1. Giving birth at home: How to change the custom & create a Descriptive Norm in Jharkhand, India Job Zachariah, India UNICEF- UPenn Program, 2012

2. Background - Jharkhand Jharkhand, Indian state with 33 million people, has poor socio-economic indicators. 42 % people live below per-capita income of half a dollar per day, $ 190 per year (NSSO, 2004) One third population illiterate (Census, 2011); Half (55%) of children under-3 are underweight; three fourth (72%) women are anemic (NFHS-3) MMR- 260 (per 100,000 live births) & IMR- 40 per 1000 live births (SRS,2009).

3. The Challenge Of 850,000 babies born every year, half are born at home without obstetric care; remaining half at hospital (HIMS,2012) 8 women (delivery) & 100 infants die every day (SRS 2009) Government bears all delivery expenses; provides free transport & escort; gives cash incentive of $ 25 to mothers & gives CCT of $ 2000 for girls born in hospital Despite facilities, incentives & safety aspects, why do women give birth at home? Can a DN on giving birth at hospital created and how?

4. IF DN created If a Descriptive Norm (DN) is created on mothers giving birth at hospital, then: Three fourth (74%) maternal deaths (PPH, Eclampsia, OL) can be prevented. One third infant deaths can be prevented (pre-term& sepsis). 22% of infant deaths can be prevented by BF within 1 hour alone (Lancet,2003).Only 11% do so in Jharkhand (NFHS-3) All Births will be registered and all will get birth certificates. Now, only 10% have birth certificates. Mothers get incentives & girls are empowered ( by education, preventing child marriage & child labour) by CCT

5. Theoretical Concept & Framework Giving birth at home/hospital is a custom, not a social norm, because EE, NE or conditional preference are not present Two customs (giving birth at home and hospital) exist side by side, in all villages, because of different factual beliefs Social convention theory doesn’t play as decision is at individual /independent level. Games theory not applicable Creating core group, community dialogue & argumentation, diffusion, public declaration, community incentive important A DN needs to be created ( to replace custom of home/hospital delivery). SN cannot be created as NE is weak. For DN, EE to be increased. DN has FB and EE, but not NE

6. Work done so far At present, the focus is on improving delivery of services which includes: Cash Incentive of $ 25 for delivery in hospital. CCT of $ 2,000 for girls born in hospital Free transport to go to and return from hospital and free escort service of village health worker Trained nurses in hospitals on SBA Number of hospitals increased, improving access 24*7 call centre which arranges transport for women to reach hospital & wide network of transporters

7. What was not done No problem-tree analysis, No study to know KAP, belief and social expectation. No communication, plan and strategy No programme result matrix No community dialogue for improving FB No core group, no diffusion, no declaration to increase EE No monitoring framework No effort to improve quality of services in hospitals

8. What needs to be done Conduct study to know KAP, social expectations & customs. Also conduct problem-tree(causality) analysis Develop communication plan/ strategy – with message, channel, medium, target audience, methodology Develop programme logframe with result matrix, activities, indicators, targets, MOV, geographical areas, risk, assumption, timeline, monitoring framework Core group of mothers to be strengthened with traditional & local self government leader & trained on IPC & facilitation Community dialogue and engagement, village mapping

9. What needs to be done … Core group members diffuse to households and to community - village health and nutrition day, gram sabha meeting Oath taking in villages, hoist flag in villages achieving zero home delivery Chief Ministers special award for communities, blocks and districts for 100% hospital delivery. Visibility and Social marketing: High visibility, high voltage events & media coverage. Catchy slogans, out-of-the box messages & innovative scripts. “My daughter got $ 2,000, did you get it”..

10. What needs to be done … New descriptive norm can be sustained only if delivery of services improves. This includes: Strengthen 24X7 call centre & network of transporters to rush pregnant women to hospital. Train nurses in hospitals on skilled birth attendance Address absenteeism of doctors and nurses Set up EMOCS with neonatal corners and blood storage units in all hospitals Streamline issue of birth certificate, provision of cash incentive, before the mother is discharged Provide waiting rooms for the family and the pregnant women

11. Conclusion Jharkhand is on a tipping point, half of the babies now are born in hospital. Hospital delivery is rapidly increasing - from 8% in 1997-98, to 14% in 2002-03 and shot up to 54% in 2011. Creating a descriptive norm on hospital delivery now may put an end to the custom of giving birth at home. Outcomes - Reduce IMR and MMR, Increase in Birth certification, reduce under nutrition and empower women.