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Evaluation of Initiative to Improve Maternal Health with Social Determinants Approach

A Report

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© Oxfam India August, 2015

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Published by Oxfam India: 4th and 5th Floor, Shriram Bharatiya Kala Kendra, 1, Copernicus Marg, New Delhi 110001 Tel: +91 (0) 11 4653 8000 www.oxfamindia.org

Oxfam India

Oxfam India, a fully independent Indian organization, is a member of an international confederation of 17 organisations. The Oxfams are rights-based organizations, which fight poverty and injustice by linking grassroots interventions, to local, national, and global polic developments.

For further information please write to: [email protected], or visit our website: www.oxfamindia.org.

This evaluation was a collaborative effort by the Essential Services team of Oxfam India and its partners. First and foremost sincere thanks and appreciation goes to the partner organizations of ‘Initiative to Improve Maternal Health with Social Determinants Approach project’ supported by Global Poverty Action Fund (GPAF) of the Department for International Development (DFID). This evaluation would not have been possible without their support and reflections. A special thanks to the communities who shared information and participated whole heartedly in the evaluation process.

Special mention to Nisha Agrawal (CE0, Oxfam India), Shaik Anwar (Director-Programme & Advocacy) and Ranu Kayastha Bhogal (Director – Policy, Research & Campaigns) for their constant support and encouragement.

The Essential Services team members (Anjali Bhardwaj, Jitendra Kumar Rath, Pallavi Gupta, Pratiush Prakash, Preeti Bohidar, Sanjay Suman, Sanjeeta Gawri) for their efforts to provide an evaluation study which can be helpful for further learning on work related to maternal health. A special thanks to Ritesh Laddha (Coordinator – Monitoring, Evaluation and Learning) for coordinating and maintaining quality standards of evaluation.

Much appreciation goes to the NRMC team, particularly Ankita Singh, Anurag Gupta, Jayesh Bhatia, and Nikhil Raj for their help in putting the study together.

Also, thanks to Deepak L Xavier (Essential Services Lead Specialist) and Aniruddha Brahmachari (Sr. Manager - Programme Quality, Management, MEL) for conceptualizing and steering the process of evaluation.

Acknowledgements

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This endline evaluation survey was approved by Institutional Review Board (IRB) of Center for Media Studies, 34 B, Research House, Community Centre, Saket, New Delhi, India -110017 with IRB Number: IRB00006230.

The IRB approval ensure that while undertaking this survey sufficient safeguards have been taken to no known physical, emotional, psychological or economic risk to individual(s) involved in this survey. It also ensured about appropriateness of the methodology used to secure informed consent and the rights and welfare of individual(s) involved.

Evaluation Transparency & Ethics

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Table of Content

List of Figures v

List of Tables vi

Acronyms vii

Executive Summary 1

1. Context 6

1.1. Efforts Towards Promoting Maternal Health 6

1.2. Issues at Hand 6

1.3. Approach towards Improvement in Health Outcomes 7

2. About the Project 9

2.1. Building social capital for generating demand for health 9

2.2. Revival of VHSNCs 10

2.3. Harnessing the Strength of Local Change Agents 10

2.3.1. Adolescent Girls Group 10

2.3.2. Barefoot Auditors 11

2.4. Towards a more responsive healthcare at the grassroots 12

3. Research Design and Methods 13

3.1. Research Objectives 13

3.2. Research Framework and Design 13

3.3. Data Collection Methods 14

3.4. Sampling Approach 15

3.4.1. Selection of Target Areas 16

3.4.2. Selection of Villages 16

3.4.3. Selection of Households 17

4. Demographic Profile 20

4.1. Social Group 20

4.2. Economic Status 20

4.3. Access to Drinking Water, Sanitation and Cooking Fuel 21

4.4. Respondent Characteristics 21

5. Birth Preparedness 23

5.1. Antenatal Care 23

5.1.1. Awareness 23

5.1.2. Information regarding ANC 24

5.1.3. Number of ANCs Received 25

5.1.4. ANC from Numbers to Meaning 25

5.1.5. Counselling by ANM or ASHA 26

5.2. Nutrition and Consumption of Iron Fortified Food and Supplements 27

5.2.1. Receipt and Consumption of Take-Home Ration (THR) 27

5.2.2. Receipt and Consumption of Iron Folic Acid (IFA) tablets 29

5.2.3. Access to Public Distribution System (PDS) 30

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5.3. Good practices on birth preparedness- Reflections from the states 31

