Improving maternal and newborn health among tribal communities in Eastern India THE EKJUT TRIAL 2 With assistance from: PRADAN Centre for International Health and Development A collaboration between:

Women’s group intervention The 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 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 days residential training The facilitator

Profile of Groups (n = 244)

Characteristics of group members % of Tribal people72.5 % Below poverty line67.5 % Having some/no land60.4 % With no schooling73.2 * Group members who delivered

Deliveries in our intervention areas NMR58 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 1 Identifying and prioritising problems together Phase 3 Implementing solutions together Phase 2 Planning solutions together Phase 4 Evaluating together

Women’s group action cycle

Sanjay river Chaibasa road To Chaibasa To Kharswan From CKP PILOT VILLAGES 1-Narangabeda 2-Ichapi 3-Uliguttu Pansua

MEETING CYCLES (first 2 phases) 1 st to 5 th Meetings : Identifying & prioritizing problems with the help of picture cards 6 th to 9 th Meetings : Planning strategies to solve the problems through story telling and bridge game

MEETING CYCLES (last 2 phases) 10 th to 18 th Meetings : Implementing identified strategies 19 th & 20 th 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 2 nd Most important 3 rd Most important

Phase Two Planning strategies Meetings - 6 to 9

Understanding cause and effect Mosquito breeding Stagnant water Malaria (fever with Chills, vomiting, Headache) Bitten by mosquito Less fetal movement Stillborn baby Not using bed nets Performing puja Unable to see ANM for 5 days Did not seek care

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

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

ProblemStrategyAction requiredPerson (s) responsible Date of implementation Transportation (Prolonged labour) Emergency fundMonthly savingsNandi DongoMarch ‘06 Skilled Attendance at birth Contacting Trainers JemamaniDecember ‘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 StrategyProgressProblems facedRemarks Emergency FundNew Savings group formedSavings defaultersReduced interest rate Training of TBAsContacted NGO for trainersConvenient 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 15 Understanding Facility based- Emergency cards Meeting 13 Preventing newborn problems Meeting 14 Understanding 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