Improving maternal and newborn health among tribal communities in

Eastern India

THE EKJUT TRIAL2

With assistance from:

PRADAN

Centre for International Health and Development

A collaboration between:

Women’s group intervention

The ekjut trialThe ekjut trial

Successful pilot community mobilisation programmes: – Jamkhed Project – Maharashtra, India

– Kakamega Project - Western Kenya???

• Communities were assisted to identify their own problems, collect data, and implement solutions.

• These demonstration projects brought substantial improvements in health for communities.

Historical perspective on community mobilisation

Previous studies

There has been little research on community mobilisation:

• SCF Warmi Project, Bolivia

- 50% reduction in PMR

(small sample size, not RCT)

• MIRA Makwanpur trial in Nepal (RCT)

- 30% reduction in NMR

- fewer maternal deaths in intervention

areas

Both projects used a participatory women’s group action cycle.

Why women’s groups?

• Existing women’s groups are an untapped resource and might have inbuilt sustainability.

• Conventional behaviour change methods are not always successful.

• Can peer groups unlock the behaviour change and personal empowerment crucial to improving health outcomes and benefit poor families?

• Can the impact seen in the Makwanpur trial be replicated in a different setting?

• Are interventions that empower groups cost-effective and benefits equitable?

Our intervention

• 1 local woman facilitator per cluster (18 facilitators in 18 intervention clusters)

• Each facilitator was responsible for an average of 13 groups. Total - 244 groups

• Each group met once a month

• Facilitators used manuals to guide their meetings

WOMEN’S GROUPS- a participatory approach to improve maternal and

newborn health

Facilitator’s Manual

• Not a teacher• Local woman selected using criteria agreed with the

community• Two thirds of the facilitators belonged to the tribal community• 5 + 2 days residential training

The facilitator

Profile of Groups (n = 244)

Characteristics of group members

% of Tribal people 72.5

% Below poverty line 67.5

% Having some/no land 60.4

% With no schooling 73.2

* Group members who delivered

Deliveries in our intervention areas

NMR 58

No skilled attendant (nurses/doctors)at birth

80 %

TBA conducted deliveries

35.5 %

Husbands conducted deliveries

12.6%

Other relatives conducted deliveries

37.5 %

Profile of group members

4 Phases of intervention

Phase 1Identifying and

prioritising problems together

Phase 3Implementing

solutions together

Phase 2Planning

solutions together

Phase 4Evaluating together

Women’s group action cycle

Sanjay river

1

2

3

Chaibasa road

To Chaibasa

To KharswanFrom CKP

PILOT VILLAGES

1-Narangabeda2-Ichapi3-Uliguttu

Pansua

MEETING CYCLES (first 2 phases)

1st to 5th Meetings : Identifying & prioritizing problems with the help of picture cards

6th to 9th Meetings : Planning strategies to solve the problems through story telling and bridge game

MEETING CYCLES(last 2 phases)

10th to 18th Meetings : Implementing identified strategies 19th & 20th Meetings : Evaluating together

Phase One

Identifying and prioritizing problems

Meetings -1 to 5

Piggy back game

Understanding cultural practices

• Cord is cut only after delivery of placenta• Fair number of men conducted deliveries• First service provider is the shamen / ojha / faith healer• Colostrum is considered to be bad for the baby• Bamboo strip, maize leaf, knife, arrow used for cord cutting• Women in postpartum period are given one meal a day

Picture cards

Prioritizing problems

Prioritizing maternal and newborn problems

by the community using 6 stones:

Most important

2nd Most important

3rd Most important

Phase Two

Planning strategies

Meetings - 6 to 9

Understanding cause and effect

Mosquitobreeding

Stagnant water

Malaria(fever withChills,vomiting,Headache)

Bitten bymosquito

Less fetal movement

Stillborn baby

Not using bed nets

Performing puja

Unable to seeANM

for 5 days

Did notseek care

Cause & effect relationship through pictorial stories, followed by ‘but why’ game

Understanding cause and effect

• 1st BRICK – Where are we now? (This refers to Meeting 2)

• 2nd BRICK – Where do we want to be?

• THE RIVER – The barriers we face (This refers to Meeting 6)

• 2 LONG STICKS – The strengths we have as a group (This refers to Meeting 1)

• SHORTER PLANKS – The strategies we come up with (We decide these now!)

Prioritizing strategies ‘Bridge Game’

Arriving at Strategies

To arrive at the causes & solutions, the facilitator needs to ask:

– “But why did this happen?” after the story telling session

– “But how can we prevent the problems from happening?”

To arrive at the strategies, the facilitator needs to ask:– How they would like to deal with these solutions?

– What can be done to prevent the problem?

– How feasible is the strategy?

Process for sharing

Deciding on…

• Reasons for holding the community meeting

• Who to invite and how to invite

• Method of dissemination to the community

• How to arrange for the meeting

Preparation and Practice

Deciding on…

• Roles and responsibilities

• Venue, time and place

• Invitation list

• Logistics arrangements

• Rehearsal and practice

Community Meeting - 1

Phase Three

Putting strategies into practice

Meetings -10 to 18

Problem Strategy Action required Person (s) responsible

Date of implementation

Transportation (Prolonged labour)

Emergency fund Monthly savings Nandi Dongo March ‘06

Skilled Attendance

at birth

Contacting Trainers

Jemamani December ‘06

Meeting 10- Taking responsibilities

• Members decide who takes what responsibility

• What resources are required and how to obtain them

• How non-members can help

• Jointly overcoming obstacles

Meeting 11 - Measuring progress

Strategy Progress Problems faced Remarks

Emergency Fund New Savings group formed Savings defaulters Reduced interest rate

Training of TBAs Contacted NGO for trainers Convenient time for all

• Group members decide on simple

indicators

• Are the strategies being implemented ?

• What are the problems faced?

• Green cards – for prevention• Brown cards – for home care• Red cards – for emergency/facility care

Picture card games (Understanding solutions)

Meeting 12 Preventing

maternal problems

Meeting 15Understanding Facility based-

Emergency cards

Meeting 13 Preventing

newborn problems

Meeting 14Understanding home care cards

• To identify emergency problems

• To discuss possible delays in responding to emergencies - ‘Emergency drill’

• To discuss how these delays could be reduced

Meeting 16 -Emergency preparedness

Meeting 17-Non-emergency Care

• To identify non- emergency problems

• To discuss how to respond to non-emergency problems and appropriate referral –

‘voting with feet’ game Picture or video

Meeting 18-Learning from others

Learning and sharing of experiences and strategies

that other groups have used

Preparation and Planning

for

Cluster level

Community Meeting - 2

Cluster level Community Meeting

Meeting 19

Phase-wise evaluation by group members:

of their achievements

and the help provided by

them

Evaluation of impact of the intervention on the larger community

- Do they think they have influenced the behaviour of others in their community? If so, how? What facilitated & what prevented

- How have men been involved in the cycle? How do the group members feel about their level of involvement?

Meeting 20

Thank You