6. Safe Delivery 34

6.1. Complications during Pregnancy and Childbirth 34

6.1.1. Awareness of Complication during Pregnancy 34

6.1.2. Incidence of Complication during Pregnancy 35

6.2. Institutional Delivery 36

6.2.1. Availing Benefits of JSY 38

6.2.2. Awareness regarding JSY 38

6.2.3. Transport and Payment for Institutional Delivery 39

6.2.4. Deliveries Attended by Skilled Birth Attendants 40

6.3. Post-Natal Care 41

6.4. Strategies that worked- Glimpses from the states 42

7. Family Planning 46

7.1. Age at Marriage 46

7.1.1. Knowledge about Legal Age of Marriage 46

7.1.2. Age at Conception of First Child 47

7.2. Safe Abortion 47

7.3. Family Planning Methods 49

7.3.1. Awareness of Temporary Methods 49

7.3.2. Awareness of availability of contraception and safe abortion services 50

7.4. Approaches towards family planning- Vignettes from States 52

8. Explaining Outcomes through the Lens of Social Determinants 54

8.1. Augmenting Birth Preparedness 54

8.2. Steps towards Safe Delivery 55

8.3. Self-Efficacy in Family Planning 56

8.4. Demand Creation versus Service Delivery 57

9. Conclusion 58

9.1. Empowering Women 58

9.2. Bringing VHSNCs to Life 58

9.3. Walking the Last Mile of Service Delivery 59

9.4. Sowing the Seeds of Change 59

Annexures 61

I. Log-frame Indicators 61

II. Data Collection Approach 63

a. Tools and Techniques 63

b. Sample Size Covered 64

c. Selection of Villages 65

d. Selection of Households 66

III. Quality Assurance Mechanism 67

IV. Calculation of SLI 68

V. Key Indicators Sheet 70

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List of Figures

Figure 1 Maternal Mortality in the Six States 7

Figure 2 Indicators of Determinants of Maternal Health in India by Area 7

Figure 3 Determinants of Health Outcomes 8

Figure 4 Broad aspects to be covered in the endline evaluation 13

Figure 5 Analytical approach 14

Figure 6 Data collection approach including the target groups 15

Figure 7 Sampling methodology 16

Figure 8 Source of Information regarding ANC (in %) 24

Figure 9 Proportion of women undergone three or more ANCs by states (in %) 28

Figure 10 Proportion of women who reported to have received iron rich/ iron fortified food by states (in %) 29

Figure 11 Proportion of women who reported to have received at least 100 IFA Tablets (in %) 34

Figure 12 Proportion of women aware about incidences of serious health problems due to pregnancy or childbirth (in %) 36

Figure 13 Place of Delivery (in %) 37

Figure 14 Proportion of women whose last child birth was attended by skilled health personnel (in %) 37

Figure 15 Proportion of women who conceived at least one year after the legal age of marriage (in %) 40

Figure 16 Proportion of women aware of availability of safe abortion services in public health facilities (in %) 48

Figure 17 Proportion of women who were aware of the time period for safe abortion (in %) 48

Figure 18 Proportion of eligible couples in the intervention area with knowledge of temporary method of contraception (in %) 49

Figure 19 Roles played by different Actors in provision of VHND services 49

Figure 20 Effect of JSY on Institutional Deliveries 55

Figure 21 Project’s efforts towards strengthening VHSNCs 56

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List of Tables

Table 1 Household Characteristics (in %) 21

Table 2 Respondent Profile (in %) 22

Table 3 Standard of Living Index (in %) 22

Table 4 Proportion of women who reported to have knowledge regarding at least 3 ANCs (in %) 23

Table 5 Proportion of women who have received counselling from ANM/ASHA on care during pregnancy (in %) 26

Table 6 Proportion of women who reported to be informed regarding their status of Anaemia (in %) 27

