baseline study on immunization in rural bihar study on immunization in rural bihar a report...

Baseline Study on Immunization in Rural Bihar

A Report

Submitted to UNICEF, India

CENTRE FOR OPERATIONS RESEARCH & TRAINING

402, Woodland Apartment Race Course Circle Vadodara 390 007.

Gujarat, India.

research tha t makes a d i f fe rence

Study Team

Sandhya Barge P. Swarup Nayan Kumar Hemlata Sadhwani Wajahat Khan Seema Narvekar Jashoda Sharma Shweta Shahane

PREFACE In order to reduce infant and maternal mortality, the National Population Policy of the country has emphasized the achievement of universal immunization of children, against the six dreaded childhood diseases, and antenatal care of the pregnant mothers. Efforts made by Government of India in this direction are fully supported by UNICEF, whose priority is to ensure that children having limited access to immunization are covered. It has taken up the task of strengthening the routine immunization programme especially in the states where immunization coverage is low. UNICEF thus requested Centre for Operations Research and Training, Vadodara to conduct a baseline survey in selected districts of Bihar state to ascertain the level of key indicators of routine immunization programme in these districts. The present report is based on the result of the baseline data obtained from the eight districts of Bihar. I am sure the findings from this report will guide the program mangers in planning their programme. We take this opportunity to thank the UNICEF officials namely, Dr Vijay Mosses, Dr. James Patterson, Dr. Samresh Sengupta, Dr Vibhavendra Singh Raghuvamshi, and Dr. Madhulika Jonathan for their constant interaction and support at each stage of the study. This study would not have been possible but for the support of all the study districts Chief Medical Officers and the other health officials for sparing their time, we acknowledge their cooperation and support. We are also grateful to all the respondents for sharing their time with us. I wish to put on record my appreciation to all team members and other CORT staff members for their contribution in completing the study with quality and within the stipulated time frame despite the area covered was quite challenging. Prof. M. M. Gandotra Director Centre for Operations Research 2005 and Training

CONTENT CHAPTER 1: INTRODUCTION Background ................................................................................................................... 1 Objective of the Study................................................................................................... 3 Methodology ................................................................................................................. 3 Questionnaires .............................................................................................................. 4 Recruitment, Training and Fieldwork ........................................................................... 5 Data Entry and Analysis ............................................................................................... 5 Format of Report ........................................................................................................... 5 CHAPTER 2: BACKGROUND CHARACTERISTICS Health Facility .......................................................................................................................7

Primary Health Centre........................................................................................... 7 Sub-centre ............................................................................................................. 9

IEC/Social Mobilization ............................................................................................... 9 Community Level..................................................................................................................9

Background Characteristics of Mothers with Children 12-23 months.................. 9 Background Characteristics of Mothers with Children 0-11 months.........................10

CHAPTER 3: IMMUNIZATION Availability of Vaccines........................................................................................................13

Stock of Vaccines in the Facility .................................................................................13 Status of Vaccines in the Facility.................................................................................15 Status of Vitamin A in Sub-centre ...............................................................................16 Cold Chain Quality .......................................................................................................16 Injection safety..............................................................................................................18 Mode of Collecting Vaccines.......................................................................................19

Accessibility of Immunization Sessions ..............................................................................19 Immunization Sessions.................................................................................................19 Access to Sessions ........................................................................................................20 Access at the Village Level ..........................................................................................21 Health Personnel who Makes the Services Accessible ..............................................22 Linkages with Anganwadi Worker with Access.........................................................23

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Utilization and Adequate Coverage .....................................................................................23 Immunization Practice..................................................................................................23 Client Perception of Immunization..............................................................................24 Socio-economic Comparison of Immunization Coverage..........................................25

Effective Coverage........................................................................................................ 26 Timing of Immunization ............................................................................................... 27 Review of Immunization Bottlenecks........................................................................... 27 CHAPTER 4: ANTE-NATAL/NATAL AND POST-NATAL Availability of Services.........................................................................................................29 Accessibility of Services.......................................................................................................31

Status of Health Personnel’s Accessible to Community.............................................32 Community Perception on Accessibility of ANC Services........................................33

Utilization of Maternal Services ................................................................................... 33 Full Coverage of ANC by Background Characteristics of Mothers ..........................35 Women’s Perception on Need of ANC Care ..............................................................37 Natal Care......................................................................................................................37 Registration of Birth .....................................................................................................39 Post-natal.......................................................................................................................39

CHAPTER 5: CHILD CARE, BREASTFEEDING AND SUPPLEMENTARY FEEDING Availability ............................................................................................................................41

ORS Packets..................................................................................................................41 Cotrimoxazole Tablets..................................................................................................41

Accessibility ..........................................................................................................................42 Knowledge among Mothers regarding Diarrhoea ......................................................42

Utilization ..............................................................................................................................43 Adequate Coverage ...............................................................................................................44 Effective Coverage................................................................................................................45 CHAPTER 6: SUMMARY AND CONCLUSION Immunization ........................................................................................................................47 Ante-natal, Natal and Post-natal Care ..................................................................................48 Child Care and Breastfeeding/Supplementary Feeding Practice .......................................48 Annexure- I PSU List Annexure-II District-wise status of Immunization by selected Indicators Annexure-III Questionnaires

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LIST OF TABLES Table 1.1: Demographic profile of study area..................................................................2 Table 1.2: Distribution of sample covered by study districts ..........................................4

Table 2.1: Infrastructure of the Primary Health Centre ...................................................7 Table 2.2: Staffing Pattern of the PHC.............................................................................8 Table 2.3: Profile of the SCs .............................................................................................9 Table 2.4: Background characteristics of mother of children 12-23 months ................ 10 Table 2.5: Background characteristics of mothers of children 0-11 months ..................11 Table 3.1: Average position of vaccine doses per facility.............................................. 14 Table 3.2: Reported and calculated stock of vaccines at facility.....................................15 Table 3.3: Position of vaccines in PHCs......................................................................... 16 Table 3.4: Position of vitamin A and vaccine carrier in sub-centres...............................16 Table 3.5: Availability of vaccines and its place of storage ............................................17 Table 3.6: Status of electricity/generator in PHC.............................................................18 Table 3.7: Type of syringes/needles used by ANMs .......................................................18 Table 3.8: Time required for collection of vaccine and handling of unused vials .........19 Table 3.9: Background of ANMs .....................................................................................20 Table 3.10: Status of immunization sessions......................................................................21 Table 3.11: Health facilities available in the villages ........................................................22 Table 3.12: Distance and mode of accessibility to health facility .....................................22 Table 3.13: Type of vaccines received by children............................................................24 Table 3.14: Status of children Immunization .....................................................................24 Table 3.15: Status of immunization by selected indicators ...............................................25 Table 3.16: ANMs knowledge on immunization ...............................................................26 Table 3.17: Percentage of children who received immunization as per schedule............ 27

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Table 4. 1: Status of Iron folic tablets at the PHC.............................................................29 Table 4.2: Status of Iron folic tablets at the sub-centre....................................................30 Table 4.3: Status of DDK in the sub centers ....................................................................31 Table 4.4: Access to health personnel ..............................................................................32 Table 4.5: Opinion of women on accessibility of ANC service......................................33 Table 4.6: Type of ANC services sought .........................................................................34 Table 4.7: Status of ANC services by selected indicators ...............................................35 Table 4.8: Adequate coverage of ANC services ..............................................................36 Table 4.9: Effective coverage of mothers for ANC services...........................................36 Table 4.10: Opinion of the women regarding need of ANC care .....................................37 Table 4.11: Place of delivery .............................................................................................38 Table 4.12: Post-natal follow up .........................................................................................39 Table 5.1: Status of ORS and cotrimoxazole at PHC and Sub-centres...........................42 Table 5.2: Knowledge regarding diarrhoea and its management....................................43 Table 5.3: Breastfeeding practice among mothers...........................................................44 Table 5.4: Nutrition pattern among children ....................................................................45 Table 5.5: ANM’s knowledge on breastfeeding and supplementary feed......................46

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LIST OF FIGURES

Figure 3.1: Percent of mothers who have immunization card ........................................23 Figure 3.2: Immunization status .......................................................................................27 Figure 4.1: No. of facilities report/having sufficient stock of IFA tablets .....................30 Figure 4.2: No. of PHCs where delivery conducted by district ......................................31 Figure 4.3: No. of PHC indicating the trend of deliveries conducted in last one year ..31 Figure 4.4: No. of ANMs trained for conducting delivery .............................................33 Figure 4.5: Percentage of mothers who registered the birth of child..............................39

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1

Introduction

1.1 BACKGROUND Our country’s National Population Policy 2000 emphasizes on “achievement of universal immunization of children against all vaccines preventable diseases” and has recognized it as one of the National Socio-Demographic Goals for 2010 along with “prevention and control of communicable disease.” This is also re-emphasized in the mission document of the National Rural Health Mission (NRHM). The Universal Immunization Program (UIP), a national programme launched in the country since 1985, desires 100 percent coverage of target population with vaccination against six preventable killer diseases - polio, diphtheria, tuberculosis, pertussis (whooping cough), measles and tetanus, which has helped in reducing the infant mortality rate in India from 104 in 1984 to 66 deaths per 1,000 live births in 2002. Despite some improvement in the infant mortality indicator in the country, the stated goals have not been fully achieved. Wide difference exists in the level of infant mortality across the various states of India. Efforts made by Government of India in striving towards its goals are further strengthened by various international and national agencies joining hands in this initiative. UNICEF is an international organization, is supporting Government of India’s efforts primarily focusing on child care and immunization. “Vaccination is widely recognized as one of the most powerful and cost-effective public health tools. Often immunization is a child's first - sometimes only - contact with the health system.” - UNICEF Executive Director, Carol Bellamy. Various socio-cultural factors often make it difficult for vaccinators to access children. Some children are excluded from immunization because they come from minority groups or live in deeply impoverished remote areas, where health services may operate poorly. Some communities have religious or traditional beliefs that make them suspicious of immunization. Bihar state is one among several states in the country, where immunization coverage has been very low in recent years. Different reasons are being speculated for the same. As per the NFHS-2, only 11 percent of the children had received all vaccinations. At the request of UNICEF and Government of Bihar, a baseline survey was conducted in eight districts of Bihar namely Aurangabad, Begusarai, Bhagalpur, Gaya, Kishanganj, Purnia, Saran and Vaishali by Center for Operations Research and Training, a multidisciplinary social science research and training organization based at Vadodara, Gujarat. The study districts are highlighted in the map below. The present report delves in the findings of this baseline survey.

Baseline Study on Immunization in Bihar

Study districts

Gaya

Auran- gabad

Begu- Sarai Bhagalpur

Purnia

Kishanganj

Vaisha-li

Saran

Demographically the population in the study districts ranges between 12,96,000 in Kishanganj to 32,48,000 in Saran. These study districts were predominantly rural, as percentage urban constitutes only five percent (Begusarai) to 19 percent in Bhagalpur. Overall the scheduled caste population in the rural areas varies from six percent (Kishanganj) to 33 percent (Gaya). Substantial difference exists in the rural and urban areas of the district especially with reference to sex ratio which is lower in urban areas than in the rural areas. Where as, overall literacy rate and among females is higher in urban areas than their counterparts in rural area. Table 1.1: Demographic Profile of Study Area

Name of the Districts Indicator

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj

Purnia Saran Vaishali Bihar

Population in 000s 2013 2349 2423 3473 1296 2543 3248 2718 82998Percent of urban 8.4 4.6 18.7 13.7 10.0 8.7 9.2 6.8 10.0Percent of scheduled castes 23.5 14.5 10.5 29.6 6.6 12.3 12.0 20.7 15.7Percent of scheduled tribes 0.1 0.6 2.3 0.1 3.6 4.4 0.2 0.1 0.9Percent of scheduled castes in rural areas 24.4 14.7 11.1 32.5 6.1 12.6

12.2

20.9 16.4

Percent of scheduled tribes in rural areas 0.1 0.1 2.7 0.1 3.8 4.5

0.2

0.1 0.1

Sex ratio urban 899 870 866 878 863 851 890 889 868Sex Ratio in rural 937 914 878 948 945 921 974 923 926Literacy rate in urban 73.5 77.7 70.7 75.7 59.3 70.9 66.1 65.6 71.9Literacy rate in rural 55.5 46.5 44.4 46.2 27.8 31.4 50.3 49.3 43.9Literacy rate among urban female 63.4 69.4 62.9 66.7 48.2 62.1 54.3 55.1 62.6Literacy rate among rural female 39.9 34.0 32.1 31.8 15.4 19.6 34.0 35.2 29.6

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Chapter 1: Introduction

3

1.2 OBJECTIVE OF THE STUDY The main objective of this baseline survey was to generate base line information on key indicators in the immunization program in rural areas. 1.3 METHODOLOGY The study design adopted for the baseline survey was the multi indicator cluster survey technique. The study was conducted in eight districts of Bihar selected by UNICEF in consultation with the Government of Bihar included Aurangabad, Begusarai, Bhagalpur, Gaya, Kishanganj, Purnia, Saran and Vaishali. The sampled clusters for the study were limited to the rural areas of the identified districts. 1.3.1 Sampling Method The sample population identified for the study in each district was selected on a two-stage sampling technique. In each district, 30 clusters were selected by using systematic probability proportional to the size (PPS) procedure. The list of selected clusters is given in the Appendix A. Steps adopted to identify the cluster and the sample was as follows:

• List of all the rural areas (villages) with the size of population, in a district, as per 2001 Census was prepared fir each of the study district.

• For identifying the cluster, a class interval was obtained by dividing the total rural population of the district by 30 (number of cluster to be covered in a district). Using this interval, 30 clusters were selected with a random start of the first cluster.

• Within each cluster, first a center point was identified with the help of villagers. All the households located in the center point were given numbers. One household among these was selected using a currency note. From the first sampled household, listing of the subsequent households was carried out clockwise. This process continued till the target sample of eight children between the age of 12-23 months and eight children aged less than a year as on the date of survey, were identified for the interview.

• Large villages with geographical spread out was initially divided either by a lane or tola situated geographically in the four direction of the village, one among this was selected by using a number on a currency note. Following this selection of the lane/tola, from the center of this selected area, process of identifying the first sample household from the center of the area was conducted in the same way as discussed earlier in case of smaller villages.

Sample size: From each selected cluster, eight mothers of children aged below one year and eight mothers of children aged 12-23 months were interviewed. In each cluster, therefore 16 mothers were interviewed. In each district, 480 mothers were interviewed comprising of 240 mothers having children below one year of age and 240 mothers who had a child aged 12-23 months. In addition to these in each village, village questionnaire was administered to the village panchayat member or local leader. An attempt was also made to interview the medical officer of the primary health center and the ANM of the sub center in which the selected cluster was located.

Baseline Study on Immunization in Bihar

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Distribution of Sample Covered by the Study Districts Name of the Districts Indicator

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj

Purnia Saran Vaishali Total

No. of PHC covered 15 18 11 22 9 14 16 19 124No. of SC surveyed 15 17 14 17 11 15 18 15 122No. of cluster covered 30 30 30 30 30 30 30 30 240No. of villages covered 31* 31* 30 30 31* 31* 30 30 244*No. of mothers (0-11 months) interviewed

240 240 240 240 240 240 240 240 1920

No. of mothers (12-23 months) interviewed

240 240 240 240 240 240 240 240 1920

* Villages were less than 50 HHs hence link village added 1.4 QUESTIONNAIRES To address the objectives of the study seven different types of tools were used. This includes (i) identification sheet (ii) village questionnaire (iii) mother’s questionnaire i.e. for mothers of children below one year (iv) children questionnaire i.e. for mothers of children aged 12-23 months (v) PHC questionnaire (vi) ANM’s questionnaire and (vii) Sub-centre questionnaire. (i) Identification sheet: This sheet was used to identify the presence of target

population. The name of the head of the household, total members in the household by sex and number of children less than two years of age were listed. If any child was found in the household within the desired age group their name, age and sex was noted and the corresponding questionnaire was administered to the mother of the child. In case if the mother was not available in the household, the reasons for the same were noted.

(ii) Village questionnaire: The village questionnaire was used to collect information

from responsible community members in the village like the sarpanch, panchayat member, teacher, etc. Through this information on distance to nearest town, transport facilities available to the village, health facilities available in the village, the nearest health facility, providers available and information regarding immunization sessions were collected.

(iii) Tool for mothers of children (0-11 months): This questionnaire collected

information from mothers of children aged below one year. The questionnaire besides collecting information on the background information of the respondents, collected details regarding ANC, PNC, breastfeeding and supplementary food practices and their opinion on various child health related issues.

(iv) Mother’s questionnaire for children of 12-23 months: This questionnaire was

administered to those mothers who had a child aged 12-23 months. Through this questionnaire, information on the background characteristics of the respondent and the index child, immunization status of the child, if the child was not immunized the reasons for the same, for each vaccine was collected. In addition to this, the mother’s opinion on various child health related issues were elicited.

(v) PHC questionnaire: PHC questionnaire collected information from Medical

Officer In-charge of the PHC. This questionnaire collected information on infrastructure, staff position and their training status, obstetric services, supply of vaccine and cold chain equipment, adequate supply of prophylactic drugs, supply and disposal of needle.

Chapter 1: Introduction

5

(vi) ANM questionnaire: ANM questionnaire collected information from the ANMs who are the frontline workers of the government health department. Through this questionnaire information about the population and number of villages covered by the ANM was collected; additional information about her background, training and job responsibilities, and service delivery was also collected.

(vii) Sub-centre questionnaire: Sub-centre is the grass root level public health facility

available in India. In this questionnaire information on the number of villages covered, population covered, infrastructure, distance to the villages, availability of DDK, etc. was collected.

