MAKING A DIFFERENCE IN MATERNAL HEALTH SERVICES:

COMMUNITY MONITORING

SAHAJ and ANANDICAH

December 24th 2013

ABOUT THE PROJECT

• A collaborative project undertaken by SAHAJ, ANANDI and TRIBUVANDAS FOUNDATION for

Enabling Community Action for Increasing Accountability for Maternal Health

Project area– 2 PHCs of Devgarh Baria, Dahod district – 2 PHCs of Gogambha block, Panchmahals district– Anand district (Anklav and Umreth taluka)– Total 76 villages

Using Report Card as a Communtiy Monitoring Tool

DEFINITIONS….

• Maternal Health Care - care around childbirth based on the concept of ‘Safe Deliveries’

• Quality of ANC and PNC based on the NRHM standards

• ‘Safe Delivery’ both from technical perspective as well as women’s perspective of what they consider Safe Delivery.

TOOL DEVELOPMENT- Discussions with women about

their perceptions of safe delivery which were incorporated in the tool.

- Dais involved in finalizing the tool to know whether women would understand the pictures and questions asked.

- Quality checks on 10 % of the filled forms are done and the issues addressed by team leaders

Tool filled for every pregnant women in 8th month and upto 20 days after delivery.

PROCESS OF MAKING THE REPORT CARD

- Compiled data of 117 forms from Devgarh Baria and 30 from Anand district.

- A pictorial Report Card produced and discussed with team and shortened considerably

- Data shared and validated with respondents, community groups like sangathan women/dairy members and health volunteers and was further shortened .

- Finally a Report Card was ready to be shared with the health system

REPORT CARD

How is the Report Card being used? • Community meetings increase women’s/families’/community

leaders’ awareness of maternal health entitlements and accepted quality standards.

• After each item is explained, they are asked how they would like the score to change next time and what they could do to make this change.

• Similarly, the report card shared with the health system - to bring about improvement in AN/PN services and facilities to lead to increased utilization of public health centers.

DEVGARH BARIA(DAHOD) AND GOGAMBHA(PANCHMAHALS)

The Report Card

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

REPORT CARD Baria (n=47)

Ghoghamba (n= 70)

Grand Total N= 117

A ANC1 Registration (within 3 months) 10 21.3 23 32.8 33 28.2

2 Weight (minimum 3 times) 1 2.1 8 11.4 9 7.8

3 Blood pressure (minimum 3 times) 1 2.1 0 0.0 1 0.84 Abdominal checkups (minimum 3 times) 2 4.2 1 1.4 3 2.65 Hemoglobin (minimum 2 times) 3 6.3

7 10.0 10 8.5

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

37 78.7 50 71.4 87 74.3

7 Iron folic tablets (minimum 100 tablets regular) 2 4.2 4 5.7 6 5.1B INFORMATION RELATED1 High Risk symptoms (Yes) 7

14.9

13 18.6 20 17.0

2 Scheme related information (Yes) 10 21.3

13 18.6 23 19.6

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

Baria (n=47)

Ghoghamba (n= 70)

Grand Total N= 117

C INSTITUTIONAL (HOSPITAL) DELIVERY Baria (n=15)

Ghoghamba (n= 10)

Grand Total N= 25

1 Place of delivery : Government 7 46.6

2 20.0 9 36.0

2 Promptness of treatment in the hospital (within 30 mins)

7 46.6

3 30.0

10 40.0

3 Delivery by whom? (Doctor / Nurse) 14 93.3 10 100.0 24 96.64 Discharge period (One day) 4 26.6 3 30.0 7 28.05 Free services of vehicle for coming and going home to hospital (Yes) 4

26.6 2 20.0

6 24.0

6 Expense for delivery in the government hospital (Yes) 5 33.3 0 5 20.07 Stitches (Yes) 4

26.62 20.0

6 24.0

D REFERRAL Baria (n=0)

Ghoghamba (n= 3)

Grand Total N= 3

Good referral: Referral with vehicle/case paper/reason informed to relatives/place (Yes)

0 2 66.6

2 66.6

E HOME DELIVERY Baria (n=31)

Ghoghamba (n= 60)

Grand Total N= 91

Trained Dai / clean place/clean hands/new blade/ sterilized thread (Yes)

18 58.0 39 65.0 57 62.6

F PNC Baria (n=47)

Ghoghamba (n=70)

Grand total N = 117

1 Live birth / >=2.5 kg 30 63.8

66 94.3

96 82.0

2 First feeding within 1 hour (Yes) 32 68.0

51 72.8

83 71.0

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

After the first Report Card

• Meetings with Taluka Health Officer and Medical Officers in Devgarh Baria and Ghoghamba in August 2013

Dialogue and Sharing the Report Card with the Health System

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

Initial responses and the decisions taken

• Initial disbelief by Medical Officers that situation of Maternal health could be so poor in their area.