Table 7 Proportion of women who consumed iron rich/iron fortified food (in %) 28

Table 8 Proportion of mothers who consumed atleast 100 IFA tablets 29

Table 9 Proportion of households with status of PDS consumption and satisfaction 30

Table 10 Percentage distribution of women who women who reported to have a problem by states (in %) 35

Table 11 Danger signs reported by women (in %) 36

Table 12 Place of treatment for complications during pregnancy by state (in %) 36

Table 13 Percentage distribution of place of delivery by State (in %) 37

Table 14 Proportion of women who reported to have benefited under the JSY scheme (in %) 38

Table 15 Percentage distribution of women who are aware about the scheme (in %) 38

Table 16 Percentage distribution of women who availed an ambulance from the hospital (in %) 39

Table 17 Percentage distribution of home deliveries assisted by health professionals (Doctors) 41

Table 18 Percentage distribution of women who are aware of legal age at marriage (boys) by states (in %) 46

Table 19 Percentage distribution of women who are aware of legal age at marriage (girls) by states (in %) 46

Table 20 Percentage distribution of women who are aware of disadvantages of early marriage by states (in %) 46

Table 21 Proportion of men and women married before legal age 47

Table 22 Percentage distribution of women who reported to be taking decision regarding family planning by states (in %) 50

Table 23 Proportion of women with knowledge regarding terminal and spacing methods of Family Planning (in %) 50

Table 24 Percentage distribution of women aware of availability of contraceptives and safe abortion services 51

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Acronyms

ASHA : Accredited Social Health Activist

AWW : Anganwadi Workers

ANC : Ante-Natal Check-Ups

ANM : Auxiliary Nurse Midwife

BFA : Barefoot Auditors

BMO : Block Medical Officer

CDPO : Child Development Project Officer

CBM : Community Based Monitoring

CHCs : Community Health Centres

DoHFW : Department of Health and Family Welfare

WCD : Department of Women and Child Development

FLW : Frontline Health Workers

IEC : Information Education and Communication

ICDS : Integrated Child Development Services

IUD : Intra Uterine Devices

IFA : Iron Folic Acid

JSSK : Janani Shishu Suraksha Karyakram

JSY : Janani Suraksha Yojana

LS : Lady Supervisor

LPG : Liquefied Petroleum Gas

MGNREGA : Mahatma Gandhi National Rural Employment Guarantee Act

MMR : Maternal Mortality Ratio

MO : Medical Officer

MDG : Millennium Development Goals

NRHM : National Rural Health Mission

NGO : Non-Governmental Organization

PNC : Post-Natal Care

PHC : Primary Health Centre

SC : Scheduled Caste

ST : Scheduled Tribes

SLI : Social Living Index

THR : Take-Home Ration

TT : Tetanus Toxoide

TFR : Total Fertility Rate

TBA : Traditional Birth Attendant

VHND : Village Health and Nutrition Day

VHSNC : Village Health, Sanitation and Nutrition Committee

WHO : World Health Organization

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A. Context

Despite several efforts at the national level, a maternal mortality ratio (MMR) of 167 per 1,00,000 live births in 2014-15 (UNICEF, 2015) continues to reflect a dismal situation of maternal health in India. A commitment towards curbing MMR has found renewed focus under the National Rural Health Mission (NRHM) since the year 2005. Adopting a mission mode of addressing the issue of high MMR, multiple schemes such as the Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK) and Integrated Child Development Services (ICDS) have been brought together work closely towards fulfilment of institutional and nutritional requirements. Further, adopting a lifecycle approach schemes such as SABLA has been rolled out to address the issue of anaemia in girls and prepare them towards a healthy motherhood. Capacity building of frontline functionaries such as the Anganwadi Workers (AWW), Accredited Social Health Activist (ASHA) and Auxiliary Nurse Midwife (ANM) have also formed key components of the national mission to reduce MMR.

However, singularity in approach through working on the supply constraints, mainly in terms of availability of resources has failed to deliver the warranted outcomes. This approach, inter alia, also meant a relatively lower importance accorded to a host of factors such as socio-economic conditions, role and status of women in the society, power relations within a household and community that could potentially have a critical role in determining and enabling improvements in maternal health in the country. It is, therefore, not surprising that the accessibility to health programs and schemes and its consequent utilisation remain low where traces of gender disparity and patriarchy are high. States like Bihar, Chhattisgarh, Jharkhand, Rajasthan and Odisha are seen to have recorded the highest MMR accounting for nearly one third of the maternal deaths in the country.