1.5 RECRUITMENT, TRAINING AND FIELD WORK A total of 47 field persons were recruited locally in Bihar for conducting the survey in eight districts. The field investigators included both male and female investigators who had some field survey experience earlier. Each team comprised of two female investigators and one male investigator. One supervisor supervised work for two teams. The training of the field staff was organized at Law College, Patna University, Patna. The training was imparted to investigators at two levels. In the first stage classroom training was given for six days, in the second stage actual field practice was carried out. Senior professionals of CORT were personally involved in giving the training. The teams conducted the field practice in the presence of trainers. Their filled-in questionnaires were thoroughly scrutinized to identify gaps if any, in their understanding. Later they were again briefed. To ensure and maintain the quality of data, entire data collection process in the four districts was monitored by two senior staff of CORT. Data collection was conducted between the last week of June 2005 to July 2005 in the selected districts of Bihar. 1.6 DATA ENTRY AND ANALYSIS Completed questionnaires were sent to CORT’s head office at Vadodara for data processing. Activities conducted here included office editing, coding, and computer editing using standard software package. CORT’s computer professional monitored and guided the office editing and data entry. On cleaning the data, the same was analyzed by using the SPSS package. 1.7 FORMAT OF REPORT This report is presented in six chapters. The first chapter of the report is introduction which illustrates the background of the study, objectives, methodology, tools used, field work and sample selected and interviewed for this study. The second chapter describes the background characteristic of the target population, while the third chapter discusses the immunization coverage in all study population. ANC/Natal/PNC and breastfeeding/nutrition status are discussed in the fourth and fifth chapter respectively. Summary and conclusions is discussed in sixth chapter.

2 Background

Characteristics The survey was carried at two levels namely the health facilities and community in Aurangabad, Begusarai, Bhagalpur, Gaya, Kishanganj, Purnia, Saran, and Vaishali districts of Bihar. At the facility level, Primary Health Centre (PHC) and Sub-centre (SC) were surveyed. At the community level, women who had a child between 0 to 11 months and in the age group of 12 to 23 months were interviewed. A brief profile of the health facilities and background characteristics of the study population is discussed in the following section. 2.1 HEALTH FACILITY 2.1.1 Primary Health Centre (PHC) In the three-tier health system, PHC plays a significant role not only because it provides the curative services at the community level but also it has the responsibility of providing preventive and promotive services in the community. Availability of basic infrastructure and sanctioned staff has an impact in providing quality services to the community. The study made an attempt to assess the basic infrastructure available at the PHC and its staffing pattern. Infrastructure: In the eight study districts of Bihar, 130 Primary Health Centres (PHCs) were visited and complete data was available for 124 PHCs. Out of the total 124 study PHCs, 72 were block PHCs and the rest were additional PHCs. Data in table 2.1 reveals that most of the PHCs in each district had their own building. Out of the total PHCs, five percent were functioning from rented building and seven percent of the PHCs from the donated building. Data on the condition of the PHC building shows that only 24 PHCs (19 percent) were in good condition and rest of the PHCs needed repairs. The condition of the building of PHCs in Kishanganj districts was the worst as all the PHCs in this district required minor or major repair. However, major repair was needed in one-third of the assessed PHC buildings. Table 2.1: Infrastructure of the Primary Health Centre (Number)

Name of the Districts Indicators Auran-gabad

Begu-sarai

Bhag-alpur

Gaya Kisha-nganj


Ownership of PHC Own Rented Donated

13

1 1

16

- 2

9 - 2

17

3 2

9 - -

14

- -

15

1 -

16

1 2

109

6 9

Condition of PHC building

Good Need minor repair Need major repair

2 8 5

2

13 3

4 2 5

5

10 7

- 5 4

4 8 2

4 2

10

3

11 5

24 59 41

Total number of PHCs 15 18 11 22 9 14 16 19 124


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Manpower: Regarding the staffing pattern of the assessed PHCs, data shows that on an average, 2.6 male doctors in each PHC was found to be in position at the time of survey. On an average one doctor in Bhagalpur and 1.5 doctors in Saran districts were reported to be in position on contract basis. It may be pointed out here that more than half of the study PHCs were block PHCs. Less than half (55 out of 124) of the PHCs had male supervisors. In these PHCs, the mean number of male supervisor was 1.9 per facility, however this varies from 1.1 in Saran district to 3.2 in Aurangabad district. None of the male supervisors was positioned on contract basis in the study districts. Eighty-seven PHCs (70 percent) had LHV/HA female and the mean number of LHV/HA female was 1.8 per facility. Only one LHV/HA per facility in Bhagalpur district was appointed on contract basis. In case of ANM, majority (95 percent) PHCs had ANM and on an average, 2.2 ANMs per facility were found to be in position. However none of the facility in the study districts had ANM on contract basis appointment (Table 2.2). Table 2.2: Staffing Pattern of the PHC (Number and Mean)


Begu-sarai

Bhag-alpur

Gaya Kisha-nganj


Average number of Male Doctors per facility In position On contract basis

2.3 -

2.2 -

4.0 1.0

2.0 -

1.9 -

2.9 -

3.2 1.5

2.4 -

2.6 0.5

Male Supervisor per facility Number of facility having male supervisor Average no. in position

9 3.2

5 1.4

5 1.8

12 1.2

3 1.7

7 2.4

7 1.1

7 1.9

55 1.9

LHV/HA Female per facility Number of facility having LHV/HA female Average number in position on contract basis

11 1.4

-

9

1.4

-

11 2.1

1.0

17 1.4

-

6

2.5

-

10 2.6

-

11 1.7

-

12 1.6

-

87 1.8

0.1

ANM (at the PHC) per facility Number of facility having ANM Average number in position

15 2.1

16 1.7

10 1.3

22 1.7

8

3.8

14 2.1

15 1.1

18 3.9

118 2.2

Total number of PHCs 15 18 11 22 9 14 16 19 124 Some of the suggestions that emerged from the medical officers regarding infrastructure included

New buildings are needed. Regular maintenance of the buildings should be there Proper cold chain arrangement should be there Quarters should be provided to all the staff. Generator should be provided with PoL to all the facilities.

Regarding the manpower at the facility most of them stated

Vacant posts should be filled up and sufficient staff should be provided Routine training should be provided to the staff. Active participation of anganwadi worker should be there for survey and other

related work Good work should be appreciated and rewarded

Chapter 2: Background Characteristics

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2.1.2 Sub-Centre Sub-centre functions at the bottom level of the three-tier health system and a male and a female health worker provide the health services at the community level. Information about the infrastructure of sub-centre and availability of IEC materials was gathered and has been presented in table 2.3. Altogether, 122 sub-centres were surveyed in the study districts. Out of the total, 38 sub-centres had own building and 72 sub-centers had pucca building. It can be assessed from the table that the condition of the sub-centres was not up to the mark as only 32 sub-centres (26 percent) were found in good condition. Electric connection was observed in only 15 sub-centres and only four sub-centres had regular/continuous supply of electricity. In Gaya and Saran district none of the surveyed sub-centers had electricity connection. Table 2.3: Profile of the sub-centres (Numbers)

Name of the Districts Indicators Auranga-

badBegu-sarai

Bhagal-pur

Gaya Kishan-ganj

Purnia Saran VaishaliTotal

Number of sub-centres having own building having pucca building buildings in good condition

413

3

795

583

312

3

666

6 7 2

4 9 4

386

387232

Number of sub-centres in which electricity connection is currently available electricity supply is regular/ continuous

2

-

2

1

5

2

-

-

1

-

3

1

-

-

2

-

15

4Number of sub-centres having at least one

IEC material available IEC on immunization

87

86

1211

88

44

8 8

11 11

99

6862

Number of sub-centres covered in the study 15 17 14 17 11

15

18 15 122

2.2 IEC / SOCIAL MOBILIZATION Information at the sub-center: Out of 122 sub-centers covered in the study area, 68 sub-centers (56 percent) had at least one IEC and 62 sub-centers (51 percent) had at least one IEC material related to immunization at their center. The distribution of this varied from four sub-centers in Kishanganj to eleven sub-centers in each Bhagalpur and Saran districts. Information at the PHC: IEC material displayed at the PHC could be an indirect way of disseminating information about the services available at the PHC. Data gathered on any poster or IEC material displayed in the PHC announcing availability of immunization either in the form of wall poster, pamphlet, charts or painting indicates that 76 PHCs (61 percent) out of the total 124 PHC have at least one form of IEC on immunization in their facility. The distribution of these PHCs across the districts was four in Kishanganj, varied between seven to nine PHCs in Purnia, Aurangabad, Begusarai, Bhagalpur and Vaishali districts, fourteen PHCs in Saran and seventeen PHCs in Gaya district. 2.3 COMMUNITY LEVEL 2.3.1 Background Characteristics of Mothers with Children 12-23 Months Almost all the mothers interviewed were currently married. The mean age of the mother interviewed was 25.9 years. Seven out of every ten women were Hindu and 22 percent were Muslims by religion. One-fifth of the mothers belonged to SC/ST. Nearly three-fourth (72 percent) of the respondents were illiterate. Majority of the respondents were housewives followed by daily wage earners. Most of the respondent’s husbands were daily wage earners or cultivators. More than half (55 percent) of the respondents lived in


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Kachcha houses. This proportion ranged between 27 percent in Saran district to 80 percent in Purnia district. Exposure to radio was only 30 percent, followed by television (17 percent) and print media (8 percent). To a certain extent exposure to these media was relatively better in Purnia district and worse in Gaya district (Table 2.4). Table 2.4: Background characteristics of mother of children 12-23 months (Percentage)

Name of the Districts Background characteristics Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


Marital status Currently married Divorced Widowed

100.0

- -

99.60.4

-

99.6-

0.4

99.60.4

-

98.80.80.4

99.60.4

-

99.6

0.4 -

100.0

- -

99.60.30.1

Religion of head of the household

Hindu Muslim Others

93.3 6.7

-

85.015.0

-

76.723.3

-

90.49.6

-

28.370.4

1.3

75.824.2

-

85.0 15.0

-

89.2 10.8

-

70.021.9

0.2Caste

SC/ST Others

20.8 79.2

16.383.7

8.891.2

30.469.6

13.486.6

18.381.7

16.7 83.3

37.5 62.5

20.379.7

Education of mothers Illiterate Literate

66.3 33.7

76.723.3

67.132.9

72.127.9

86.713.3

73.326.7

65.4 34.6

70.0 30.0

72.227.8

Occupation of mothers Daily wage earners Cultivators Small business Housewife Other

13.8

4.2 0.4

80.8 0.8

6.3-

0.491.2

2.1

5.81.30.8

87.54.6

21.35.41.3

69.62.4

9.6--

90.00.4

15.41.3

-82.1

1.2

4.6 0.8 1.3

92.1 1.2

5.4 2.9 1.3

88.8 1.6

10.32.00.7

85.31.7

Occupation of fathers Daily wage earners Cultivators Pvt. Services Govt. services Skilled worker Small business Others

36.3 28.8 10.0

1.7 9.2 9.2 4.8

51.317.5

5.80.8

10.010.0

4.6

35.020.412.5

1.314.2

8.87.8

42.927.9

8.30.88.88.33.0

49.223.3

4.25.08.84.65.0

52.920.8

4.60.86.3

12.12.5

30.4 19.6 17.5

2.1 10.8 15.0

4.6

38.3 13.8

8.3 1.7

15.4 15.4

7.1

42.021.5

8.91.8

10.410.4

5.0Type of house

Kachcha Semi-pucca Pucca

55.0 39.6

5.4

45.446.7

7.9

56.336.7

7.1

57.937.5

4.6

74.222.1

3.8

80.414.2

5.4

27.1 65.0

7.9

43.8 49.6

6.7

55.038.9

6.1Exposure to media

Exposure to print media Exposure to radio Exposure to T.V.

5.8

27.5 7.5

8.326.712.5

11.727.918.8

4.623.3

7.5

4.624.617.5

10.437.530.8

7.5

36.7 24.2

7.5

32.9 20.8

7.629.617.4

Total mothers of 12-23 months children

240 240 240 240 240 240

240

240 1920

2.3.2 Background Characteristics of Mothers with Children 0-11 Months Almost all the mothers interviewed were currently married. The mean age of the mother interviewed was 24.8 years. More than three-fourth (78 percent) of them were Hindus and the rest were Muslims. Caste wise analysis of study population shows 19 percent of respondents belonged to scheduled tribe or scheduled castes. Regarding their literacy level 72 percent of the respondents were illiterate. Occupation wise, most (91 percent) of the respondents were housewives followed by daily wage earners (6 percent), while 38 percent of their husbands were daily wage earners and 22 percent were cultivators. More

Chapter 2: Background Characteristics

11

than half (54 percent) of the respondent resided in kachha houses and 39 percent in semi-kachcha houses. On an average they had 3.6 live births and 3.2 living children. It is a well known fact that exposure to media plays a vital role in increasing knowledge. Hence data was collected on exposure to media in the study. It was found that only eight percent of the respondents read or listened to newspaper, while 33 percent heard Radio and 20 percent viewed television (Table 2.5). Table 2.5: Background characteristics of mother of children 0-11 months (Percentage)

Name of the Districts Background characteristics Auran-gabad

Begu-sarai

Bhaga-lpur

Gaya Kishan-ganj


Marital status Currently married Divorced Widowed

100.0

- -

100.0--

99.2-

0.8

99.60.4

-

100.0--

99.6

- 0.4

99.2

0.8 -

100.0--

99.70.20.2

Religion of head of the household

Hindu Muslim

93.3 6.7

89.610.4

73.326.7

90.49.6

32.167.9

72.5 27.5

86.2 13.8

83.716.3

77.722.3

Caste SC/ST Others

25.4 74.6

17.582.5

13.886.2

29.170.9

10.989.1

13.3 82.7

13.7 86.3

25.474.6

18.781.3

Education of mothers Illiterate Literate

62.1 37.9

81.318.7

73.326.7

72.117.9

81.718.3

72.5 27.5

66.3 33.7

66.333.7

71.928.1

Occupation of mothers Daily wage earners Cultivators Housewife Other

3.8 2.1

92.5 1.6

6.70.4

91.71.2

9.60.4

88.81.2

10.03.3

85.80.8

4.60.4

94.60.4

7.1 1.7

85.8 5.6

3.3 1.3

94.6 0.8

2.10.4

95.81.6

5.91.3

91.21.7

Occupation of fathers Daily wage earners Cultivators Pvt. Services Govt. services Skilled worker Small business Others

28.3 31.7 13.7

2.5 6.3

13.8 3.8

42.912.5

7.11.3

21.711.3

3.4

37.520.0

8.81.3

12.910.4

8.8

30.829.614.6

1.312.9

8.31.7

48.325.4

5.02.17.57.14.6

41.7 24.2

6.3 1.3 7.9

13.8 5.0

39.6 17.1 10.4

2.9 10.0 12.5

7.5

32.912.5

9.22.1

17520.0

5.8

37.821.6

9.41.8

12.112.1

5.0Type of house

Kachcha Semi-pucca Pucca

50.8 44.2

5.0

40.854.2

5.0

51.337.910.8

57.935.4

6.7

76.721.3

2.1

77.9 16.3

5.8

29.6 55.4 15.0

42.949.6

7.5

53.539.3

7.2Average number of total live births Average number of male live births Average number of female live births

3.4

1.7

1.7

3.7

1.9

1.8

3.4

1.7

1.7

3.8

1.8

2.0

3.9

2.0

1.9

3.5

1.8

1.7

3.5

1.8

1.7

3.3

1.6

1.7

3.6

1.8

1.8Average number of total children living Average number of male living Average number of female living

3.0

1.5

1.5

3.3

1.7

1.6

3.0

1.5

1.5

3.4

1.7

1.8

3.4

1.8

1.7

3.1

1.5

1.6

3.1

1.6

1.5

3.0

1.5

1.6

3.2

1.6

1.6Exposure to media

Exposure to print media Exposure to radio Exposure to T.V.

7.9

31.3 12.1

5.822.110.8

7.534.216.3

3.824.612.5

3.825.015.0

11.7 43.8 29.2

13.8 41.7 35.0

10.441.328.8

8.133.019.9

Total mothers of 0-11 months children

240 240 240 240 240

240

240 240 1920


12

The above discussion indicates that among the surveyed PHCs only 19 percent were in good condition. Among the remaining facilities, need for strengthening several components have emerged. Supply of regular/continuous electricity in both PHC and sub-center is poor. Mothers who have been interviewed from the community are 22 percent Muslims and the remaining are Hindus, almost seven out of ten women are illiterate, more than four fifth of the woman are housewife, a little more than half of the woman stay in Kachcha house with not much of exposure to media.

3 Immunization

Success of health programmes depends on the extent of interaction between the service and target population. This interaction ranges over the whole process from making available the services, creating knowledge about the services, providing the services to all especially the under served and un-reached section of the community. The interaction therefore ranges from resource allocation to achievement of the desired objectives. According to Tanahashi (1978) to measure coverage of any health programme it is useful to evaluate it at broadly in five stages that is availability, accessibility, utilization, adequate coverage and effective coverage. Keeping in line with this, the present study too makes an attempt to understand the reach of the immunization programme in the eight study districts of Bihar. This chapter initially discusses availability of services followed by the section on accessibility and the utilization component that is the reach of immunization programme in the community. Given this scenario the chapter then tries to assess the adequate and effective coverage for the same. 3.1 AVAILABILITY OF VACCINES Availability of all the vaccines is the key component in the immunization programme. An attempt to assess the same was made in the 124 PHCs that were surveyed in the eight districts.

