD

C INSTITUTIONAL (HOSPITAL) DELIVERY N=25 N=46

1 Place of delivery Government Hospital 9 36.0 13 28.6

2 Promptness of treatment in the hospital (within 30 mins) 1 40.0 31 67.3

3 Delivery by whom? (Doctor / Nurse) 24 96.6 43 93.4

4 Discharge period (after one day) 7 28.0 15 32.6

5 Free services of vehicle for coming and going home to hospital (Yes) 6 24.0 8 17.3

6 Expense for delivery in the government hospital (Yes) 5 20.0 7 15.2

7 Stitches (Yes) 6 24.0 16 34.7

8 Injection after delivery (Yes) 27 58.7

D REFERRAL N=4

Good referralReferral with vehicle/case paper/reason informed to relatives/place (Yes)

2 66.6 3 75.0

E HOME DELIVERY N=140

Trained Dai / clean place/clean hands/new bled/ sterilized thread (Yes) 57 62.6 83 59.2

F PNC N=117 N=187

1 Outcome of pregnancy Live birth / >=2.5 kg

96 82.0 148 79.1

2 First feeding within 1 hour (Yes) 83 71.0 120 64.1

3 First bath of baby (seventh day) (Yes) 0 0.0 0 0.0

How would reds change into yellows and yellows to green?

Community’s response o In Anklav– Several senior women said that they would talk about the importance

of AN checkups to women in their falia

– Dairy cooperative secretary – should show film showing importance of AN checkups, entitlements and report card.

– Shortened Report card shared at Hathipura, Anklav - the exercise was completed within 2 hours.

Sharing the Report Card with the Health System

Date and Place of meeting Health system representatives

ANANDI/TF representatives

3rd August 2013, Gogambha, Taluka health Office

THO/MOs (Gamani and Simaliya), Gogambha block

ANANDI and SAHAJ team.

6th August 2013, THO office, Devgarh Baria

THO/MOs (Dhabhva and Sevaniya), Baria block

ANANDI and SAHAJ team.

29th August 2013, Anklav

PHC

THO, Anklav Tribhuvandas Foundation and SAHAJ team.

31ST August 2013 Gamani PHC

THO/MOs (Gamani and Simaliya),Gogambha block

ANANDI and SAHAJ team.

Documents shared with the THO/MOs

• Maternal Health forms

• Maternal Health Report along with the Report Card

• Social Autopsies of Maternal Deaths in the block

Dialogue and Sharing the Report Card with the Health System

Meeting with THO and MOs of Ghoghamba block on August 31, 2013

Problems identified and decisions taken

•ANANDI requested for an extra day for holding AN clinic in Baria and Gogambha- decided to get women for AN care on every Monday in Sevaniya PHC and on Tuesday in Dabhava PHC. • Similar decision for Gamani and Semaliya PHC – emphasis on high risk women.

•ANANDI took the responsibility of arranging vehicle and mobilize women to come to PHC . •Baria health officials will review the Report Card after 3 months (15th November 2013)

•Sickle Cell test was not being done during ANC. The THO in Baria offered to find out more information about it. •Periodic meeting with the MOs and ANANDI for planning ongoing program follow up and action for improving maternal health.

•

Problems identified and decisions taken

In Gamani and Semaliya blocks (Gogambha) women were unaware about the availability of the MO and the staff in the PHC.

The THO offered to give the monthly work plan and the MOs offered their telephone numbers to ANANDI staff.

-In Anklav,it was decided to improve AN care checkups in a phased manner.

-focused intervention by tracking every pregnant woman as per the severity of anemia.

-After 6 months, this pilot project could be reviewed and if successful it could be leveraged to intervene in other blocks in the district.

Changes that followed………

Number of AN women who attended Sevaniya and Dhabva PHC clinic after Report Card meeting

Total villages Pregnant women Lactating women High risk women identified

24

68

4 57

54

8

August September

Gaps identified in the health system

•Unavailability of kits for urine test • B.P instruments not working in some PHCs•Lack of malaria fumigation•Managing transport services for a few high risk women - PHCs are ready to give transport if there are 5-6 women. •Women lack information about AN clinics and Mamta diwas in the villages. Monthly plans are now being shared and leading to reduction in the communication gap and better utilization of services.