Executive Summary

B. About the GPAF Project

Within this larger context, Oxfam India undertook an initiative with a social determinants approach to improve maternal health in selected states with support from GPAF (DFID). Working through local civil society organisations the project envisaged to bring about a change in the health seeking behaviour of the rural communities, focussing primarily on maternal health. This was accomplished through addressing both demand and supply side factors and bridging the gap between them resulting in smooth and hassle free medical experience. The demand side was strengthened through awareness generation of the community of their entitlements, capacity building to claim those entitlements, harnessing the strength of in situ change agents (Barefoot Auditors and groups of adolescent girls) and empowering the community institutions to sustain the change in long run. On the other hand, the supply side interventions focused on capacity building of the frontline functionaries and leveraging on the government programs through closer interface. The project was implemented during 2012-15 in six states namely, Bihar, Jharkhand, Chhattisgarh, Odisha, Maharashtra and Rajasthan.

C. Evaluating the change

NRMC India was commissioned by Oxfam India to conduct an endline evaluation to measure project progress, understand the processes involved and document the best practices, learnings and challenges faced in the project. To achieve the above objectives, a survey of select project villages was conducted and the impact of the project measured by a comparison of the endline estimates of the indicators with the baseline. The study design and analytical approach for endline study was formulated to measure impact on aspects of birth preparedness and ante-natal check-ups (ANC), institutional delivery, promoting

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intake of nutritious food, family planning and community participation. The evaluation framework of the study rests on the log frame indicators developed for the GPAF project and social determinants approach using a pre-post analysis to estimate the effect of the project by comparing the baseline and endline evaluation figures. A cross-section study was conducted using a mix-methods approach which employed both quantitative and qualitative methods. Structured questionnaire was administered to 1,437 respondents (pregnant women and mothers having a child below two years of age) drawn from 12 districts from the project states. Focus Group Discussions and other qualitative techniques such as H-Form Tool were used to understand the role of various social determinants, both at individual and institutional levels, in influencing maternal health outcomes. The entire study was conducted by NRMC during May-June 2015.

C.1. What do the demographic indicators suggest?

With the exception of Bihar, there was a high concentration of tribal groups across the study states (34 percent). In Bihar there was a higher percentage of Scheduled Caste (SC) (30.5 percent) and Muslims (38.6 percent). The project villages chosen across the states are poor and marginalised with 71 percent of the households reported as poor. Almost 50 percent of the households are kaccha and over 53 percent of them have Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) job cards. Nearly 42 percent of the households reported farming as their main source of income and 46 percent of the households were dependent on daily wage or agricultural wage labour as their primary source, with only a handful engaged in government or private jobs or petty business of their own.

The Social Living Index (SLI), calculated using the data on 30 household assets, indicates that almost 40 percent of the households lie in the ‘low’ category and over 57 percent belong to the medium category.

In terms access of drinking water, 61.6 percent of households use hand pump to draw water, with less than 20 per cent having access to piped water. Overall, only 10 percent of the households reported to have a functional toilet facility within the household which is similar to that of the baseline. A high reliance on wood (71.4 percent) as cooking fuel is seen across the states. Maharashtra and Rajasthan show use of LPG as a fuel for cooking. The mean age at marriage for girls at the project level is 18 years (lower at 15 years in Rajasthan) and the mean age at first pregnancy is 20 years (and 17 years in case of Rajasthan). The states depicted a wide difference in terms of educational status among women, with states such as Jharkhand (51.8 percent), Maharashtra (51.1 percent) and Odisha (43.7 percent) reporting a higher level of education among the respondent where majority women reported to have studied up to higher secondary as compared to Bihar, Rajasthan and Chhattisgarh. It must be mentioned here that demographic profile at the endline closely resembles that observed at the baseline, adding to the comparability of the endline findings with the baseline.

C.2. Are women better prepared for delivering a child?