3.1.1 Stock of Vaccines in Facility For immunization programme it is imperative that the PHC has the required stock of vaccines at the facility. During the survey, data was gathered from the facilities on the position of the available vaccines in the facility. As indicated in Table 3.1, data reveals that there is a wide dispersion in the stock available across the facilities in each district. Attempt was made to understand the average stock that is available at the facility among those who receive the stock. The average doses available per facility varied from 143 doses for BCG, 141 doses for DPT to as high as 961 doses in case of polio. Not only the stock of the vaccines varies by its type, but also it varies across the eight study districts as well as among the surveyed facilities within the district. For routine immunization programme too, the officials reported that they do not normally encounter problem in receiving the vaccine supply from the district headquarters. Almost all medical officers reported that in case they request for additional vaccines the same is received without any problems.


14

Table 3.1: Average position of vaccine doses per facility Name of the Districts Indicator

Auran gabad

Begu-sarai

Bhagalpur

Gaya Kishan Gunj

Purnia Saran Vais- hali

Total

BCG No. of facilities have stock on the day of visit Mean SD Minimum Maximum

4 90.7

163.5 -

470

278.6

152.4-

400

8220.0168.4

-540

6352.5671.0

-2200

3280.0492.0

-1260

344.394.8

-300

2 123.3 297.2

- 730

1 17.3 57.3

- 190

29 142.5 330.9

- 2200

DPT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

5 64.3

153.8 -

570

220.044.7

-120

7445.6473.7

-1080

6236.7402.0

-1090

388.3

125.0-

320

4128.6246.8

-640

2 91.7

205.6 -

510

2 36.4 97.1

- 320

31 141.4 285.5

- 1090

OPV No. of facilities have stock on the day of visit Mean SD Minimum Maximum

4 97.1

299.1 -

1120

131.483.2

-220

6902.2

1516.3-

4000

6256.7448.1

-1320

57444.5

13955.1-

35560

71177.13423.3

-13000

2 330.0 788.9

- 1940

- - - - -

31 960.8

4295.00 -

35560 Measles No. of facilities have stock on the day of visit Mean SD Minimum Maximum

5 57.1

167.1 -

630

262.9

116.9-

300

8206.1353.5

-1080

671.3

134.10-

440

337.557.6

-145

398.6

247.5-

900

2 40.0 93.2

- 230

3 36.4 90.7

- 300

32 78.4

188.8 -

1080 DT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

5 53.6

132.7 -

500

295.7

166.5-

390

7134.4172.6

-540

6130.0223.9

-650

218.332.5

-80

339.388.1

-300

2 48.3

113.6 -

280

- - - - -

27 65.1

140.0 -

650 TT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

4 2549.6

9351.38 -

35035

2177.1

398.78-

1070

6105.6174.3

-540

5193.8302.5

-900

447.762.5

-150

346.493.3

-250

2 163.3 395.2

- 970

1 0.9 3.0

- 10

27 533.4

3937.74 -

35035 Total no. of facilities where vaccine stock was observed

14 7 9 12 6 14

6

11

79

Vitamin A solution No. of facilities have stock on the day of visit Mean SD Minimum Maximum

9 246.8 461.7

5 1200

1038.961.2

1200

4223.5253.9

60600

1819.724.0

587

9403.2975.3

83000

1080.7

115.44

348

13 187.2 348.0

2 1200

14 77.0

163.3 6

600

87 135.7 384.4

1 3000

Total number of facilities where stock was observed

12 11 7 21 9 10

13

14

103

Total number of PHC 15 18 11 22 9 14 16 19 124

Chapter 3: Immunization

15

In addition to assessing the stock of the vaccines in the facility, the medical officers were also probed, on whether they perceived the available stock to be sufficient for the week or not. As can be observed from Table 3.2, only 16 PHCs to 22 PHCs out of the total 124 PHCs reported the stock to be sufficient. Due to the above dynamics in the collection and distribution of the vaccine stocks, an attempt was made to understand from the medical officer whether the facility had sufficient stock available for a week. The stock available at the PHC as per the standard norm (that is having required number of vaccines in the facility as per the estimated number of children below one year in the coverage area and considering the number of doses and wastage of the vaccines) was calculated. The number of facilities having the adequate stock of the vaccine as per the calculation was less for all the vaccines. In Vaishali district none of the facilities had any vaccines in stock. Table 3.2: Reported and calculated stock of vaccines at facility (Number)

Name of the Districts Type of vaccines Auran gabad

Begu-sarai

Bhagalpur

Gaya Kishangunj

Purnia Saran Vaishali

Total

BCG PHCs stock available for next week

As reported As per calculation

33

21

51

24

32

4 3

1 1

--

20 15

DPT PHCs stock available for next week


3-

2-

31

23

2-

4 1

1 -

--

17 5

OPV PHCs stock available for next week


31

2-

41

22

53

5 4

1 1

--

22 12

Measles PHCs stock available for next week


31

21

22

23

3-

4 2

1 1

--

17 10

TT PHCs stock available for next week


32

21

1-

24

3-

4 1

1 1

--

16 9

Total number of PHC 15 18 11 22 9 14 16 19 124 3.1.2 Status of Vaccines in the Facility For complete coverage of immunization programme in the target population, it is assumed that vaccines for BCG, OPV, DPT, and measles are available with the health facility. Analysis of the same in the surveyed facilities indicates that 75 facilities did not store any vaccines in the facility. . These facilities are spread across all the surveyed districts. The reasons for not storing the vaccine in the facilities could be due to the poor electricity supply, as 31 facilities did not have regular electricity and 42 facilities electricity was not available. In other two facilities though electricity was there, ILR was not working. Among the 47 facilities in which vaccine was stored, 22 of them had all the vaccines in the facility, seven of them did not have any vaccine in the facility, while 18 of them had only partial vaccines. This was true for three PHCs each in Begusarai and Vaishali, and two PHCs each in Aurangabad, Bhagalpur and Kishanganj district and six PHCs in Purnia district.


16

Table 3.3: Position of vaccines in PHCs (Number)

Name of the Districts Vaccine storage in facilities Auranga-

badBegu-sarai

Bhagal-pur

Gaya Kishan-gunj


No. of PHCs surveyed with complete data 15 18 11 22* 9 14

16

19 124*

No vaccine stored in the facility Vaccines stored in the facility No vaccines are available on the day of field visit All vaccines were available Partial vaccines were available

87

232

153

--3

29

162

128

26-

36

132

59

126

14 2

- 2 -

16 3

- - 3

7547

72218

* 2 facilities observation was not possible

3.1.3 Status of Vitamin A in Sub-Centre Out of the 122 sub-centers surveyed only 94 of them had Vitamin A solution on the day of survey. The average number of bottles available per facility varied from 15 bottles in Purnia to 787 bottles in Begusarai. Vaccine carriers were available in 101 sub-centers only. In Aurangabad and Purnia district while all the sub-centers had the vaccine carrier, in Begusarai only 35 percent of the facilities had the same. Table 3.4: Position of Vitamin A and vaccine carrier in sub-centers (Mean and Number)

Name of the Districts Indicator Auranga-

badBegu-sarai

Bhagal-pur

Gaya Kishan-gunj


Number of sub-centres having Vitamin A solution 14 10 10 12 10 11

13

14 94

Average number of vitamin A solutions bottles available 219.4 787.3 338.4 151.8 19.1 14.8

63.1

19.2 194.5

Number of SCs having vaccine carrier 15 6 13 13 8 15

17

14 101

Total number of sub-centres 15 17 14 17 11 15 18 15 122 3.1.4 Cold Chain Quality From the programme point of view it is essential that the PHC should have the vaccine as well as they should be kept in the cold storage as per their norm. This is essential to ensure the potency of the vaccines. Any deviation from this might negatively influence the potency of the vaccine. As is evident from Table 3.5 though a certain number of PHCs have the vaccines, not all of them are stocking it as per the norm. For instance in 31 PHCs, BCG was available, but as per the norm it has to be kept in ILR and this was evident in only 15 PHCs. Storage of OPV, DPT, and Measles vaccine as per norm was evident in only 26, 16 and 17 facilities respectively. Facilities deviating from the norm should be looked into for the maintenance of potency of the vaccine.


17

Table 3.5: Availability of vaccines and its place of storage (Number) Name of the Districts Indicators

Auranga-bad

Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Number of PHCs where BCG

Kept as per norm in ILR Kept in deep freezer Kept in cold box Not stored Not observed

221

10-

-2-

16-

71-21

132

133

2-25-

2 - 1

11 -

1 1 -

14 -

--1

18-

1597

894

OPV Kept in ILR Kept as per norm in deep freezer Kept in cold box Not stored Not observed

3

219-

1

1-

16-

2

7-2-

-

42

133

1

5-3-

2

5 1 6 -

-

2 -

14 -

-

-1

18-

9

265

813

DPT Kept as per norm in ILR Kept in deep freezer Kept in cold box Not stored Not observed

3318-

11-

16-

71-21

14232

1125-

2 - 1

11 -

1 1 -

14 -

--1

18-

1611

787

3Measles

Kept in ILR Kept as per norm in deep freezer Kept in cold box Not stored Not observed

3

318-

1

1-

16-

5

3-21

-

42

133

1

125-

-

2 1

11 -

-

2 -

14 -

-

11

17-

10

177

864

Total number of PHC 15 18 11 22 9 14 16 19 124 For the storage of vaccine effectively either in ILR and/or deep freezer it is imperative that the PHC should have regular supply of electricity or generator facility. Analysis of the same indicates (Table 3.6) that only 56 percent of the PHC mentioned of having electricity connection. The distribution of this varied from 31 percent in Saran to 82 percent in Bhagalpur. Among these only six percent of the PHCs reported that they had regular supply of electricity. Facilities having irregular supply were probed for the average hours for which they receive electricity. Data indicates that electricity was available here for only around three hours during the day and in the evening/nights. On the day of data collection in the facility, electricity was available in only 12 of the 124 assessed PHCs (that is 10 percent). Out of the total 124 PHC surveyed, 68 percent of them had a generator facility, though only 47 percent of PHCs had a generator in working condition. Source of fund to manage the fuel for the generator was the government in 17 percent of the PHCs, 24 percent of them reported UNICEF fund and 23 percent of them managed it from other sources. On an average, generators would have to run 3-4 hours a day to make up the required 8 hours day power supply. In three districts, there is less than 4 hours of mains power supply a day, making it difficult to make up the balance power requirement using a generator set.


18

Table 3.6: Status of electricity/generator in PHC (Percentage) Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


Percentage of PHC having electricity connection regular supply of electricity

66.720.0

38.9-

81.827.3

63.64.5

55.6-

64.3-

31.3

-

52.6

- 55.6

5.6Average hours of electricity available in facilities having irregular electricity

During day During evening/ night

2.63.2

1.31.3

4.63.8

3.13.8

3.03.0

2.12.5

2.5 1.5

2.7 1.8

2.82.8

Percentage of PHCs having electricity on the day of teams visit to the facility 6.7 - 27.3 9.1 22.2 7.1

-

15.8 9.7

Percentage of PHCs having generator In working condition Not in working condition

66.7-

38.95.6

63.618.2

40.936.4

66.722.2

50.021.4

37.5 31.3

31.6 26.3

46.821.0

Source of fund for POL of generator Government fund UNICEF Others

13.326.726.7

22.211.1

5.6

54.527.3

-

4.536.436.3

33.333.3

-

14.3-

57.1

18.8 18.8 25.0

-

36.8 15.8

16.924.222.6

Total number of PHC 15 18 11 22 9 14 16 19 124 3.1.5 Injection Safety ANMs need sterile syringes/needles for immunization. Out of 139 ANMs, 47 percent reported that they use disposable syringes, while 20 percent reported the use of Auto-disabled (A.D.) syringe for non-BCG immunization injections. About 30 percent of the ANM reported that she used sterilized needles. For providing BCG vaccination, 22 percent ANMs reported that they use A.D. syringe, while 32 percent reported that they use disposable syringes. Table 3.7: Type of syringes/needles used by ANMs

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


N N N N N N N N N % Kind of syringes/needles used for NON-BCG vaccines Sterilized needles/ syringes Disposable AD syringes Others Total

1 4

13 0

18

6914

20

413

10

18

04

120

16

11600

17

5910

15

8 11

0 0

19

7 9 0 0

16

42 65 28

4 139

30.246.820.1

2.9100.0

Kind of syringes/needles used for BCG vaccines Sterilized needles/syringes Disposable AD syringes Others Total

1 2

15 0

18

9614

20

8910

18

03

130

16

14300

17

8610

15

13 6 0 0

19

6 9 0 1

16

59 44 31

5 139

42.431.722.3

3.6100.0

No. of ANM heard of AD syringes

14 6 10 15 5 3

0

2

55 39.6

No. of ANM who have ever used AD syringes

14 4 3 15 2 1

0

1

40 28.7

Except for ANM in Saran, 40 percent of the ANM had heard of A.D syringes and 29 percent had seen it. Regarding its disposal, small percent of them mentioned that they burn it (5 percent) or cut the hub and bury it (5 percent), or bury it in pit (4 percent) or thrown out (4 percent).


19

3.1.6 Mode of Collecting Vaccines The vaccine supplies reach the Block PHC/PHC weekly rather than monthly due to the problems in electricity supply and availability of cold chain. These are usually supplied by Tuesday evening and the ANM has to collect the same for the routine immunization programme to be held on Wednesday. It is this collection by the ANM from the PHC till its actual utilization in the immunization session, which differs across the facilities. In most cases, ANMs collect the vaccine from the PHC on Tuesday and takes it to the immunization session the next day from her residence. The mode of carrying the vaccine from the PHC till it is utilized for immunization was further understood from the ANM. Ninety percent (125 ANMs) out of the total 139 did mention that they go and get the vaccine from the PHC. Five ANMs report that they send someone to PHC to collect the vaccine, and the remaining ANMs reported that the PHC delivers the vaccine at the sub-center or in the immunization session. Ninety-four percent (131 ANM) of them did also mention that the vaccine was carried in thermocol, vaccine carrier/ice box. Probing into the time required from collection of vaccines to administering it to the child was reported to be on an average 13 hours (table 3.8). District wise the average time varied from eight hours in Begusarai to 16 hours in Gaya. Minimum time was reported to be two hours as reported in Kishangunj district and the maximum time reported was 28 hours in Gaya district. All the ANMs were asked what they do with the unused vials, if any. Seventy-one percent (99) of the ANMs out of 139 reported that they return the same to the PHC. Probing further on the partially used vials 23 ANMs reported that they throw it away and a small number, six ANMs, reported that they keep it at somebody’s else’s refrigerator and one mentioned she use it again. Table 3.8: Time required for collection of vaccine and handling of unused vials

Name of the Districts Indicator Auran- gabad

Begu-sarai

Bhagal-pur

Gaya Kishangunj


Time to collect vaccines until use(Hrs) Average Standard deviation Minimum Maximum

14.6 7.9 5.0

25.0

8.24.95.0

24.0

14.29.54.0

26.0

16.48.73.0

28.0

9.25.32.0

23.0

9.0 3.3 6.0

16.0

15.8 8.0 5.0

26.0

14.77.45.0

24.0

12.97.72.0

28.0Unused vials (Number) Disposed Returned to PHC Used Never happened so far

4

13 - 1

213

-5

115

2-

7621

314

--

2

13 - -

2

14 3 -

211

21

2399

98

Total number of ANMs 18 20 18 16 17 15 19 16 139

3.2 ACCESSIBILITY OF IMMUNIZATION SESSIONS In addition to the availability of essential vaccines, it is essential that the same are accessible to the community through planned, fixed immunization sessions. An attempt has been made to understand this at various level of the health facility as well as village level, in the following discussion. 3.2.1 Immunization Sessions Details were gathered from the ANM regarding how they plan and conduct immunization sessions in their area. Hundred and nine ANMs reported that they have fixed day immunization. While 14 ANMs mentioned that they follow work plan for immunization programme. The remaining ANMs mentioned that they inform the AWW and take their help in organizing the immunization sessions.


Table 3.9: Background of ANMs (Number) Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


No. of ANMs covered 18 20 18 16 17 15 19 16 139No. of ANMs received field training 13 20 11 12 10 13 16 15 110No. of ANMs staying in the quarter 1 - 3 - 3 2 2 1 12No. of ANMs in the SC head quarter villages 5 2 3 1 4

3

3

3 24

No. of ANMs having fixed days immunization 17 16 10 13 13

8

19

13 109

Average number of villages having more than 1000 population covered by ANM where immunization session was conducted in last three months

2.6

2.5

2.1

1.1

2.8

2.3

3.2

2.4

3.7

3.0

3.8

2.1

2.7

1.9

2.8

2.0

2.9

2.1Average number of villages having less than 1,000 population covered by ANM where immunization session was conducted in last three months

2.8

1.9

2.8

1.3

2.7

2.3

3.8

2.9

5.4

3.1

2.1

1.3

1.8

1.3

2.4

1.6

3.0

1.9 3.2.2 Access to Sessions All the ANMs were asked about the number of villages they conduct immunization programme in a month. Probing on the coverage of villages by their size to assess whether the ANMs actually covers only the large size village or also the smaller villages which are usually remote and accessibility is difficult. Data reveals that on an average ANMs covers around three villages that have more than 1000 population among which on an average two villages were covered in the last three months. Coverage of the small villages (having population less than 1000) was also around three per ANM. Average number of villages among these in which the immunization sessions were conducted in the last three months was slightly less than two villages per ANM, constituting around 62 percent. To a small extent ANM have the tendency to avoid small villages from immunization session (Table 3.9). Conducting routine immunization sessions in the villages, ANMs encounter various kinds of problems which are apparently both at the facility level as well as in the community (Box 1). In continuation to this the ANMs were also asked how do they motivate mothers to come to the immunization sessions. A positive attitude and motivation of the ANM will equip her to have strategies to reach to the mothers. Some of the strategies used include: providing detail information, visits house to house etc. (Box 2).

