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Community Partnership for Safe Motherhood, Uttar Pradesh
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Subject Area="Public / private partnership (including NGOs)." Objective="Mobilising community participation."
Details for Reform Option "Community Partnership for Safe Motherhood, Uttar Pradesh"
Summary

Background: The project partners (NGO Shramik Bharti, PRIME, USAID) had identified that the high rates of maternal and infant deaths during childbirth could be drastically improved by teaching simple, home-based emergency life-saving skills. Traditional birth attendants lacked the basic health education they needed to assist and there was extremely low use of local referral centres with emergency obstetric services. Action: The Community Partnership for Safe Motherhood (CPSM) project aimed: (i) to teach communities home-based maternal and neonatal life savings skills, (ii) to reduce delays in transport to referral centres for treatment and (iii) to promote post-abortion and post-partum family planning. The project also included strengthening community workers in research, data management and design and implementation of health intervention capacities. Set up: Assessments made of the situation in the community: numbers of maternal and infant deaths; assessment of referral facilities; community self assessment; discovering existing practices, perceptions and beliefs about childbirth and care of newborns. Findings: Questionnaires of women aged 21 to 30 found 60% were illiterate; 97.7% gave birth at home; only 30% had antenatal care; 1.7% of women put their baby to the breast within one hour of birth; two % of pregnancies ended in maternal death; 7% of pregnancies ended in neonatal death. Intervention: Self help groups were established in the villages and stakeholder meetings held. Villages encouraged to set up their own health committees to guide the project and select Village Health Guides (VHGs) – women volunteers from the local community to carry out the training. Training: VHGs were trained as health educators by master trainers (recruited by the NGO) to teach expectant mothers and those planning to attend the birth (eg mother, mother-in-law, sister) basic information and skills about obstetric emergency. The VHGs were taught a 6 module programme of Home-based Life Saving Skills (HBLSS) – initially developed by the American College of Nurse Midwives and then adapted to address local needs - using Take Action Cards (TAC) (see Documents and Illustrations section) as visual aids. They were then responsible for identifying the pregnant women in each village and teaching them and their birth attendants these skills. They also advised on tetanus toxoid, the use of iron tablets, condoms and pills and were able to earn money by selling these at a subsidised rate (subsidised by the project managers). Despite an effort to direct women towards a facility with Emergency Obstetric Care (EmOC) in times of emergency, it was found that they or their families repeatedly insisted on contacting the rural medical practitioner (lay practitioners) instead. The anecdotal evidence showed this was because they knew these practitioners, were more comfortable with their style of care and perceived them as more affordable and personal. It was decided therefore to also train these practitioners (who are largely untrained) life saving skills so they recognised danger signs and knew to refer on to EmOCs when necessary. Anecdotal evidence showed that training these practitioners did result in them referring dangerous cases on when necessary Awareness building: The VHGs also worked to make sure the community knew what hospital and clinic facilities (both public and private) were available nearby with emergency obstetric care and what transport was available should they need medical help quickly. Wall writing and traditional theatre shows were used to spread the word and two-day workshops were also held to educate husbands, father-in-laws and brother-in-laws – identified as the decision makers in the community - about when pregnant women should be sent to referral centres for specialist help. Loans: Self Help Groups (SHGs) were given funds to provide emergency loans so that women could get emergency medical help and meet transportation costs immediately. Part of the interest from the loans was used to compensate the time spent by the VHGs training the community. Grain collections were also held to raise funds to pay the VHGs. Results: Women who had completed the HBLSS series were more likely to accept tetanus toxoid, 75% said they had put their newborn to the breast feed within one hour (traditional advice was to feed the baby sugar and water for the first three days) and 40% had accepted modern methods of family planning. TACs were demonstrated as an extremely effective tool for spreading messages about HBLSS to the community and as job aids to the home-based attendant.

Cost Shramik Bharti estimates the programme costs INR 16 lakh to INR 18 lakh per year per administrative block (roughly 150,000 population).
Place The CPSM project was conducted in north UP covering about 20,000 population in approximately 10 villages (about 32 hamlets) of Kanpur Dehat district June 1998 – June 2002. Has been continued by NGO Shramik Bharti in more than 150 villages covering a population of 150,000 (information as of August 2004).
Time Frame 18 months to carry out community assessment, develop training programme and select VHGs.
Advantages

Simple and good quality visual aids: because the HBLSS modules were limited and were supported by the TACs, the VHGs and the community found the lessons and procedures easier to remember. Community involvement: this greatly increases the probability of the project’s effectiveness and willingness to implement antenatal care and family planning.

Challanges

Necessity for frequent assessment and refresher training: For VHGs. Master trainers also need continuing education. Incentives needed: To keep VHGs motivated.

Prerequisites

Master trainers and a training curriculum. The HBLSS curriculum from this project (written in Hindi but can be translated) is available from Shramik Bharti for adaptation and is particularly suitable for Northern India. Thorough consultation with the community and an understanding of their needs. Intervention must be tailored to meet their requirements if enthusiasm for the project is to be maintained. Key TACs must be designed so they are culturally acceptable.

Who needs to be consulted

NGO (in this case Shramik Bharti). The local community. Local practitioners and both public and private hospital referral facilities.

Risks

Sustainability

The project is sustainable if intervention is modified to suit the local community culturally and socially and costs are available to meet the training and loan fund.

Chances of Replication

Replicable provided there is a reasonable access to an emergency obstetrics care facility and sufficient funding. Data management and record keeping should be a key component of any replication. Monitoring should occur at field level. Any decision to scale-up the programme should take into account compensation for the community-based trainers (VHGs in this case) and the possibility of finding local financial and human resources to provide emergency funding for transportation and other purposes. Stakeholders should assess the advantages and disadvantages of alternative scale-up models within the context of local circumstances and the feasibility of incorporating the core elements of CPSM and HBLSS interventions within the context of other Safe Motherhood programmes in the public and private sectors locally.

Comments

Shramik Bharti reports a need for a flexible attitude. The programme must be able to change to meet circumstances as they arise. Intervention must address the realities on the ground with a well co-ordinated approach. It is essential to reinforce key messages to ensure retention. Lack of affordable transport to encourage community to use FRUs also remained a challenge.

Contact

Submitted By

Clare Kitchen, Research Consultant, European Commission Technical Assistance, New Delhi. September 2004.

Status Active
Reference Files
CPSMFinalEvaluationReport-executive summary.doc CPSM Final Evaluation Report - executive summary
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