In the context of birth preparedness, the program targeted the Village Health and Nutrition Days (VHNDs) as platforms for information sharing (particularly on ANCs and nutrition) and triggering behaviour change among expectant mothers. The VHNDs are found to be held regularly and most of the women attend it. Enhancing the utility of the VHNDs, community institutions, such as the Village Health, Sanitation and Nutrition Committees (VHSNCs) in several villages are walking the extra mile (by ensuring privacy for facilitating abdominal check-ups and having plans to even buy a machine to test the Haemoglobin level in the blood). The findings suggest that the proportion of women who had undergone three or more ANCs has significantly increased from 60 percent at the baseline to 80 percent at the endline. Apart from receipt of Iron Folic Acid (IFA) tablets and Tetanus

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Toxoide (TT) injection, women in Maharashtra, Chhattisgarh, Odisha and Jharkhand reflect a greater degree of awareness regarding the other constituents of ANCs such as the abdomen check, blood pressure and weight checks. In terms of individual outreach, ASHAs and ANMs are reported to be the most important source of information in generating awareness among the women regarding ANCs. The proportion of women who reported to have received counselling from the ASHA or ANM shows an increase by 43 percent during the project period.

Nutrition indicators also show some improvements, particularly those related to supply responses. Compared to the baseline, a greater proportion of women reported to have received Take-Home Ration (THR) (particularly in Chhattisgarh and Rajasthan). However, poor taste and high salt content of the food packets seem to have pushed down the offtake of THR by women in Jharkhand. Receipt and consumption of IFA tablets too has registered an improvement across all states, except Bihar, wherein supply chain breaks were reported to have constrained the distribution of IFA tablets. Strong recall among the women regarding the nutrition fairs held under the project underlines the relevance of visual demonstration as an intervention in creating a lasting impression for behaviour change on nutrition for improvements in maternal health.

C.3. How safe are the deliveries?

With an increase in the VHND and the activity of the ASHA, women are now more aware of the symptoms during pregnancy that could be danger signs. The counselling sessions carried out through the frontline functionaries have led to an increase of 17 percent over the baseline in the proportion of women who were aware of at least two danger signs of pregnancy and at least two complications during and after child birth. In fact, it was this awareness that made over 40 per cent of the respondents to have noticed some danger signs during pregnancy. It is encouraging to note that the awareness has led to change in

health seeking behaviour related to complications during pregnancy. Nearly three-fourths of the women reported to have sought medical care for pregnancy related complications.

An important indicator of improvements in maternal health is the increase in institutional delivery. In Maharashtra, Odisha and Rajasthan, there is a significant increase in deliveries at public hospitals. The role of the frontline functionaries, Barefoot Auditors (BFA) and the community level platforms such as the VHND seem to have jointly played a role in triggering the behaviour change among pregnant women to opt for institutional delivery. Importantly, the conditional cash transfers that accrue through the JSY has also been significant pull factors to register an increase in institutional delivery. It is interesting to note that the project has enabled the community to raise their voice demanding their entitlements as JSY beneficiaries. The proportion of women whose last child birth was attended by a doctor has increased across all states with close to 55 percent of deliveries being attended to by doctors. However, not all states seem to have benefited from the JSY, as in Bihar, Jharkhand and Chhattisgarh. Constraints in the flow of funds for cash transfers under JSY appear to have adversely affected measurable change in the institutional delivery.

C.4. Moving along a continuum – from Preparation to Delivery to Family Planning

Nearly 75 percent of women (along with their husbands) are now taking decisions regarding planning their family. What is important to note is that 60 percent of the women who are taking these decisions belong to the age-group of 18-25 years. In fact, greater proportion of women reported to have knowledge regarding availability of contraception and safe abortion services (37 per cent increase) and options of male and female sterilization compared to the knowledge levels recorded at the baseline. It is also encouraging to note that of the 51 percent women who knew about the availability of contraceptives and safe

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abortion services, 79 percent were those who took decision regarding their family planning along with their husbands and 71 percent are those who have two or lesser number of children. This is indeed reflective of humble steps towards gender equity within the households.

D. Understanding Outcomes in the Light of the Determinants

The project has identified components of nutrition, safe delivery and family planning as its core factors at play that are instrumental in reduction of MMR in India. It has taken the route of community based mobilization in voicing their demand for the entitlements under the existing public programmes and schemes.