BOX 2 Strategies used to motivate mothers to come to immunization clinic mentioned by interviewed ANMs • Talk about the importance of the disease it

prevents • Go house to house and explain • Explain that it is for the health of the child • Explain them and household members about the

importance of immunization and call them at stipulated place for immunization

• Motivate mothers during their field visit

BOX 1 Problems encountered in conducting routine immunization session • People are mainly illiterate; it is difficult to

convince them • People believe that due to immunization, children

get temperature, wound • No sitting arrangement at the facility, no support

staff available • There are problems in bringing the vaccine from

the PHC Some people believe this is from government and hence vaccines are not of good quality

20


21

3.2.3 Access at the Village Level Out of the 244 villages and hamlets surveyed, immunization session were reported to be conducted in 58 percent (142) of the villages. In around two-fifths (37 percent) of the villages, these sessions were held at the sub-centre. This was 53 percent in Bhagalpur district and 23 percent in Kishanganj district. Some of the other sites used for immunization sessions included school (21 percent) and anganwadi center (13 percent). Regarding the frequency at which these sessions were conducted, around half (47 percent) of them did mention that it was held once in a month. However, in 14 percent of the villages the frequency mentioned varies between two to three months, less frequently and rarely, as the immunization status of the children in these villages will be affected. Further probing on whether the place of immunization is accessible to all the sections of the community. In 63 villages (44 percent) some section of the community did not have accessibility to the immunization session. Table 3.10: Status of immunization sessions (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


% of villages in which immunization session conducted

64.5 51.6 63.3 53.3 41.9

64.5

66.7 60.0 58.2

Place where the immuni-zation sessions are held Sub-centre School Anganwadi APHC/PHC Any household in the village Other

12.919.416.1

6.5-

9.7

25.86.5

--

3.216.1

33.3-

3.33.3

-23.3

23.310.013.3

--

6.7

9.716.112.9

3.3--

22.6 25.8

- 9.7

- 6.5

20.0 9.9 3.3 9.9 9.9

13.3

26.79.9

13.3--

9.9

21.712.3

7.84.11.6

10.7Frequency at which sessions conducted Once in a week Once in a month Once in 2-3 months Less frequently/not fixed/ rarely Other

12.951.6

---

12.99.79.76.5

12.9

23.330.0

3.33.33.3

23.329.0

---

-22.6

9.79.7

-

12.9 29.0 19.4

- -

39.9 16.7

6.7 -

3.3

26.726.7

6.7-

3.3

18.927.0

7.01.22.9

Immunization place accessible to all sections of the community 61.3 51.6 60.0 46.7 41.9

64.5

66.7 53.3 55.7

Total number of villages 31 31 30 30 31 31 30 30 244 Related to the accessibility of the services is also accessibility of the health facilities in these villages were also analyzed. In Bihar, 244 villages were surveyed. The average distance to the nearest town among the surveyed villages was found to be 13.4 kms. Sub-centre and PHC were present in 39 and eight percent of sampled villages respectively; private doctors were available in seven percent (16 villages) of the villages. Among the eight districts comparatively more villages in Kishanganj did not have any health facility. Health committees were there only in three percent of the villages. For 58 percent of the villages sub-center was the nearest government health facility while for 35 percent of the villages, PHC was the nearest public health center. Thirty-four villages reported that the nearest government health facilities were not accessible in all the seasons.


Table 3.11: Health facilities available in the villages (Mean and Percentages) Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


Average No. traditional birth attendants available 2.7 4.7 2.3 3.3 1.8 2.7

4.6

5.5 3.4

Average No. of medical shops available 0.6 2.1 1.7 0.4 0.6 1.0

2.3

3.0 1.5

Distribution of villages by the type of health facilities None Sub-centre PHC Private doctor ANM visits the village Other

51.616.1

3.23.2

25.8-

22.651.6

3.26.4

35.53.2

43.356.7

6.710.030.0

3.3

36.746.7

3.33.3

26.73.3

74.29.7

-3.2

12.9-

48.435.512.9

3.23.2

-

20.0 43.3 23.3 10.0 23.3

6.7

23.3 50.0 13.3 13.3 16.7

-

40.238.9

8.26.6

21.72.0

Villages that have any health committee 3.2 3.2 6.7 - - 3.2

-

3.3 2.5

Nearest government health facility from the village Sub center Primary health center Community health centre District hospital Other

71.025.8

-3.2

-

74.222.6

-3.2

-

76.720.0

-3.3

30.0

33.363.3

3.3--

61.332.3

3.2-

3.2

54.835.5

3.2-

6.4

36.7 50.6

- 6.7

13.3

63.3 33.3

- -

3.3

58.235.2

1.22.03.3

Total number of villages 31 31 30 30 31 31 30 30 244 Average distance to nearest govt. health facility was found to be three kilometers (Table 3.12). It varied from one km in Bhagalpur to five kms each in Gaya and Saran. Access to these health facilities was mainly on foot followed by bicycle. In 230 villages there was no bus facility to nearby health facility. Table 3.12: Distance and mode of accessibility to Health facility (Mean and Percentages)


Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


Average distance to the nearest government health facility (in kms) 3.3 2.2 1.3 4.8 4.1 2.8

4.6

2.0 3.1

Mode of accessibility to the health facility Bus/minibus Private vehicle Train On bicycle On foot Other

9.79.7

-67.796.8

3.2

9.716.1

3.287.1

100.09.7

---

40.0100.013.3

10.020.0

-76.7

100.06.7

-19.4

3.293.593.5

6.5

3.219.4

-64.587.119.4

10.0 20.0

3.3 83.3 86.7 26.7

3.3 26.7

- 83.3 93.3 16.3

5.716.4

1.274.694.712.7

Total number of villages 31 31 30 30 31 31 30 30 244 3.2.4 Health Personnel who Makes the Services Accessible

22

As per the norm each Auxiliary Nurse Midwife (ANM) has certain areas assigned to her. She is responsible for the care and management of health services in this area with special emphasis to the health of the pregnant mothers and children. During the study a total of 139 ANMs were interviewed. Brief characteristic of the ANM is provided in Box 3.

Characteristic of ANMs • Mean age of ANM• Average populatio• Twenty-two ANM• Twelve ANMs

quarters • Seventy-seven AN • Average distance f

7 kms

BOX-3

s was 40 years n covered was 7,846 s were provided with quarter were actually staying in the

Ms reside in neighboring village rom sub-center to residence was


3.2.5 Linkages with Anganwadi Worker with access: Villages do have an Anganwadi worker who is in constant touch with the community especially mothers with young children. Contact with her by the ANM should make the Immunization services more accessible to the community. It was in this context that the ANM were asked whether they have advance tour programme and share it with Anganwadi workers. One hundred twenty six ANMs responded positively, among these 73 (53 percent) of them did mention that they do share their advance tour programme with the Anganwadi worker. Six ANMs from Bhagalpur and four from Purnia reported that they do not share the program. Such positive linkages at the village level should help in increasing the accessibility to immunization services. 3.3 UTILIZATION AND ADEQUATE COVERAGE It is well established that by vaccinating children against the six killer diseases, infant mortality and morbidity will decline. Hence in the study area status of immunization of children aged 12-23 months was collected. As per the study design a total of 1920 mothers of children aged 12-23 months were interviewed from the selected districts with 240 from each district. 3.3.1 Immunization Practice Information was gathered from the 1920 mothers on various details regarding immunization like details about the immunization card, vaccine that the child had received, if provided at what age it was provided, source of immunization, etc.

Figure 3.1: Percent of mothers who have immunization card

43

37

38

38

17

56

59

44

0 10 20 30 40 50 6

Aurangabad

Begusarai

Bhagalpur

Gaya

Kishanganj

Purnia

Saran

Vaishali

Total

62

0

As observed from Figure 3.1 only 44 percent of the mothers reported having an immunization card. This was highest at 62 percent in Saran and lowest (17 percent) in Kishangunj. Regarding the utilization of immunization services, as the data in the Table 3.13 indicates that this varied across the vaccines and across the districts. Analyzing the same vaccine wise shows that 52 percent of children had received BCG vaccination. Among the eight districts, the proportion of children who received BCG was lower in Kishanganj (17 percent) than the other districts. Regarding DPT coverage, around 52 percent of the children had received DPT 1, while 44 percent and 36 percent received DPT 2 and 3 respectively; a drop out of 16 percent from the first to the third dose. Coverage of this vaccination was lowest in Kishanganj, but the drop out from the first to the third dose was observed more often in Vaishali district. The percentage of children who received polio '0' shows that only 22 percent of the study population had received it. This was comparatively low in Bhagalpur district. The coverage of Polio I dose to III dose decreased from 52 percent for Polio I dose to 36 percent for Polio III; a drop out of 16 percent. This drop out was higher in Vaishali district than in other districts. About 26 percent of the children in the study area had received Measles vaccination. If we look into Vitamin A Prophylaxis, about 28 percent of the children had received at least one dose of vitamin A. Overall, in the study area 57 percent of children received at least one vaccine.

23


24

Table 3.13 Type of vaccines received by children Name of the Districts Background characteristics

Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


% of Children received BCG 51.7 46.7 57.9 44.6 16.7 63.8 69.6 65.4 52.0% of Children received DPT I DPT II DPT III

54.245.438.8

47.138.330.4

51.343.337.5

47.139.231.7

17.110.4

7.5

62.955.045.4

69.6 61.7 50.8

65.4 54.6 44.2

51.843.535.8

% of Children received Polio ‘O’ Polio I Polio II Polio III

22.954.245.038.8

24.648.840.831.3

17.153.844.640.0

20.046.339.231.3

12.117.510.4

7.5

29.262.955.045.4

24.6 67.9 60.8 49.6

25.0 64.2 54.2 45.4

21.951.943.836.1

% of Children received Measles 24.6 20.4 28.3 26.3 6.3 35.4 34.6 32.1 26.0% of Children received Vit. A 22.1 24.2 37.9 24.2 22.5 33.8 25.8 31.7 27.8Total number of children (12-23 months) 240 240 240 240 240 240

240

240 1920

The data indicates that in the study area only 23 percent of the children were fully immunized (BCG, DPT, OPV, Measles). This varies from five percent in Kishanganj district to 32 percent in Purnia district. The percentage of partially immunized children was 57 percent. In other words the immunization programme had at some point or the other had reached these children, but had failed to contact them for the required subsequent doses. Forty-four percent of the children have still not been reached for any vaccine. This was highest at 80 percent in Kishanganj district and lowest at 27 percent in Saran district. Taking into consideration the Immunization Plus Programme, if we look into the status of complete immunization of children with vitamin A , the percentage drops to 15 percent, while the partially immunized increases slightly, apparently because Vitamin A was given. Table 3.14: Status of children’s immunization (Percentage)

Name of the Districts Percentage of children who received Auran-

gabadBegu-sarai

Bhagal-pur

Gaya Kishan-ganj


No Immunization 42.9 47.1 36.3 50.4 80.0 34.2 27.1 30.0 43.5At least one immunization 57.1 52.9 63.8 49.6 20.0 65.8 72.9 70.0 56.5Complete immunization 23.3 15.4 25.4 22.5 4.6 31.7 31.3 28.3 22.8At least one immunization +Vit ‘A’ 58.8 57.5 70.8 52.5 31.7 68.3 74.2 72.5 60.8Complete immunization + Vit ‘A’ 14.6 10.0 17.1 15.4 4.6 22.9 17.9 17.9 15.1Total number of children (12-23 months) 240 240 240 240 240 240

240

240 1920

3.3.2 Client Perception of Immunization Accessibility to health facility even if it is available will be under utilized if the users are not aware of the problem. In this case of immunization, if mothers do not have the required knowledge on the need of getting their children immunized, it might act as a barrier, especially in the absences of health services reaching them at their door steps. In light of this, as per the study design 1920 mothers who had delivered 12 months prior to the date of survey were interviewed. In addition to other details, their knowledge about immunization was also assessed. Knowledge of Immunization All the respondents were asked if they were aware that to protect children from disease, they should be immunized. Data indicates that about 79 percent of the mothers are aware about it. All these mothers who were aware about


immunization were further asked about the source of their information. Twenty three percent of the respondents reported that ANM/Health workers were their source of information. Three percent mentioned that they came to know about immunization through Anganwadi worker. Negligible percent of the mothers came to know about immunization through their family members. All those mothers who mentioned that they do not know about immunization were asked whether they know that on certain days health workers come and provide injections/ and put drops in the children mouth. About 10 percent reported positively.

25

BOX 4 Reasons for not immunizing • Not aware about immunization • Not aware of the place of immunization • Immunization not carried out in the village • Child was not keeping well • Place too far • Opposition from family member

Reasons for not immunizing: All 1920 mothers whose children had not been given any immunization were asked the reasons for the same. Analysis of the same indicates varied kind of response. Some of the main reasons includes that they were not aware about immunization, immunization not carried out in the village, child was sick on the day of immunization, etc. Overall the reasons do point out the need to address the community on the importance of immunization and remove the misconceptions regarding it. They will have to be told where and when the same are available. Simultaneously the access issues also needs to be strengthened. 3.3.3 Socioeconomic Comparison of Immunization Coverage Further analysis of the socio-economic characteristics of children not immunized by any vaccine, partially immunized and completely immunized is presented in Table 3.15. It is evident from the table that the percent of completely immunized children was lower among Muslim population as compared with Hindu and other religious groups. (District by district breakdowns are annexed.) Status of immunization improves with mother literacy, as complete immunization of children was 42 percent when the child's mother was literate while the same was only 15 percent for illiterate mothers. While looking into exposure to any media, complete immunization was 33 percent among those who were exposed to any media while it was only 17 percent among those who were not exposed to any media. Similarly complete immunization in villages where immunization sessions were held was 25 percent while it was 19 percent in villages where no sessions were held. Chi-square tests show relation between religion, education of mother, exposure to media, availability of health facility within the village,

Table 3.15: Status of immunization by selected indicators Back ground characteristics

Percent Not

immunized

Percent Partially

Immunized

Percent Completely Immunized

Total

Mothers Religion χ2 42.42 Hindu 36.5 37.6 25.9 1497 Muslims 67.9 20.0 12.1 420 Others 100.0 - - 3 Education level of mother χ2 83.15 Illiterate 52.7 32.0 15.3 1386 Literate 19.7 38.0 42.3 534 Exposure of mothers to any media χ2 54.56 Exposed to any media

31.3

35.5

33.2

699

Not exposed to any media

50.5

32.7

16.9

1221

Health facility within the village χ2 35.26 Available 32.5 39.4 28.1 944 Not available 54.1 28.2 17.7 976 Immunization session in the village χ2 35.26 Yes 37.3 37.4 25.3 1136 No 22.4 28.3 19.3 784 Total 43.5 33.7 22.8 1920


26

availability of immunization sessions in the village and immunization to be highly significant. 3.4 EFFECTIVE COVERAGE Correct and complete knowledge of immunization will help the ANM in reaching out her services to the target group effectively. In case of immunization, it is essential that the ANM is aware about the disease which the vaccine prevents, number of doses a child should receive to be completely protected, age at which the first dose of immunization should be given and the route of administration. Analysis of the same is presented in Table 3.15. It is evident that 32 ANMs were having the correct knowledge on the details of all immunizations. Eighty-one of them had correct knowledge on at least one immunization. Still there is a need to ensure that the ANMs have the requisite information, as it will strengthen them to provide the services adequately. Table 3.16: ANMs knowledge on immunization (Number)


Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


Number of ANMs correctly knows

the name of all the six diseases which the vaccine prevents

the no. of doses for each of the four vaccines

the schedule of the first dose for all four vaccines

route of administration of vaccines

4

4

2

9

-

8

1

9

8

3

1

8

3

6

6

11

7

9

12

13

4

5

6

4

3

2

2

10

3

5

4

9

32

42

34

73ANM has correct knowledge on the name of disease prevented, no of doses, age of first dose and route of administration for

BCG OPV DPT Measles

16161511

14151515

18141716

12121411

12141311

11878

17 17 15 11

15 14 14

7

11511011064

No of ANMs who correctly knows all the details of

All the four vaccinations Knows about at least one vaccination

-

15

-

4

-

6

-

13

2

14

1

9

-

12

1

8

4

81Number of ANMs reporting the conditions are contra indication for vaccination Pre-term/low-birth weight Mild diarrhoea Seizure following previous immunization Minor low grade fever

95

85

1112

912

99

510

117

49

35

85

65

67

4 7

9 9

7 8

9 5

6058

5862

Total number of ANM 18 20 18 16 17 15 19 16 139 In addition to the details of the vaccines, ANMs were also asked whether they were aware about the conditions that are contraindications for vaccination. In this case too, as the data (Table 3.16) indicates 60 and 58 ANMs were having the wrong knowledge that immunization should not be given to a pre-term/low birth weight baby and a child suffering with mild diarrhoea respectively. However, 58 of them had correct knowledge that seizure following previous immunization was contraindication.


3.5 TIMING OF IMMUNIZATION As seen earlier the data shows that 52 percent of the total children had received BCG, whereas only 16 percent received BCG within one month of age. Similarly only 12 percent each of the children received three doses of DPT and polio and 11 percent received the measles doses at the correct age. Table 3.17: Percentage of children who received immunization as per schedule (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-ganj


% of children received vaccination at the correct age for BCG Three doses of DPT Three doses of Polio Measles

17.114.614.212.5

14.27.98.87.9

9.29.6

10.07.5

19.613.312.510.8

7.53.32.92.5

21.7 18.8 19.2 19.2

15.0 13.8 12.9 12.1

19.615.015.412.9

15.512.012.010.7

Total number of children (12-23 months) 240 240 240 240 240

240

240 240 1920

3.6 REVIEW OF IMMUNIZATION BOTTLENECKS

27

Figure 3.2: Immunization status

80

58

57

23

4

0 20 40 60 80 100

Percent of PHCs having allvaccines

Percent of villages reporting regularsession

Percent of children had anyvaccination

Percent of children completelyimmunized

Percent of children immunized atright age

Percent

Hence, understanding the immunization services in the study district in terms of its availability (vaccines in the PHC), accessibility (villages with regular immunization sessions), utilization (children received at least one vaccination), adequate (children received complete vaccination) and effective coverage (children received complete immunization as per schedule), as seen from the figure here, there is a wide gap between the supply of vaccines and timely, full immunization coverage. Though the programme has reached out to slightly more than half of the target population, it has not been successful to follow this population for follow-up services, hence the biggest bottlenecks appear to be in availability of vaccines, tracing drop-outs and ensuring correct timing of immunization. Initial contacts of the service should be utilized to inform the community about the need of subsequent services available and importance of it.