• Wanted separate Report Cards for each PHC to assess and confirm facts

• MO from Dabhva said that he wanted to change the reds to yellow.

• Decisions taken • Motivation and Mobilization for early registration of pregnancy along

with ANANDI and PHC staff.

• ANANDI to mobilize pregnant women for ANC at Sevaniya PHC on Monday and Dabhva PHC on Tuesday .

Utilization of Sevaniya and Dhabhva PHC clinics by Women

Total Pregnant and Lactating women who attended AN Clinics in Dhabva and Sevaiya PHC in Baria block and Gamani PHC in Gogambha block

August September October November December

Dhabva

Sevaniya

Dhabva

Sevaniya

Gamani

Dhabva

Sevaniya

Gamani Dhabva Sevaniya

Dhabva

Sevaniya

Total villages

13 12 17 2 11 9 9 7 5 7

Total pregnant

37 31 39 4 17 19 26 9 6 12 0

Lactating

4 2 0 0 5 0 0 0 0 0 0

Referred

5 0 2 0 7 7 0 0 0 0

• Women were checked for weight, BP, TT, blood group, HIV, Hb, abdominal check up and given Iron folic acid tablets and all these checkups were noted in the Mamta card.

Monitoring Mamta Diwas – November 2013

Block Baria block Gogambha block

Name of village

1 Sadiya Galibili

2 Junebedi Malmuhadi

3 Kasatiya

4 Khandaniya

5 Bara

6 Sagtala

7 Chotra

8 Ruparel

How the system has started responding………

Ward Meetings held in Baria/GogambhaVillage Date Ward

number/Gram Sabha

Members present

Women Men Sarpanch Panchayat members

Total

1

Junibedi

4-10-013 3 13 14 1 2 30

2

Khandniya

9-10-013 3 11 7 0 1 19

3

Bara

10-10-013 3 14 10 0 1 25

4 Bara 19-10-013 7 11 19 0 2 32

5 Junibedi 12-10-013 0 15 7 0 0 22

6 Santhdiya 19-10-1-013

Gram sabha

0 10 1 5 16

7 Lavariya 22-10-013 Gram sabha

3 30 1 6 40

8 Fhangiya 25-10-013 Gram sabha

0 15 1 5 21

9 Gajapura 26-10-013 4 28 25 0 1 54

10 Jhojh 30-10-013 1 12 6 0 3 21

Issues discussed at ward meetings

1. Lack of information about service guarantees like ANC/PNC check ups and entitlements during pregnancy.

2. In Jhoj village ,members decided to demand for repairing the Sub Centre in the Panchayat meeting.

3. For monitoring Mamta diwas, a samiti of 2 men and 2 women was formed .

4. Reasons for home deliveries• Faith in dais and low cost • No one to care for other children at home ( Also a reason for early discharge from the hospital)

Major decisions taken during the ward meetings

• Social determinants like unemployment ,migration were discussed as the reasons for poor maternal health and malnutrition amongst women and children.

• In Bara village, the ward members decided to attend mamta diwas and observe the type of checkups done and suggested that the names of high risk women should be written on the the Anganwadi wall and the checkups should be pictorially depicted there.

• Maternal deaths are being discussed in the ward meetings and members try to identify the reason for deaths. For example, in Muwada village, a maternal death took place on 18.10.13 because of unavailability of blood in Baria.

Conclusion

1. Community women and their families have become aware about the importance of AN checkups and their entitlements

2. Health system has become more responsive – PHCs have got activated and more women are availing AN services

3. Report card has given an opportunity for a dialogue with health system and the community stakeholders

Conclusion contd…..4. Monitoring Mamta diwas has helped to identify the lacunae in service delivery like Lack of time for giving information on • health education and Schemes • Mamta card not being filled the same day • Vaccine stock gets over

5. After community awareness meetings and the impact of the tool ,the following changes are being observed:

• Women either do not get or get delayed benefits of the scheme. So women have started demanding money from the ANM and one woman got her entitled amount after one year.

• Women have started asking for rotten wheat to be replaced by good quality grains at AWW centres.

• Involvement of the health system in MDR process

Conclusion contd……6. Dialogue with MO - Meetings with dai sangathan members who advocated about

• Pregnant women who migrate should get services at work place – Mobile Health Services

• Awareness camps – women’s family members should participate

• Infrastructure and good referral at the PHC

• Training to dais should be given about Safe delivery and Child Care and dai and ASHA should work together as a team

• Should keep dai and NGO representative in MDR committee

• Follow up needed after Family Planning operation

Dai Sangathan leader presented the above demands in writing to the MO

Conclusion contd……

7.Continous dialogue with AWW and ANM for recording infant deaths

8. Maternal death Review • Meetings are held with the community about the

reasons for doing maternal death reviews.• Meeting with CDHO on maternal death reviews.• Majority of the Maternal deaths are reported to

the MO/THO/CDHO through sms.• Timely Verbal Autopsies are done.

Thank You