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
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