4

Ante-natal/Natal and Post-natal

Infant mortality rate is an important indicator as it reflects the status of survival of children. Part of the infant mortality rate is the neo-natal mortality, which constitutes almost two-thirds of all deaths during infancy. These deaths can be best avoided if deliveries are held in hospitals under medical supervision. This study made an attempt to understand the situation of ante-natal, natal and post-natal services sought by 1920 mothers spread across eight study districts of Bihar. The mothers interviewed for the study had a child less than twelve months as on the date of survey. This chapter presents the findings from the same. As in the earlier chapter, in this case too an attempt has been made to understand the services by taking the minimum bottleneck approach of Tanahashi this basically includes availability of services, accessibility, utilization, adequate and effective coverage. As per the information available in the study tools each of these components have been assessed for ante-natal, natal and post-natal care. 4.1 AVAILABILITY OF SERVICES Iron Folic tablets: As per national norms all pregnant women should consume at least 100 IFA tablets regularly. Hence, availability of these IFA tablets in the facility becomes crucial.

Table 4.1: Status of Iron folic tablets at the PHC (Number)

Name of the Districts Indicator Auran- gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


No. of PHC stock IFA Large tablets Small tablets

12 12

1010

77

2121

99

1414

13 13

16 16

102102

Stock of IFA tablets large (on the day of survey) Average number Standard deviation Minimum Maximum

19341.7 14977

- 34000

17835.016233

75045000

2431.45592

-15000

22495.238821

-180000

100244.492779

6400300000

133905.7212307

-654000

13195.8 18606

- 52500

49426.9 61553

- 255000

45481.696531

-654000

Stock of IFA tablets small (on the day of survey Average number Standard deviation Minimum Maximum

14166.7 11606

- 27000

14925.014198

75039000

3857.16256

-13000

20981.933962

-156000

131711.1114907

3900311000

133692.1227556

-770000

10017.9 15265

- 52500

35061.3 53111

- 221000

44462.5103893

-770000

Total Number of PHC 15 18 11 22 9 14 16 19 124

Out of the 124 PHC surveyed, 102 (82.3) PHCs had stock of IFA tablets on the day of data collection (Table 4.1). This included the presence of both large (100 mg) and small tablets (50 mg). The average stock available at the PHC was 45,482 tablets and 44,463 for large and small size tablets respectively. The availability of these tablets varies widely across the facilities. On the day of visit there were certain facilities which did not have any stock, while the maximum number ranged even up to 6,54,000 and 7,70,000 for large and small size tablets respectively.


Medical officers were asked whether the available quantity is sufficient for the next week, it was reported that the stock was sufficient in 80 PHC (62 percent). However, analysing the sufficiency of IFA stock available in the facility as per the norm, it was observed that only 71 PHC (55 percent) had sufficient stock (Figure 4.1). Sufficiency of the IFA stock per week was calculated considering the number of pregnant women per thousand populations including pregnancy wastage and the norm that women should consume minimum of 100 tablets per pregnancy.

In the three tier health system, sub-centers are at the lowest level and relatively more accessible to the community. Assessing the same stock in the 122 sub-centers surveyed, data reveal that 108 (89 percent) sub-centers had large IFA tablets with an average stock of 12,990 tablets per facility. Whereas only 106 sub-centre had small IFA tablets with an average 15,007 tablets per facility. In this case too there was a wide dispersion in the stock available at the facility, for instance the distribution for large tablets ranged from minimum 10 to maximum 75000, while the same for small tablets was 13 to 2,50,000 within the facilities of same district. Overall the data does indicate that to a large extent stock is available at the sub-center level too (Table 4.2). Table 4.2: Status of Iron folic tablets at the Sub-centre (Number)

30

Name of the Districts Indicator Auran gabad

Begu-sarai

Bhag alpur

Gaya Kishangunj

Purnia Saran Vais hali

Total

No. of sub-center stock IFA Large tablets Small tablets

15 15

1614

1111

1515

1010

1213

15 15

14 13

108 106

Stock of IFA tablets large (on the day of survey Average number Standard deviation Minimum Maximum

15101.3 10018.0

1000 35000

11198.111697.6

1044460

13892.521683.5

1775000

18310.014385.7

50043000

19870.025090.8

100070000

10847.510566.9

270030000

6268.0 6480.5

300 15000

10494.3 6752.9

720 23370

12990.4 14001.6

10 75000

Stock of IFA tablets small (on the day of survey Average number Standard deviation Minimum Maximum

13040.0 9170.8

1300 30000

13892.913427.0

110049000

35416.673430.5

13250000

17529.315001.2

35055000

19790.024280.5

100065000

9215.07507.2

18526000

6050.0 5441.9

50 13000

10744.3 6013.9

1000 25230

15007.0 26597.6

13 250000

Total number of sub centres

15 17 14 17 11 15

18

15 122

Figure 4.1: No. of Facilities Report/Having Sufficient Stock of IFA Tablets

16

19

11

22

10

16

16

20

8

10

3

14

9

13

10

13

8

8

2

14

9

10

7

13

0 5 10 15 20 25

Aurangabad

Begusarai

Bhagalpur

Gaya

Kishanganj

Purnia

Saran

Vaishali

Total PHC Reported sufficient stockCalculated sufficient stock

Chapter 4: Ante-natal/Natal and Post-natal

Disposable delivery kits (DDK): In the absence of institutional delivery it is essential to maintain at least the five cleans and use the delivery kits for home deliveries. Availability of these disposable delivery kits therefore becomes an important factor to ensure clean and safe delivery. Information was gathered on the situation of disposable delivery kits supplied to the sub-center in the previous twelve months and the stock available on the day of visit. It was found that practically DDK was not supplied to the sub-centers as only 10 (8 percent) sub-centres had got the supply of DDK in the past one year (Table 4.3). Among which on the day of survey only 5 (4 percent) sub-centres had DDK. In which the number of DDK varied from one to five DDK in the sub center. Table 4.3: Status of DDK in the sub centers (Number)


Begu-sarai

Bhagalpur

Gaya Kishangunj

Purnia Saran Vais hali

Total

No. of sub centers that had Received DDK in the past 12 months DDK on the day of visit

11

42

--

--

21

1 -

1 -

11

10

5 Stock of DDK Average number Standard deviation Minimum Maximum

1.0011

1.50.5

12

----

----

5.0055

- - - -

- - - -

1.0011

1.0

0 1 1

Total number of sub centres 15 17 14 17 11 15 18 15 122 4.2 ACCESSIBILITY OF SERVICES Deliveries conducted: Delivery at the health facility helps to ensure a safe delivery for the mother and child in case of any complication to the mother or the new born child the same can be attended to immediately. Out of 124 PHCs surveyed only 77 PHCs were conducting delivery. The distribution of these PHCs varies across the study districts (Figure 4.2). In Begusarai only 39 percent of the surveyed districts were conducting delivery.

31

Figure 4.3: No. of PHC indicating the trend of Deliveries Conducted in last One Year

0

5

2

1

2

0

0

0

2

0

2

6

4

2

3

0

5

2

1

2

0

0

0

1

0 2 4 6 8 10

Aurangabad

Begusarai

Bhagalpur

Gaya

Kishanganj

Purnia

Saran

Vaishali

SameNo. of PHC where deliveries conducted increasedNo. of PHC where deliveries conducted decreased

Figure 4.2: Percentage of PHC where where delivery conducted by distirct

63

50

93

44

73

55

39

73

0 10 20 30 40 50 60 70 80 90 100

Vaishali

Saran

Purnia

Kishangunj

Gaya

Bhagalpur

Begusarai

Aurnagabad


32

An attempt was also made to understand the volume of deliveries conducted in these facilities (Figure 4.3). From the fifty seven facilities for which the data was reported, on an average 33 deliveries were conducted per facility in three months. Comparing these data of the last three months that is March ’05 to May’05 with the same time frame in the year 2004, it was observed that in 27 facilities the number of deliveries conducted has decreased, where as in twenty it has increased. Distance to health facility: While availability of the services in the facility is important, it is equally important that they are located within reasonable reach of the target population who should benefit from it. As discussed in the earlier chapter the average distance to nearest health facility was 13 km. and this distance was more in Kishangunj. The average time to cover this distance varied from 35 minutes in Begusarai to one hour and 17 minutes in Gaya. 4.2.1 Status of health personnel’s accessible to community Facility level: The presence of doctors and/or para medics in the health facility for twenty four hours has an implication on the utilization of services. This is possible only when they are staying in the close vicinity of the facility. The study made an attempt to understand this. As table 4.2.1indicates in 65 PHCs (nearly half) it was reported that at least one doctor resides within PHC compound. This was four each in Bhagalpur and Kishanganj and eleven in Aurangabad, 10 in Begusarai, 13 in Gaya, eight in Purnia, nine in Saran and six in Vaishali. In 31 and 57 PHC at least one LHV/female health assistant and a ANM respectively were staying within the PHC premises. Village level: In rural areas, typically traditional birth attendants conduct most deliveries at home. TBAs can be trained in using DDK and help to ensure a clean delivery. But are they really available in all the villages? From the data collected during the study (Table 4.4), it was found that in 70 percent (171) of the villages out of the total 244 (4 link village) surveyed, traditional birth attendants were available. Thirteen villages each in Bhagalpur and Kishanganj and nine villages each in Aurangabad and Begusarai did not have any birth attendant staying within the village, whereas in Gaya, Purnia, Saran and Vaishali relatively more villages (11, 7, 5 and 6 respectively) did not have a traditional birth attendant. The presence of a qualified doctor was still worse as only five villages in Purnia and Saran and four village in Aurangabad and Bhagalpur, three villages in Begusarai and Kishanganj, two villages in Vaishali and one village in Gaya had at least one MBBS doctor staying in the villages (Table 4.4). Table 4.4 Access to health personnel (Number)

Name of the Districts Indicator Auran-gabad

Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


In the facility No. of PHC where at least one doctor resides in PHC compound LHV/female health assistant reside in PHC compound ANM

11

7 8

10

4 10

4

5 5

13

6 9

4 - 5

8

5 8

9

4 5

6 - 7

65

3157

Total number of PHC 15 18 11 22 9 14 16 19 124In the village No. of villages having at least one traditional birth attendant One qualified doctor (MBBS) within Village

22

4

22

3

17

4

19

1

18

3

24

5

25

5

24

2

171

27Total number of villages 31 31 30 30 31 31 30 30 244


ANM trained for conducting delivery: Given the accessibility of the ANM with the community, an ANM who has been trained for conducting delivery will be beneficial to the community. Findings from the 139 ANMs interviewed (Figure 4.4) reveals that only 38 (27 percent) ANMs had received this training in the last three years. All of them had found the training to be useful.

33

4.2.2 Community Perception on Accessibility of ANC Services At the community level all the mothers who had delivered in the twelve months prior to the survey were asked to opine on certain statements related to their opportunity, ability and motivation to seek services during pregnancy. Anlaysis of the same is presented in Table 4.5. Only 42 percent of the mothers mentioned that care for pregnant women was available within 30 minutes of walking distance from their house. This varied from 30 percent in Kishanganj district to 79 percent in Bhagalpur district. However a lesser percentage (38 percent) agreed that a healthcare provider who provides information on care during pregnancy is available within 30 minutes of walking distance (Table 4.5).

Figure 4.4: No. of ANMs trained for conducting delivery4

7

1

5

8

5

3

5

14

13

17

11

9

10

16

11

0 5 10 15 20 25

Aurangabad

Begusarai

Bhagalpur

Gaya

Kishanganj

Purnia

Saran

Vaishali

Trained Not trained

Table 4.5: Opinion of women on accessibility of ANC service (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Percentage of women Agreed that care for pregnant woman are available within 30 min walk Agreed that a health care provider who provides information on care during pregnancy is available within 30 min walk

35.8

32.1

42.5

39.2

78.8

66.3

37.5

38.8

30.1

25.5

43.4

42.5

37.5

30.5

32.5

27.5

42.3

37.8

Total number of women 240 240 240 240 240 240 240 240 1920 4. 3 UTILIZATION OF MATERNAL SERVICES ANC Details regarding ANC services sought were collected from 1920 mothers. As Table 4.6 reveals only 31 percent of the mothers reported that they had ANC checkups. In other words the majority, two-thirds of the women did not seek or receive any ANC services. This percentage varied from 40 percent in Bhagalpur to 25 percent in Saran. As per the recommended norm a pregnant woman should undertake a minimum of three check-ups. However, as the data indicates only 13 percent of the women reported that they had undergone three or more check ups. From the programme point of view it is also important that the woman should receive her first check up in the first trimester of pregnancy. Only 18 percent of the women had done this. Five percent of the women had gone for the first ANC check up only in the third trimester.


34

Probing further on the source of ANC checkups, data shows that 26 percent of them had their checkups from private doctors and only five percent got their checkups at government hospitals. Two percent and about one percent each availed the services from PHC and Sub-centre. About one percent of the women also availed the services from RMP, quacks, etc. Mothers need more iron during pregnancy and in India anaemia is a common and major ailment among pregnant and lactating women. Among the study population 30 percent of the mothers were given IFA tablets (Table 4.6). NFHS –2 reported this to be 24 percent. However, only 5 percent of mothers reported that they had received 100 + IFA tablets. In other words those women who do receive the IFA tablets do not receive the total amount as per the required norm. Twenty one percent of the mothers did report that they had consumed all the tablets received. The percentage of women who consumed more than 100 tablets was five percent. This data does indicate that to a large extent women do consume IFA tablets provided they receive the same. Table 4.6: Type of ANC services sought (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Percentage of women had at least 1 ANC check up 32.9 28.3 40.4 27.1 33.8

31.7

25.4 27.1 30.8

Number of ANC checkup sought by mothers 1 2 3 and above Don’t remember

10.89.2

12.50.4

8.89.69.60.8

12.95.8

20.91.3

7.15.4

13.71.7

12.510.412.9

-

10.4 10.0 11.3

0.8

6.7 7.9

10.5 0.8

7.96.3

12.11.3

9.68.1

12.90.9

Percent of mothers who went for 1st check ANC in First trimester Second trimester Third trimester

20.07.55.5

13.311.3

4.2

27.18.85.1

15.09.62.9

17.910.9

7.0

18.7 10.1

3.4

13.4 7.5 4.5

16.37.53.8

17.79.14.6

Source of ANC Checkups Sub-centre PHC Govt. Hosp. Private Doctor Others Don’t remember

-1.34.6

26.70.4

-

-0.41.7

25.80.4

2.91.72.9

31.31.30.4

1.33.31.3

20.8-

0.8

0.83.80.4

28.80.4

-

-

1.3 1.3

27.9 1.3

-

0.4 1.7 1.7

20.8 0.8

-

0.41.70.4

23.80.80.4

0.71.91.8

25.70.70.2

Iron folic tablet given Percent of mothers who were given Iron folic tablet Percent of mothers who got 100+ or more IFA tablets Do not remember

32.1

4.1-

26.7

4.6-

36.7

9.20.4

31.3

5.0-

19.6

5.00.4

35.4

3.8 0.4

26.7

5.5 -

30.4

5.41.7

29.8

5.30.4

Iron folic tablet consumed Percent of mothers consumed all the tablets Percent of mothers who consumed 100 or more tablets

22.1

4.2

16.7

4.6

24.6

9.2

19.2

5.0

15.0

5.0

27.5

3.8

18.8

5.0

23.3

5.4

20.9

5.3Tetanus toxoid injection Percent of mothers received one TT Percent of mothers received 2 or more TT

3.3

87.5

5.8

69.2

1.7

79.6

3.3

78.3

8.3

62.9

10.0

70.8

2.5

81.3

4.6

84.6

4.9

76.8Total number of women 240 240 240 240 240 240 240 240 1920


35

Box 1 Reasons for not taking IFA

• Due to side effects/ there were health

problems • Do not like • The tablet tastes bad/ it smells • Feel bad/nauseating after taking tablet • Forget to take • Relatives, in-laws object to my taking

One hundred and seventy three women who had not consumed all the IFA tablets that they had received were asked why they had not taken all the tablets. Varied reasons (see Box 1) were mentioned for the same. The reasons indicate that these women and their immediate family members should be sensitised on the need of consuming iron folic tablets during pregnancy. Compared to the above services sought during ANC, the coverage of tetanus toxoid injection during pregnancy was encouraging. Eighty percent of the women had received at least one TT injection, while 77 percent had received two or more TT injections. This is again an increase over the data reported in NFHS-2, which was 58 percent for the state. Among the eight study districts, the coverage was relatively better in Aurangabad district and relatively worse in Kishanganj district. Full Coverage of ANC by Background Characteristics of Mothers As promotion of maternal and child health has been one of the important components of the family welfare programme, it is essential that a pregnant woman should receive at least three ante-natal check ups, at least one tetanus toxoid injections and receive at least 100 IFA tablets. A pregnant woman receiving all these components is considered as having received `full ANC’ services, any services received other than this would be ‘partial ANC’ and those who have not received any services mentioned earlier are considered as ‘no ANC’. These data indicate that only two percent of the women had received full ANC services, 82 percent of the mothers had received some or the other services required during ANC, whereas 16 percent of the mothers had not been reached for any services during pregnancy. Analysing the same data by the background characteristic of the women, data (Table 4.7) shows that two percent of Hindus and one percent of Muslims had complete ANC care. Chi-square analysis shows religion has significant relation with ANC care (p<.01). Similarly, if we look into ANC care by education, the percentage of women having received complete ANC care was five percent in case of literate women and one percent in case of illiterate women. Twenty percent of the illiterate women had not taken any services during pregnancy. Further, availability of health facility within village also has significant relation with percentage of mothers who had received some or the other services during ANC. Table 4.7: Status of ANC services by selected indicators (Percentage) Back ground characteristics

Percent Not received any ANC

Percent Partially Received ANC

Percent Received full ANC

Total

Mother’s religion χ2 13.60 Hindu 14.2 83.4 2.4 1491 Muslims 21.0 77.9 1.2 429 Education level of mothers χ2 77.23 Illiterate 19.6 79.4 1.1 1381 Literate 5.8 89.4 4.8 539 Health facility within the village χ2 12.48 Available 12.7 85.0 2.3 944 Not available 18.5 79.5 1.9 976 Total number of women 15.7 82.2 2.1 1920 As discussed earlier, ANC service should at minimum consist of three ANC check-ups, at least one TT injection and 100 IFA tablets during pregnancy. Taking this as adequate coverage, the data was re-analysed to understand the coverage of pregnant mothers with respect to each component as well as taking all the three components together.