How identification of gaps in the Health System and the Community is helping in activating the system

•Lack of information about maternal health entitlements and high risk symptoms.

•Dais kits not been given for home deliveries.

•Unavailability of lab technician because of delay in renewing the contract.

•In Anklav, abdominal checkups are not done – majority of the sub centres are unequipped or have no privacy during examination.

Gaps identified in the health system (contd.)

Gaps identified in the Community

•Community leaders/CBOs need to motivate and mobilise women for early registration

• Ensure that all AN checkups are done before she migrates

• Ensure that AN women receive all services on Mamta Diwas and at the PHC.

• Tracking and monitoring severely anemic women

• Birth preparedness and male involvement

Building a synergy between Health System and Community

Improvement in maternal health and

reduction in Maternal

deaths

Responsive

health system

Increase in

Community awareness

Social Autopsies for Maternal Deaths

•Training Partner teams

•Review of the Social Autopsy tool, finalization of guidelines and tool filling

Inclusion of NGO representative in MDR at present

•In Dahod and Panchmahals, there is no NGO representative in the Maternal Death Review

•In Anand district, TF Director is invited for the Maternal Death Review.

Number of Social Autopsies done

Anklav Umreth Total Gogambha

Devgarh Baria

Total

Number of Social autopsies done

5 3 8 9 20 29

Number of Social Autopsies compiled and analysed

5 2 7 1 11 12

Outcome of the MDR training and Social Autopsies

Community•Reporting of deaths from the community has increased.•Sangathan leaders have started discussing about maternal deaths in their meetings• ANANDI team sends regular sms to THOs/ Medical Officers about maternal deaths.

Health System• THOs in the three blocks said that verbal autopsy is done for all maternal deaths. After the list of maternal deaths was handed over to THO in Gogambha ,he said that he would match the list with theirs.

Advocacy efforts at the State level•State Level Advisory Meeting was held on 11th September 2012 at Ahmedabad with public health experts and researchers like Dr. Leela Visaria, Dr. Pankaj Shah and district health officials from Anand and Panchmahal district and project partners.

•Positive responses from the health system officials helped in initiating this process forward.

• No meeting with the Health Commissioner, Gandhinagar

•Good response from the health system officials at block level.

•Panchayat members, dairy cooperative members have been extending their help in organizing meetings at the village dairies and schools.

Training Manuals, Films and Website

•Training Manual in English is prepared and can be accessed on SAHAJ as well as CommonHealth website.

• Simplified Gujarati training module on Maternal Health from a Gender and Rights Perspective for community leaders is ready for review.

•A Gujarati voiceover of the film on respectful delivery titled ‘In silence’ which was originally made in English by Whit Ribbon Alliance has been done.

•SAHAJ website is in operation - tools and reports updated

Capacity building training/Workshops attended

• ‘Dead Women Talking’ organized by RUWSEC, CHAD and SOCHARA and CommonHealth at Chennai June 2-3, 2012.

• CommonHealth Regional Meeting at ARTH, Udaipur on September 29-30, 2012. Eight participants from Gujarat

•SAHAJ and ANANDI staff participated in the South Asian Region Workshop on Social Accountability and Community Monitoring and Health on September 21-25, 2013, organized by COPASAH at New Delhi.

•This team along with participants from SARTHI will conduct Gujarati community monitoring training with support from COPASAH.

• Participation in a workshop on Civil Society Participation in Public Policy and Governance in India and Improving Maternal Health Programming through Increased Accountability organized by Centre for Health and Social Justice, New Delhi, November 15-16, 2012.

Workshops organized and networking with other State level networks

•The CommonHealth National Convention was held in Hotel Savshanti, Vadodara on March 21-23, 2013.

•Attended the State Level Jan Swasthya Abhiyan meeting held in SEWA Rural, Jhagadia September 4-5, 2013

• Co organised (with CommonHealth, SOCHARA, SAMA and CEHAT) and attended a Maternal Health Consultation, August 12-13, 2013 at New Delhi

Plans for the year

-Midterm Evaluation

-Finalizing Gujarati training module for health workers

-Training for dairy/ sangathan members/village health volunteers

-Position paper on accountability

-Jan Sunwais