36

As discussed earlier, among the three components of ANC services the percentage of women seeking tetanus toxoid injections was the highest. Women need to be equally sensitised on the importance of going to health facility for ANC checkup and receiving IFA tablets. Considering all the three components together, it emerges that only two percent of the women have been adequately covered for all the said services. Sixty seven percent of the women have received at least one adequate service, the percentage decrease to 13 percent when two services are considered together. Table 4.8: Adequate coverage of ANC services (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Percentage of women who Went for 3 or more ANC visits Received 100+ IFA tablets Received at least one TT injection

12.54.2

90.8

9.64.6

75.4

20.89.2

81.3

13.85.0

81.7

11.75.0

71.3

11.3

3.8 80.8

10.4

5.0 83.8

12.15.4

89.2

12.8

5.3 81.8

No. of ANC services adequately taken by women No ANC care taken Taken ANC service but inadequate Any one adequate service Any two adequate service Any three adequate service

6.72.1

77.511.3

2.5

19.24.2

64.212.1

0.4

16.31.3

57.920.4

4.2

15.82.1

66.313.3

2.5

26.31.7

57.513.3

1.3

17.1 1.7

68.8 10.4

2.1

13.8 1.3

72.1 11.7

1.3

10.40.0

75.411.3

2.9

15.7 1.8

67.4 13.0

2.1 Total number of women 240 240 240 240 240 240 240 240 1920 Though the programme has identified a minimum service package for ANC, the coverage might be considered as effective if the woman has had at least three visits to the health facility with the first one being taken in the first trimester, has received 2 TT injections and consumed 100 or more IFA tablets. Taking these three components individually and together to understand effective coverage the data was re-analysed. As observed from Table 4.9, effective coverage for visit to the health facility was only 10 percent. This was 17 percent in Bhagalpur and seven percent in Begusarai. The percentage of women who consumed more than 100 IFA tablets was lowest in Begusarai at three percent and highest at six percent in Bhagalpur. Coverage for tetanus toxoid injection was also relatively better in Aurangabad at 88 percent but lowest in Kishanganj district at 63 percent. Analysing all these three components together, the data reveals that only 67 percent of the women have been effectively covered for at least one service, this drops down substantially to 10 percent for two services and only two percent of the women have actually been covered effectively for all the services. A wide gap exists between the utilization of various services, which is essential to be bridged. Table 4.9: Effective coverage of mothers for ANC services (Percentage)


Begu-sarai

Bhagalpur

Gaya Kishangunj

Purnia Saran Vaishali

Total

Percent of mothers who had effective first visit in first trimester and three visit to health facility consumed 100 or more IFA tablets received two TT injections

9.24.2

87.5

6.72.5

69.6

16.76.3

79.6

10.43.8

78.3

9.22.9

62.9

8.8 3.8

70.8

9.2 3.3

81.3

8.32.9

84.6

9.8 3.7

76.8 Percent of mothers effectively covered Did not receive any ANC Received ANC but ineffective Any one effective service Any two effective service Any three effective service

6.75.4

77.18.82.1

19.210.063.3

7.10.4

16.33.8

61.315.0

3.8

15.85.0

67.110.8

1.3

26.310.053.3

9.60.8

17.1 10.9 62.5

7.9 1.7

13.8

3.8 72.1

9.6 0.8

10.44.2

76.37.91.3

15.7

6.6 66.6

9.6 1.5

Total number of women 240 240 240 240 240 240 240 240 1920


37

Women’s Perception on Need of ANC Care Two fifth (39 percent) of the women agreed that the community worries about services during pregnancy. In other words to a large extent pregnancy continues to be perceived by majority as a natural physiological phenomena that does not require any special health care from the providers (Table 4.10). Understanding the ability of the rural women to seek services, 55 percent of the women did respond that their in-laws have influence on their health seeking behaviour during pregnancy. This was highest at 65 percent in Bhagalpur. Only 39 percent of the women agreed that women seek services from health provider during pregnancy. Further only 32 percent of the women disagreed that man decides whether his wife can seek services during pregnancy. In other words almost two-thirds of them depend on their husbands decision regarding natal care. Given the scenario only 40 percent of the women agreed that they can take the services during ANC. This was highest at 57 percent in Bhagalpur and least at 32 percent in Gaya. Further, twenty five percent of the women did report that their family members are against seeking any health services during pregnancy. This was also highest at 56 percent in Bhagalpur and least at 19 percent in Aurangabad district. Table 4.10: Opinion of the women regarding need of ANC care (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Agree that the community worries about ANC

40.4 42.9 40.4 30.4 44.2 38.8 33.4 38.8 38.6

Percentage of women Agreed that in-laws have influence on women seeking services during pregnancy Agreed that most of women seek services from health provider during pregnancy Disagreed that it is only the man can decide whether his wife should seek services during pregnancy

49.6

34.6

29.6

55.0

35.8

38.0

64.6

61.7

33.7

57.1

32.9

28.3

45.0

30.0

31.3

62.5

40.8

36.3

54.6

40.0

25.4

49.2

34.2

25.0

54.7

38.7

32.2

Percentage of women Agreed that she can take all the services during her pregnancy Agreed that their family member against to ANC services

32.1

18.8

42.5

27.1

56.7

56.3

31.7

19.6

35.9

19.6

45.0

19.6

39.2

20.0

40.5

22.1

40.4

25.4 Total number of women 240 240 240 240 240 240 240 240 1920 Natal care Place of delivery and type of birth attendant who attend the delivery, are the two important factors influencing maternal and neonatal mortality. It is safest to have delivery in an institution with appropriate medical facility. Delivery in a hospital also ensures newborn care and therefore, can reduce the incidence of infant mortality substantially. In the study area, only 14 percent of births were institutional and of them, nearly all were in private hospitals. Statistical analysis of socio economic characteristics of the women with the place of delivery reveals no significant relation.


38

Eighty six percent deliveries continue to take place at home. The percentage of home deliveries attended by trained personnel that is either a doctor or ANM/nurse was only four percent. The percentage of home deliveries attended by doctor or ANM was negligible in Gaya (0 percent), and Kishanganj (0.8 percent). In 76 percent of the cases it was the traditional birth attendant who conducted the delivery. If the traditional birth attendant are not available in the same village, they are called upon from the neighbouring villages. In Bhagalpur this was still lowest at 64 percent, as family members/neighbours conducted the delivery in three percent. All those mothers whose last delivery took place at home were asked whether DDK was used or not. Only six percent of the mothers reported that DDK was used in the delivery.

All those women who did not have institutional deliveries were probed for the reason as to why they did not go to the health facility. The most common reason that emerged included: did not feel the necessity for the same (27 percent), cost too much (21 percent) and better care at home delivery (16 percent). Table 4.11: Place of delivery (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Place of Delivery Institutional PHC Govt. Hosp. Private Hospital/Maternity Home Others Home

-2.5

15.00.8

81.7

-1.3

10.4-

88.3

0.40.4

14.20.4

84.6

0.80.4

15.00.8

82.9

0.82.17.1

-90.0

- 1.3 9.2

- 89.2

0.8 1.7 7.9 1.3

88.3

0.81.3

17.90.8

79.2

0.5 1.4

12.1 0.5

85.5 Home deliveries conducted by Dai/TBA Family members/neighbours ANM/Nurse Doctor Others/None

77.51.32.10.40.4

81.31.70.80.44.2

63.83.39.23.84.6

81.70.4

--

0.8

80.42.1

-0.86.7

69.6 12.1

6.7 -

1.3

79.2

3.8 1.2 2.5 1.7

71.71.33.32.10.8

75.6

3.2 2.9 1.3 2.6

Percentage of home deliveries in which DDKs are used 5.0 8.3 20.0 2.9 2.5

1.7

4.2 3.8

6.0

Reasons for not going to health facility Not necessary Not customary Cost too much Too far/no transport Better care at home Poor quality of services No time Family does not allow Lack of knowledge Others

32.12.5

13.81.3

19.61.74.22.12.91.7

28.32.1

19.22.9

18.82.52.96.36.3

-

23.31.7

20.46.7

16.32.1

10.81.31.70.4

27.92.9

19.25.8

15.41.72.53.84.2

-

26.3-

25.08.8

20.42.53.81.7

-1.7

26.7

2.9 28.3

4.6 11.7

2.9 3.3 5.4 3.3 0.4

23.8

2.5 20.0

4.6 20.0

2.1 5.0 4.6 5.0 0.8

30.85.4

18.82.99.21.34.63.81.31.7

27.4

2.5 20.6

4.7 16.4

2.1 4.6 3.6 3.0 0.8

Total number of women 240 240 240 240 240 240 240 240 1920


Registration of Birth

39

All the mothers were probed on whether they had registered the birth of their child. Only 4 percent of the mothers confirmed this. According to these data, no birth was registered in the district of Aurangabad (Figure 4.5). Post-natal During the post-natal period the new mother and baby are vulnerable to set of risks. As per the norm a health worker should visit the mother at her home at least once within a week of delivery. Data collected on this from the study indicates that, only three percent of mothers were visited by health workers within 10 days of delivery (Table 4.12). This visit by health worker was marginally better in Purnia (5 percent) as compared to other districts. The health workers visited less than one percent of mothers on the same day of delivery. This negligible percentage, points out the absences of adequate coverage to mothers during PNC. As per the norm a minimum of three visits by the health worker is required within 10 days, with the first visit being within 24 hours of delivery.

Figure 4.5: Percentage of mothers who registered the birth of child

4

9

3

4

4

3

5

0

0 5 10 15

Aurangabad

Begusarai

Bhagalpur

Gaya

Kishanganj

Purnia

Saran

Vaishali

Table 4.12: Post-natal follow up (Percentage)


Begu-sarai

Bhagal-pur

Gaya Kishan-gunj


Percent of mothers visited by health worker within 10 days after delivery 3.8 3.3 3.8 1.3 1.7

5.0

2.9 2.5

3.0

Day of visit On the same day of delivery Within one day after delivery 2-5 days After 5th day Do not remember

-1.7

-1.70.4

0.40.80.81.7

-

0.40.40.41.70.8

-0.40.40.40.4

0.40.40.80.4

-

1.3 1.3 2.1 0.4

-

0.4 0.4 1.7 0.8

-

0.80.8

-0.40.4

0.5 0.8 0.8 0.9 0.3

Total number of women 240 240 240 240 240 240 240 240 1920 The above findings indicates that the PHC (82 percent) have the stock of both large and small IFA tablets, but there exist a wide dispersion in the stock available. As per the norm only 55 percent of the facilities have sufficient stock for a week. Disposable delivery kits are largely not available. The percentage of facilities conducting deliveries varies widely among the study districts from 39 percent to 93 percent. Regarding accessibility to health personnel’s, in 52 percent of the facilities where at least one doctor was residing in the PHC compound and in 46 percent there was a ANM. Among the study villages at least one traditional birth attendant was available in seven out of ten villages. Only 27 percent of the ANM had received training for conducting delivery in the last three years. Utilization of the services for ANC largely remains partial as 82 percent of the pregnant women came in this category. In other words, although some services are being sought by a pregnant woman at some or the other point during her pregnancy but it is far below the norm. Community has to be sensitised on the importance of ANC care. More than four-fifth of the delivery continue to take place at home largely by traditional birth attendant with hardly any post natal follow up services by the health personnel.

5 Breast Feeding, Supplementary Feeding

and Child Care Malnutrition directly or indirectly accounts for more than 50 percent of all deaths during infancy and early childhood. It is often thought that malnutrition is due to inadequate food intake resulting form poverty and deprivation. However, ignorance about feeding of the newborn and young infant and certain cultural practices associated with child’s nutrition play an important role in malnutrition. Acute respiratory infections (ARI) and diarrhoea are the major causes of death among infants and children. Both these life threatening illnesses are preventable unless timely treatment has been initiated. This chapter makes an attempt to understand the breastfeeding practice and supplementary feeding practices among the surveyed mothers. It also understands the position of ORS and Cotrimoxazole in the facility and the level of knowledge among the mothers. Each of these have been analysed based on whether it constitutes a component of availability, accessibility or utilization 5.1 AVAILABILITY ORS packet: All the PHCs and sub-centres were assessed for the availability of ORS packets and cotrimoxazole tablets, the basic requirement for treatment of diarrhoea and ARI that should be available at the facility. It was found that 102 PHCs out of a total 124 of PHCs surveyed had stocks of ORS packets; an average 1560 packets of ORS per PHC were available. There was wide disparity in the stock available at the PHC. There were some PHC in which no stock was there. The highest stock of ORS packets was 70,000 in Saran PHC. Similarly out of 122 SCs covered 99 sub-centres had ORS packets. On an average each sub-centre had 165 ORS packets. The stock of ORS was more maximum (750) in Bhagalpur sub-centre compared with other sub-centres, while it was least in Begusarai sub-centre with 5 packets. There thus, exists a wide dispersion in the stock availability at different facilities. Cotrimoxazole tablets: Regarding the availability of cotrimoxazole tablets, this was available in 102 out of 124 PHCs and 99 out of 122 sub-centres surveyed. The average stock of cotrimoxazole tablets available at the PHCs was 4490 varying from 1,00,000 tablets in Kishanganj district PHC to no stock in same district other PHCs. Similarly, the average stock of cotrimoxazole tablets in sub-centres was found to be on an average 1066, which varied from 1 to 12,000 tablets in different sub-centres. Maximum stock (12,000 tablets) was found in a sub-centre of Purnia district. Thus, the average stock of cotrimoxazole tablets availability varied widely across both these facilities (PHC and sub-centre) and across the districts.


42

Table 5.1: Status of ORS and Cotrimoxazole at PHC and Sub-centres Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-Pur

Gaya Kishan-ganj


Number of PHCs Having ORS packets Average no. of ORS packets Standard deviation Having cotrimoxazole Average no. of cotrimoxazole Standard deviation

12216.5

212

121367.9

1304

10491.4

998

103013.0

5382

7178.6

202

7214.3

393

21246.2

399

211517.1

2529

91256.2

945

916911.1

31816

14

3464.9 7808

14

9661.3 17197

13

5756.2 19332

13

2510.0 7087

16657.41053

163623.3

5100

1021559.8

7506

1024489.912437

Total number of PHCs 15 18 11 22 9 14 16 19 124Number of Sub-Centres Having ORS Average number of ORS packets Standard deviation Having cotrimoxazole Average no. of cotrimoxazole Standard deviation

14182.4138.0

141093.2749.3

15115.0142.7

11956.9852.3

12234.4216.3

12950.3

1404.2

13206.8155.5

151275.7977.5

10266.8196.4

91064.91292.5

12

98.9 83.0

12

1545.9 3350.5

10

135.5 140.3

13

540.8 433.1

13103.8110.8

131078.11596.4

99164.8157.2

991066.21520.7

Total number of sub- centre 15 17 14 17 11 15 18 15 122 5.2 ACCESSIBILITY For health interventions delivered at the household, knowledge among mothers rather than contacts/visit by the health workers is often the requirement to ‘access’ a particular service. In this section we assess the knowledge of mothers of key household health interventions for diarrhoea. Knowledge among mothers regarding diarrhoea Diarrhoea is one of the major childhood illnesses, which can be easily preventable provided the management of the same begins at home as soon as the child passes the first loose motion. Hence in the study area all the mothers (with children 12-23 months old) were asked about the signs of severe diarrhoea (when the sick child should be taken to a health worker). Eighty eight percent and eighty three percent of mothers reported about frequent watery motions and frequent vomiting respectively. One-fourth of the mothers reported high fever. Six percent and four percent reported about blood in motions and feeling thirsty respectively. Around nine percent of mothers reported that they do not know any signs of diarrhoea. Mother’s having no knowledge about the signs of diarrhoea, varied from three percent in Kishanganj district to 19 percent in Bhagalpur district. Further probing on when a child suffers from diarrhoea, whether he/she should continue to be fed with the same amount of liquid diet during diarrhoea or should the child be fed with less or more than normal liquid. About 44 percent of mothers reported that the baby should be given less liquid than before diarrhoea, while another 44 percent correctly reported that the baby should be provided with either the same or more fluid than normal. About nine percent of mothers reported they don’t know about it. In addition to giving increased fluids, mothers should continue to feed the child even during diarrhoea. Around seven percent of them reported that the baby should not be given any food. Eighty percent of mothers reported that the child should be given less feed than what is given before diarrhoea, which is a wrong misconception. Only five percent mothers correctly opined that they should be given same or more food as before diarrhoea. Nine percent of the mothers said that they don’t have any knowledge about it.

Chapter 5: Breastfeeding, Supplementary Feeding and Child Care

43

Table 5.2: Knowledge regarding diarrhoea and its management (Percentages) Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-Pur

Gaya Kishan-ganj


Signs of Severe Diarrhoea Frequent watery motions Frequent vomiting Blood in motions High fever Feel thirsty Not taking any food and water Others Do not know

90.488.3

6.324.2

3.80.4

10.45.8

88.887.5

8.321.3

2.50.49.66.7

68.675.0

4.228.8

4.60.85.0

18.8

88.385.8

2.120.8

3.30.49.6

10.4

96.780.8

8.835.4

2.90.4

18.82.5

90.4 77.5

2.1 8.8 6.3 2.1

13.8 8.3

87.9 85.0

7.1 20.0

2.9 0.4 9.2 9.2

91.385.8

5.827.9

5.80.85.46.3

87.883.2

5.623.4

4.00.7

10.28.5

Opinion on liquid diet during diarrhoea None Less than before diarrhoea Same as before diarrhoea More than before diarrhoea Do not know

1.333.8

4.253.8

7.1

5.037.5

6.743.3

7.5

6.767.5

4.63.3

17.9

2.935.4

7.145.0

9.6

-55.811.327.9

5.0

4.2 38.3

7.5 43.3

6.7

1.7 41.3

5.4 41.3 10.4

5.042.1

8.839.6

4.6

3.344.0

6.937.2

8.6Opinion on feeding during diarrhoea None Less than before diarrhoea Same as before diarrhoea More than before diarrhoea Do not know

2.984.6

2.13.37.1

7.579.6

3.80.88.3

6.372.9

2.90.4

17.5

5.482.1

2.11.78.8

2.185.8

4.22.55.4

10.0 76.3

3.3 3.8 6.7

8.3 75.0

5.8 0.8

10.0

10.479.6

4.60.84.6

6.679.5

3.61.88.5

Percent of women aware of ORS Place from where ORS can be availed From ANM/SC PHC Can prepare at home Chemist RMP Doctor Others

32.1

5.41.7

-23.3

--

1.7

43.3

4.62.91.3

33.3-

0.80.4

19.6

5.43.3

-9.6

--

1.3

37.9

11.31.7

-23.3

1.3-

0.4

48.3

2.13.31.7

37.11.71.31.3

44.2

2.5 3.3

- 37.1

- -

1.3

39.2

1.3 2.5 0.8

34.2 - -

0.4

45.4

2.54.60.8

35.8-

1.30.4

38.8

4.42.90.6

29.20.40.40.9

Total number of women of 12-23 months children

240 240 240 240 240 240 240 240 1920

All the mothers were asked whether they know about ORS. It was found that 39 percent of the mothers were aware about it. All these mothers, who were aware about it, were asked from where one can get ORS; 75 percent of these mothers (29 percent of all mothers) said it can be availed from a chemist, while ANM/sub centre/PHC was mentioned by only 19 percent (7 percent of all mothers). Around two percent of these mothers reported about preparing ORS solution at home. Others opined, it can be obtained from doctors, RMP or other sources such as anganwadi worker. 5.3 UTILIZATION Initiation of breastfeeding: All the mothers who had delivered a child in the 12 months prior to the survey were asked when they initiated breastfeeding to their child. It was found that only seven percent of mothers initiated breastfeeding within two hours of birth. This was highest (15 percent) in Bhagalpur district. Only 28 percent of the mothers reported that they initiated breastfeeding within a day of delivery. More than two-fifth (44 percent) of the mothers initiated breastfeeding between the first and the third day. About one-fifth of the


44

mothers reported that they breastfed their child only after 3 days. Less than one percent mothers never breastfed their children. Feeding colustrum is important to a baby as it increases the immunity power of the child. Hence in the survey mothers were asked whether they squeeze out the yellow milk before initiating breastfeeding to the baby as it is generally followed in certain cultural practices. Around 40 percent of mothers reported that they squeezed out the yellow milk before initiating breastfeeding to their child. It varied from 29 percent in Vaishali district to 48 percent in Bhagalpur district. Probing into the reasons for the same, milk is dirty (13 percent), it is our custom (11 percent) and it is harmful to baby (7 percent) were some of the common reasons mentioned. Other reasons mentioned included relatives, in-laws, asking to do so, removing initial milk will increase the production of milk, and dai advising them to do so. Surprisingly, around one percent of the mothers mentioned that a health work (doctor/nurse/ANM) advised them to squeeze the yellow milk before initiating breastfeeding. Almost all mothers (98 percent) reported that they are currently breastfeeding their child. Table 5.3: Breastfeeding practice among mothers (Percentages)


Begu-sarai

Bhagal-Pur

Gaya Kishan-ganj


Initiation of breast feeding Immediately/ within two hrs. of birth 2- 6 hrs of birth 7-12 hrs 13-24 hrs 1-3 days After 3 days Not breastfed

5.45.06.3

14.650.816.3

1.7

5.08.3

13.316.742.913.3

0.4

14.66.39.2

12.942.113.8

1.3

7.98.3

11.711.343.317.1

0.4

2.92.94.22.5

39.248.3

-

10.8

7.5 7.9

11.3 42.5 19.2

0.4

5.8 4.2 9.6

10.4 47.9 10.8

1.3

5.47.5

13.318.845.8

8.80.4

7.26.39.4

12.344.319.7

0.7Percent of mothers squeeze out yellow milk 40.0 45.8 47.5 42.9 42.1

44.6

30.4 28.8 40.3

Reasons for not feeding colostrum Dirty milk Customary Harmful to baby Relatives asked to do so Doctor/nurse/ANM advise Dai advise Others

12.57.19.68.3

-2.94.7

11.718.4

9.69.2

-0.8

-

13.27.08.2

10.43.31.74.2

14.610.9

4.610.8

0.82.5

-

17.113.7

4.25.4

--

2.0

18.8

7.9 12.9

5.0 0.4

- 3.3

10.4

7.1 3.8 7.5 0.8

- 2.5

7.512.5

2.14.20.42.51.2

13.310.9

6.97.60.71.32.2

Percent currently breast feeding 97.9 98.8 96.7 98.8 100.0 97.1 98.3 97.5 98.1Total number of women of 0-11 months children

240 240 240 240 240 240 240 240 1920

5.4 ADEQUATE COVERAGE Exclusive breastfeeding: Exclusive breastfeeding means that except for breast milk no other food or fluids, including water and pre-lacteal feeds, should be given to a child from birth to six months. Feeding anything other than breast milk, including water, is not only unnecessary but is also harmful as it increases the risk of infection. Analysing the breastfeeding practice of children under six months, the data show that 18 percent of the children are currently being breastfed. Three percent of these children were exclusively breastfed for four months. The survey data was reanalysed for the children above six months to understand the percentage of children who were exclusively breastfed. Analysis of the data shows that among the children aged above six months about four percent of children were breastfed exclusively for six months and above, while 30 percent of the children received exclusive breastfeeding for four months.

Chapter 5: Breastfeeding, Supplementary Feeding and Child Care

45

On an average it emerges that mothers breastfeed their child exclusively for slightly more than two months. It was found that, on an average, they gave water to the baby at 5.4 months of age. At the average age of 6.6 months they start giving supplementary feeding. Supplementary feeding practice indicates that only 68 percent of the children received mushy or semi-solid food on the previous day of the survey. Similarly the percentage of children who received fruits and green leafy vegetables was only 11 and seven respectively. Table 5.4: Nutrition pattern among children (Percentages)


Begu-sarai

Bhagal-Pur

Gaya Kishan-ganj


Percentage of children 0-6 months of age breast-fed Exclusively from birth until survey Exclusively on previous the day of survey

8.620.4

11.526.4

15.235.9

5.330.5

31.347.0

42.9 48.8

14.9 24.8

12.739.2

18.034.2

No. of children under six months 93 87 92 95 115 84 101 79 746Percentage of children 6-11 months exclusively breastfed for: Four months Six months

15.61.4

32.05.9

37.84.1

17.92.1

34.40.8

41.7 4.5

19.4 5.8

31.16.2

28.93.9

Average months the children aged more than 6 months Breastfed exclusively Was given water

1.31.6

2.32.8

2.22.7

1.41.5

2.73.4

2.9 3.3

1.7 2.1

2.42.7

2.12.5

Mean age (in months) at which children above six months Given liquid other than breast milk Food (other than water or breast milk)

5.46.4

5.62.0

5.77.2

5.46.7

4.66.0

5.3 6.5

5.1 6.6

5.76.6

5.46.6

Percentage of children aged above 6 months on the previous day had

Green leafy vegetables Mean number of times

10.82.4

5.22.1

2.71.0

12.42.1

15.22.1

3.8 1.5

2.1 1.3

6.21.8

7.22.0

Fruits Mean number of times

2.76.5

10.51.9

4.73.9

6.21.2

15.22.3

8.9 2.6

21.6 1.4

19.33.3

11.12.5

Semi-solid Mean number of times

72.62.3

55.62.3

47.92.1

78.62.3

64.02.2

60.3 2.1

82.0 2.3

78.92.0

68.12.2

No. of children 6-11 months 147 153 148 145 125 156 139 161 1174 5.4 EFFECTIVE COVERAGE Skill/Knowledge among ANM: Auxiliary nurse midwives are the paramedical health persons who directly interact with the community at the grass root level. They are the first hand information providers on health related matters to the community. Hence in the present study ANMs were asked, when a mother should start breastfeeding ideally to her newborn baby. One hundred and twenty out of the 139 ANMs responded that breastfeeding should start within one hour. Further analysis of the ANMs responses shows that as per her perception mothers should initiate breastfeeding on an average 2.9 hours after delivery. This duration was more (6.4 hours) in Aurangabad while it was less in Vaishali at around one hour.


46

Table 5.5: ANMs knowledge on breastfeeding and supplementary feed Name of the Districts Indicators

Auran-gabad

Begu-sarai

Bhagal-Pur

Gaya Kishan-ganj


Number of ANMs reporting baby should be breastfed Within an hour Average hours when mother should initiate Baby should be given supplementary feed (number) Before 4 months 4-6 months 6+months Don’t know

14

6.4

-6

111

15

3.2

37

10-

17

2.3

15

102

14

2.6

286-

15

3.2

296-

14

2.5

2 7 6 -

17

1.9

4 5

10 -

14

1.3

1781

120

2.9

155467

3Total number of ANM 18 20 18 16 17 15 19 16 139 They were also further probed at what age a child should be given supplementary feeding. Only 15 ANMs reported that the baby should be given supplementary feeding before 4 months, while 54 and 67 ANMs reported that it should be between four to six months and after six months respectively.

6 Summary and Conclusion

Multi-indicator cluster survey was conducted in eight districts namely Aurangabad, Begusarai, Bhagalpur, Gaya, Kishangunj, Purnia, Saran and Vaishali of Bihar state. In each district 30 clusters were selected by using PPS procedure. The clusters identified were in the rural areas of the identified districts. Within each cluster, eight mothers each of children aged 0-11 months and 12-23 months were surveyed. In addition to this a village questionnaire was also filled. Public health facilities, which included the PHC and the sub-center within the cluster, was also identified and surveyed. In the process 124 PHC and 122 sub-centers were surveyed. Further 139 ANMs across the study districts were interviewed. As discussed in the earlier chapters, the major findings which emerged from this were as follows: IMMUNIZATION • Seventy five PHCs out of the 124 PHC surveyed did not store vaccine in the facility. Only

in 22 of them were all vaccines available. • Wide disparity was found in the quantum of the stock available at the facility. Sufficient

stock for one week as per the norm calculated was found in 15 facilities for BCG, 12 facilities for OPV, 5 facilities for DPT and 10 facilities for measles. Tetanus toxoid was calculated to be sufficient in 9 facilities.

• To maintain vaccine potency, it should be kept in either ILR or in deep freezer as the

required norm of the vaccine. However in only 15 PHC and 16 PHC, BCG and DPT respectively were kept as per norm. Whereas polio and measles was properly kept in 26 PHC and 17 PHC respectively.

• Electricity supply was reported to be regular in only seven PHCs. Whereas generator

facility in working condition was reported from 58 PHCs. • Of the total 244 villages surveyed, immunization sessions were reported from 142

villages. However the frequency of these sessions varied across the villages. • Twenty-three percent of children 12-23 months old survey were fully immunized. Forty

four percent of the children had not received any immunization; 57 percent had received at least one immunization. Forty-four percent of the mothers had an immunization card. Only four percent of the children received all the vaccines as per schedule.

• Statistical test shows a statistically significant correlation between religion, education of

mother, exposure to media, availability of health facility and immunization session within the village and immunization.


48

ANTE-NATAL, NATAL AND POST NATAL • One hundred and two PHC and 108 sub-centers had IFA large tablets on the day of

survey. Wide disparity was observed in the stock available at the facility. • Only five sub-centers had DDK at the facility on the day of the survey, although ten of

them had received DDK in the last 12 months. • Seventy-seven PHCs were conducting deliveries. On an average 33 deliveries were

conducted per facility in the last three months. Formal training in delivery was received by only 38 ANMs.

• Percentage of women who received at least one ANC check-up was 31 percent. Twenty

six percent of the total women had received check-ups from private doctors. Only 30 percent of the women had received IFA tablets but only five percent had received more than 100 tablets. Consumption of at least 100 tablets was only five percent. Seventy seven percent of the mothers received at least two tetanus toxoid injection.

• Percentage of women who received complete ANC care (three check-up, one TT and

received 100 IFA tablets) was two percent. Sixteen percent of the mothers had not received any services whereas 82 percent had received some or the other service. Statistical analysis reveals significant correlation with religion, mothers education and availability of health facility within the village.

• Institutional deliveries were only 14 percent, with majority of the deliveries being

conducted at home by traditional birth attendant. Follow up for postnatal care was only three percent as norm of 3 visits within 10 days of delivery.

CHILD CARE AND BREAST FEEDING/SUPPLEMENTARY FEEDING PRACTICE • Hundred and two PHC (out of 124 PHC) and 99 sub-centers (out of 122 sub-centers) had

ORS packets on the day of survey. However a wide disparity was found in the quantum of stock across the facilities.

• Eighty eight percent of the mothers considered `frequency watery motion’ as the sign of

severe diarrhoea. The other signs were mentioned by lesser percentage. Correct knowledge on the practice of giving same or more liquid was known to just under half of the mothers whereas about other practice of giving same or more food was practices by approximately 5 percent of mothers.

• Only seven percent of the mothers initiated breast-feeding within two hours of delivery.

Practice of not feeding colostrums was followed by around 40 percent of the mothers. • Twenty-nine percent of surveyed children 6-11 months were exclusively breastfed for 4

months; however at 6 months exclusive breastfeeding, coverage drops to 4 percent. The average duration of exclusively breastfeeding was two months, with water being initiated after third month. While the vast majority of ANMs do have adequate knowledge on the initiation and duration of exclusive breastfeeding, knowledge of supplementary feeding was less common.

Chapter 6: Summary and Conclusion

49

From the above discussion it may be inferred that to a certain extent the health facilities do have the requisite stock, however given the condition under which it operates, it is essential to understand and ensure that the potency of the vaccine is maintained which needs to be assessed. Technical skill of the para-medics should be strengthened as it will equip them to serve the beneficiaries better. Further efforts are needed to reach out to all sections of the community (particularly mothers with low literacy and muslim), taking the first contact as the opportunity to enlighten the beneficiary on the need of subsequent contacts and repeat contacts with the health services. All contacts for antenatal and postnatal care need to be strengthened. Strategies will have to be developed to make the community aware about the need of protecting infants through timely vaccination and seeking ANC services by pregnant woman. Myths and misconceptions prevailing in the community related to this must be removed.

Aurangabad District, Bihar (based on Census 2001) Total Population 1,842,998 (Rural only) Clusters 30 Size 61433 Random number 0.680 Starting cluster 25718 Cluster Value Block Village Population Households

1 25,718 Daudnagar Gobardhanpur Kanap 8,062 1,217

2 87,151 Daudnagar Mayapur 1,384 181

3 148,584 Haspura Purahra 1,791 307

4 210,017 Haspura Chanhat 1,233 196

5 271,450 Goh Kurwan 1,961 299

6 332,883 Goh Kaithi Beni 836 115

7 394,316 Goh Hasampur 1,171 191

8 455,749 Rafiganj Rampur Parasiya 1,109 137

9 517,182 Rafiganj Kotwara 1,451 219

10 578,615 Rafiganj Dharhara 1,277 177

11 640,048 Rafiganj Dugul 3,553 560

12 701,481 Obra Dekuli 1,713 243

13 762,914 Obra Aranda 1,399 173

14 824,347 Obra Bel 3,020 418

15 885,780 Aurangabad Bakhari 648 84

16 947,213 Aurangabad Rajoi 1,337 174

17 1,008,646 Barun Sonbarsa 458 64

18 1,070,079 Barun Barun 6,675 928

19 1,131,512 Nabinagar Sasna 1,177 122

20 1,192,945 Nabinagar Khanria 312 39

21 1,254,378 Nabinagar Khajuri Panru 3,261 433

22 1,315,811 Nabinagar Bairawan Loknath 973 156

23 1,377,244 Kutumba Suhi 1,522 201

24 1,438,677 Kutumba Amba 4,758 758

25 1,500,110 Kutumba Basdiha Gopal 732 121

26 1,561,543 Deo Dhanari 740 107

27 1,622,976 Deo Kauriari 1,268 182

28 1,684,409 Madanpur Kakan 398 60

29 1,745,842 Madanpur Narkapi 1,770 231

30 1,807,275 Madanpur Dewajara 769 110

Begusarai District, Bihar (based on Census 2001) Total Population 2,241,743 (Rural only) Clusters 30 Size 74725 Random number 0.494 Starting cluster 49341 Cluster Value Block Village Population Households

1 49,341 Khudabandpur Chak Jaddu 784 165

2 124,066 Chhorahi Amari 10,632 1,851

3 198,791 Garhpura Manikpur 2,849 507

4 273,516 Cheria Bariarpur Aure 788 122

5 348,241 Cheria Bariarpur Majhaul 31,261 5,336

6 422,966 Bhagwanpur Bishunpur 2,048 373

7 497,691 Mansurchak Santha Rasidpur 4,770 924

8 572,416 Bachhwara Chakka 763 118

9 647,141 Bachhwara Gopalpur 1,587 319

10 721,866 Teghra Binalpur 2,836 514

11 796,591 Teghra Barauni 19,786 3,818

12 871,316 Teghra Phulwaria 30,396 4,876

13 946,041 Barauni Badh Mirzapur 288 46

14 1,020,766 Barauni Malhipur 12,342 2,305

15 1,095,491 Barauni Ninga 8,683 1,427

16 1,170,216 Birpur Dihpur 4,753 810

17 1,244,941 Begusarai Khamhar 5,993 1,059

18 1,319,666 Begusarai Kusmaut 6,376 1,250

19 1,394,391 Begusarai Pachmma 4,901 849

20 1,469,116 Begusarai Dumri 13,391 2,206

21 1,543,841 Naokothi Isufa 593 117

22 1,618,566 Bakhri Semri 3,335 649

23 1,693,291 Bakhri Sinduari 340 79

24 1,768,016 Dandari Dandari 4,677 815

25 1,842,741 Sahebpur Kamal Chauki 8,335 1,302

26 1,917,466 Sahebpur Kamal Shahpur Kamal 19,037 3,202

27 1,992,191 Balia Fatehpur 2,518 414

28 2,066,916 Balia Balia Lakhminian 39,643 6,358

29 2,141,641 Matihani Saidpur Khalsa 975 160

30 2,216,366 Shamho Akha Kurha Jagan Saidpur 4,454 743

Bhagalpur District, Bihar (based on Census 2001) Total Population 1,970,745 (Rural only) Clusters 30 Size 65692 Random number 0.983 Starting cluster 13349 Cluster Value Block Village Population Households

1 13,349 Narayanpur Nagarpara 18,450 3,083

2 79,041 Narayanpur Mirzapur 3,883 540

3 144,733 Bihpur Bihpur 20,699 3,605

4 210,425 Kharik Kharik 32,302 5,494

5 276,117 Kharik Akidatpur 5,150 888

6 341,809 Naugachhia Partapnagar 29,584 5,468

7 407,501 Rangra Chowk Sadhua 10,986 2,054

8 473,193 Gopalpur Saidpur Dabra 31,617 5,356

9 538,885 Pirpainti Pirpainti 5,930 790

10 604,577 Pirpainti Rifadpur 14,666 2,401

11 670,269 Pirpainti Jairam Bandhu 1,836 302

12 735,961 Colgong Shankarpur Khawas 28,858 4,731

13 801,653 Colgong Sangalbahita 8,101 1,639

14 867,345 Colgong Jagesarpur 1,301 215

15 933,037 Colgong Barahamchari 1,954 327

16 998,729 Colgong Bholsar 14,642 2,705

17 1,064,421 Sabour Sabour 9,114 1,568

18 1,130,113 Sabour Ibrahimpur 2,249 409

19 1,195,805 Nathnagar Semaria 4,191 739

20 1,261,497 Nathnagar Bishunrampur 2,163 377

21 1,327,189 Sultanganj Akbarnagar 24,560 3,842

22 1,392,881 Sultanganj Khanpur 1,228 200

23 1,458,573 Shahkund Dewakharkita 973 136

24 1,524,265 Shahkund Berai 2,030 353

25 1,589,957 Goradih Salpur 2,190 362

26 1,655,649 Goradih Kurudih 2,027 345

27 1,721,341 Jagdishpur Kurban 1,167 214

28 1,787,033 Jagdishpur Shahjangi 4,282 673

29 1,852,725 Sonhaula Tarar 7,769 1,433

30 1,918,417 Sonhaula Madhepur 3,022 707

Gaya District, Bihar (based on Census 2001) Total Population 2,997,479 (Rural only) Clusters 30 Size 99916 Random number 0.875 Starting cluster 15042 Cluster Value Block Village Population Households

1 15,042 Konch Wahab Chak 933 137

2 114,958 Konch Angra 1,067 200

3 214,874 Tikari Hasanpur 771 126

4 314,790 Tikari Mahmanna 3,310 474

5 414,706 Belaganj Alalpur 1,079 142

6 514,622 Belaganj Murgawan 655 82

7 614,538 Khizirsarai Hurma 2,691 470

8 714,454 Neem Chak Bathani Tilari 9,583 1,301

9 814,370 Muhra Sarsu 5,176 771

10 914,286 Manpur Usri 4,619 790

11 1,014,202 Gaya Town CD Block Bemata 797 131

12 1,114,118 Gaya Town CD Block Khiriyawan 2,388 407

13 1,214,034 Paraiya Paranpur 959 120

14 1,313,950 Guraru Kanausi Belkhara 2,725 381

15 1,413,866 Gurua Akothara 562 70

16 1,513,782 Amas Barki Sawo 2,034 321

17 1,613,698 Banke Bazar Saifganj 3,085 478

18 1,713,614 Imamganj Duleahal 2,628 419

19 1,813,530 Dumaria Kachar 3,050 454

20 1,913,446 Sherghati Nawada 1,335 213

21 2,013,362 Dobhi Kurmawan 3,237 456

22 2,113,278 Bodh Gaya Kurmawan 3,225 461

23 2,213,194 Bodh Gaya Mohimapur 153 21

24 2,313,110 Tan Kuppa Chamu Khap 358 48

25 2,413,026 Wazirganj Amethi 3,883 544

26 2,512,942 Wazirganj Baliari 666 86

27 2,612,858 Fatehpur Partappur 1,046 149

28 2,712,774 Fatehpur Majhila Kalan 879 129

29 2,812,690 Mohanpur Raundawa 1,400 187

30 2,912,606 Barachatti Bhadeya 728 98

Kishangunj District, Bihar (based on Census 2001) Total Population 1,167,340 (Rural only) Clusters 30 Size 38911 Random number 0.628 Starting cluster 13688 Cluster Value Block Village Population Households

1 13,688 Terhagachh Khaniabad 3,785 713

2 52,599 Terhagachh Pharhabari Nankar 485 105

3 91,510 Terhagachh Gargaon 429 74

4 130,421 Dighalbank Sat Kauwa 5,350 1,028

5 169,332 Dighalbank Mustalaganj 1,734 345

6 208,243 Dighalbank Padampur 6,447 1,356

7 247,154 Dighalbank Algachhia 2,684 540

8 286,065 Thakurganj Nazagachh 7,402 1,461

9 324,976 Thakurganj Sakhuadali 3,321 616

10 363,887 Thakurganj Bahadurpur 2,290 462

11 402,798 Thakurganj Sabodangi 3,750 796

12 441,709 Thakurganj Balka Dobha 161 31

13 480,620 Pothia Purandarpur 512 106

14 519,531 Pothia Nimalagaon 1,194 244

15 558,442 Pothia Udgara 4,252 797

16 597,353 Pothia Singhiamari 580 115

17 636,264 Pothia Adhikari 1,207 258

18 675,175 Bahadurganj Altabari 5,434 1,100

19 714,086 Bahadurganj Mahesh Bathna 2,500 529

20 752,997 Bahadurganj Mahadeo Dighi 3,731 708

21 791,908 Bahadurganj Bangaon 6,947 1,439

22 830,819 Bahadurganj Chorkattakurhaila 724 137

23 869,730 Kochadhamin Burhimari 2,440 455

24 908,641 Kochadhamin Haldikhora 6,133 1,177

25 947,552 Kochadhamin Natuapara 921 176

26 986,463 Kochadhamin Tegharia 2,807 627

27 1,025,374 Kochadhamin Mahadha 3,061 652

28 1,064,285 Kochadhamin Sundarpuchhi 399 85

29 1,103,196 Kishanganj Singhia 7,500 1,392

30 1,142,107 Kishanganj Kirdah Samda 1,776 322

Purnia District, Bihar (based on Census 2001) Total Population 2,321,544 (Rural only) Clusters 30 Size 77385 Random number 0.438 Starting cluster 35364 Cluster Value Block Village Population Households

1 35,364 Banmankhi Ramnagar Pharsahi 15,435 2,798

2 112,749 Banmankhi Balua Kachhari 12,271 2,502

3 190,134 Banmankhi Jianganj 9,831 2,095

4 267,519 Barhara Rustampur 1,083 226

5 344,904 Barhara Maldiha 6,128 1,320

6 422,289 Bhawanipur Bhawanipur Rajdham 24,718 4,454

7 499,674 Bhawanipur Bhamet 2,008 360

8 577,059 Rupauli Goriar 21,173 4,203

9 654,444 Rupauli Dhobgidha 1,947 389

10 731,829 Rupauli Lachhimipur Girdhar 5,402 1,217

11 809,214 Dhamdaha Barkona 4,704 901

12 886,599 Dhamdaha Damgari 4,380 854

13 963,984 Dhamdaha kuari 4,829 863

14 1,041,369 Krityanand Nagar Ganeshpur 12,254 2,370

15 1,118,754 Krityanand Nagar Parora 8,611 1,621

16 1,196,139 Purnia East Phasia 1,699 283

17 1,273,524 Purnia East Maranga 22,386 3,896

18 1,350,909 Kasba Semaria 1,793 415

19 1,428,294 Kasba Lakhna 6,830 1,308

20 1,505,679 Srinagar Cinghia Bhagta 2,938 533

21 1,583,064 Jalalgarh Dansar 2,526 558

22 1,660,449 Amour Amour 5,359 1,066

23 1,737,834 Amour Tarauna 2,229 521

24 1,815,219 Amour Routi 1,107 225

25 1,892,604 Baisa Bhebra 3,348 665

26 1,969,989 Baisa Mahesh Khunt 150 31

27 2,047,374 Baisi Panisadra 3,519 692

28 2,124,759 Baisi Parant 466 86

29 2,202,144 Dagarua Pipra 1,598 374

30 2,279,529 Dagarua Saura 1,534 311

Saran District, Bihar (based on Census 2001) Total Population 2,950,064 (Rural only) Clusters 30 Size 98335 Random number 0.602 Starting cluster 97410 Cluster Value Block Village Population Households

1 97,410 Mashrakh Gandaman 2,115 359

2 195,745 Panapur Basahiya 1,907 288

3 294,080 Taraiya Shahnewazpur 2,339 312

4 392,415 Ishupur Rampur Atauli 2,339 385

5 490,750 Ishupur Agauthar Nanda 1,977 281

6 589,085 Baniapur Katsa 2,204 317

7 687,420 Baniapur Pirauta Megha 1,157 160

8 785,755 Ekma Khajuhan 1,848 286

9 884,090 Ekma Ghaziapur 2,031 279

10 982,425 Manjhi Raiwal 775 124

11 1,080,760 Manjhi Jaitpur 9,808 1,307

12 1,179,095 Manjhi Manjhi 15,915 2,310

13 1,277,430 Jalalpur Kopa 13,697 2,062

14 1,375,765 Revelganj Inai 4,394 583

15 1,474,100 Chapra Basarhi 1,628 232

16 1,572,435 Chapra Kotwapatti Rampur 9,458 1,283

17 1,670,770 Nagra Shahpur 1,904 259

18 1,769,105 Marhaura Salimapur 3,615 521

19 1,867,440 Amnour Dumaria 784 111

20 1,965,775 Amnour Amnaur Sultan 3,164 468

21 2,064,110 Maker Bhathna 3,403 558

22 2,162,445 Parsa Kuaribir 2,017 283

23 2,260,780 Dariapur Derni 1,848 297

24 2,359,115 Dariapur Patti Sital 1,107 186

25 2,457,450 Dariapur Mangarpal Murtuza 3,009 381

26 2,555,785 Garkha Garkha 8,242 1,131

27 2,654,120 Garkha Kothia 14,044 1,952

28 2,752,455 Dighwara Jhaua 7,874 1,154

29 2,850,790 Sonepur Saidpur 5,922 793

30 2,949,125 Sonepur Sabalpur 1,878 251

Vaishali District, Bihar (based on Census 2001) Total Population 2,531,766 (Rural only) Clusters 30 Size 84392 Random number 0.851 Starting cluster 21926 Cluster Value Block Village Population Households

1 21,926 Vaishali Bhagwanpur 5,426 791

2 106,318 Vaishali Kamtauliaurf Harpur Gopi 1,948 323

3 190,710 Paterhi Belsar Birmamath Urf Harnathpur Harna 1,042 171

4 275,102 Lalganj Bhagwanpur Pakri 2,615 374

5 359,494 Lalganj Ghataro Chaturbhuj 20,147 3,051

6 443,886 Bhagwanpur Partap Tanr 8,042 1,284

7 528,278 Bhagwanpur Bhagwatpur Patera 822 135

8 612,670 Goraul Sandhodullah 9,054 1,412

9 697,062 Chehra Kalan Hedayatpur Katahra Dakhali 1,448 209

10 781,454 Chehra Kalan Kaila Jalalpur Urf Jalalpur 2,952 388

11 865,846 Patepur Marai Dih 6,147 934

12 950,238 Patepur Sultanpur Chak Harihar 838 142

13 1,034,630 Patepur Khajepur Basti 4,096 610

14 1,119,022 Mahua rasulpur Mohiuddin Urf Madhaul 5,204 779

15 1,203,414 Mahua Sherpur Chhatwara 1,982 288

16 1,287,806 Mahua Paur Malshah Mohammadpur 2,092 330

17 1,372,198 Jandaha Khizirpur Jasparha 2,682 427

18 1,456,590 Jandaha Hazrat Jandaha 5,991 890

19 1,540,982 Raja Pakar Bhatha Dasi 4,444 702

20 1,625,374 Hajipur Arazi Shahbazpur 1,443 193

21 1,709,766 Hajipur Daulatpur Deoria urf Daulatpur 3,341 419

22 1,794,158 Hajipur Phulhara Banu 2,200 356

23 1,878,550 Raghopur JafrabadTok-araziBeshiNaoBarar 1,991 405

24 1,962,942 Raghopur Jagdishpur Idrakarai Barari 1,828 235

25 2,047,334 Bidupur Gurbiswa 943 165

26 2,131,726 Bidupur Khilwat 6,412 1,015

27 2,216,118 Bidupur Panapur Sukhanand 1,538 239

28 2,300,510 Desri Tayabpur 2,980 450

29 2,384,902 Sahdai Buzurg Sultanpur 8,428 1,248

30 2,469,294 Mahnar Rupnarayanpur 2,152 369

Back ground characteristics Percent Not

Immunized Percent

Partially Immunized


Total

Aurangabad Religion χ2 0.45 Hindu Muslims

6.7 6.3

90.6 93.8

2.7 0.0

224 16

Education χ2 12.18 Illiterate Literate

10.1

1.1

89.3 93.4

0.7 5.5

149 91

Health facility within the village χ2 2.13 Available Not available

5.4 7.1

94.6 89.7

0.0 3.3

56

184 Total 6.7 90.8 2.5 240 Begusarai Religion χ2 4.31 Hindu Muslims

20.9

4.0

78.6 96.0

0.5 0.0

215 25


23.6

0.0

76.4 97.8

0.0 2.2

195 45


18.8 19.8

81.3 79.2

0.0 1.0

144 96

Total 19.2 80.4 0.4 240 Bhagalpur Religion χ2 0.26 Hindu Muslims

15.9 17.2

79.5 79.7

4.5 3.1

176 64


21.0

3.1

76.7 87.5

2.3 9.4

176 64


11.8 22.1

82.4 76.0

5.9 1.9

136 104

Total 16.3 79.6 4.2 240 Gaya Religion χ2 1.23 Hindu Muslims

15.2 21.7

82.0 78.3

2.8 0.0

217 23


20.2

4.5

78.0 91.0

1.7 4.5

173 67


10.9 21.4

87.5 75.0

1.6 3.6

128 112

Total 15.8 81.7 2.5 240 Kishangunj Religion χ2 0.48 Hindu Muslims

23.4 27.6

75.3 71.2

1.3 1.2

77

163

Back ground characteristics Percent Not Immunized

Percent Partially

Immunized


Total


28.6 15.9

69.9 84.1

1.5 0.0

196 44


16.7 27.3

83.3 71.3

0.0 1.4

24

216 Total 26.3 72.5 1.3 240 Purnia Religion χ2 15.27 Hindu Muslims

11.5 31.8

85.6 68.2

2.9 0.0

174 66


17.2 16.7

81.6 78.8

1.1 4.5

174 66


18.8 15.6

77.7 83.6

3.6 0.8

112 128

Total 17.1 80.8 2.1 240 Saran Religion χ2 1.24 Hindu Muslims

14.5

9.1

84.1 90.9

1.4 0.0

207 33


17.6

6.2

81.8 91.4

0.6 2.5

159 81


13.1 15.3

86.3 81.9

0.6 2.8

168 72

Total 13.8 85.0 1.3 240 Vaishali Religion χ2 0.40 Hindu Muslims

10.9

7.7

86.1 89.7

3.0 2.6

201 39


14.5

2.5

84.9 90.1

0.6 7.4

159 81


7.4

18.8

88.6 81.3

4.0 0.0

176 64

Total 10.4 86.7 2.9 240

baseline study on immunization in rural bihar study on immunization in rural bihar a report...

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