The project had worked with social groups that were comprised mostly of Scheduled Castes (SC) and Scheduled Tribes (ST). Thus, the evaluation was also conducted with these groups to asses a change using pre-post analysis. However, the homogeneity of the groups that were visited during the endline survey tend to be a limiting factor to look at a causal analysis or understand latent factors at play instrumental in the change, through quantitative data at this stage. The analysis, therefore, draws upon inferences from qualitative findings of the discussions in the field.

D.1. Augmenting Birth Preparedness

Birth preparedness, under the ambit of the project, consists of improved nutrition, increase in ANCs and reduction in incidents of anaemia. VHNDs have been instrumental in the improvement of indicators pertaining to the three components. With increased awareness about the features of VHND mandated as per government rules, the VHSNCs have made the frontline workers accountable towards provision of adequate check-ups during pregnancy, information regarding care to be taken during pregnancy and the nutrition supplements that are provisioned for the women. The success of VHND across states is attributed to a responsive supply side that has met the demands of the

community. VHND effectively, underscores the convergence of health and nutritional aspects of mother and child health where one day every month, pregnant and lactating mothers can receive health check-ups and receive nutritional supplements that help reduce incidents of anaemia. This model has worked under the project as the efforts have brought a synthesis of the work of the community based institution and the service providers to benefit the individual.

D.2. Steps towards Safe Delivery

The program has specifically raised awareness of the community regarding the JSY benefits that they are entitled to. However, supply side bottlenecks in Bihar, Chhattisgarh and Jharkhand have led to non-payment of the monetary benefit under JSY. While awareness about the scheme has increased in these states, the supply side has not conformed to its mandates. Thus, poor responsiveness from the service providers has led to a decline in the deliveries that happen at public health facilities.

Many efforts across the three states, in petitioning for the entitlement have been made but they have not resulted in significant outcomes. Thus, a larger advocacy with the state level officials of the concerned departments is needed for the effects to be observed at the ground level.

D.3. Reliance on local change agents for family planning

The project has harnessed the strength of the adolescent girls in the villages and used a life-cycle approach to educate the young girls on issues related to early marriage and need of spacing and limiting children. In this component, the services at public facilities were already available, however, knowledge regarding the same and a discussion amongst women was found to be lacking at the beginning of the project. Through the empowerment of girls, the project has brought about an increase in awareness. Thus, the barrier of discussions around family planning have been reduced as younger women being more active are

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discussing it in their community with the married women in the reproductive age.

D.4. Demand creation versus service delivery

While the context of each state, pertaining to the efficacy of the supply side and the strength of demand from the community, has been different, the outcomes have shown progress across various indicators of maternal health. The social determinants at play particularly the community’s attitude, their capacity and the social norms have been very well captured in the project. However, supply side bottlenecks, including the health care facilities and the policy environment need special attention and perhaps stronger lobby towards a better service delivery mechanism. The demand for the entitlements has been raised, the community is aware and mobilised as they await a responsive service delivery system from the state.

E. What patterns are reflected for sustaining the behaviour change?

Across the chosen themes, the project indicates an increase in awareness regarding safe practices of motherhood amongst the beneficiaries. This awareness has shown a translation into compliance with safe behaviour such as increase in consumption of minimum number of IFA tablets, uptake and consumption of THR and counselling from ANM and ANC.

However, issues of concern emerge from the supply side in Bihar, Jharkhand and Chhattisgarh, where delivery in public hospitals has reduced due to poor functioning of the JSY scheme, lack of female doctors and inadequate infrastructure and facilities in the public health facilities.

Further, access to contraceptives and safe abortion facilities has increased with women now

taking decisions regarding family planning along with their husbands. However, what is required is to understand whether the awareness has translated into better practices. While limiting is understood well by the women, the need for spacing is yet to be well absorbed. Safe abortion services at public health facilities may be known to the women, but they have indicated a preference towards the private services given the social norms that underline the taboo around the subject.

It must be noted that while village based institutions have been reconstituted and a new cadre of Barefoot Auditors have been introduced, the sustainability of their efforts may be a question at this stage. The institutions have strongly expressed their need for further guidance lest they are unable to sustain their work. As the project has withdrawn, the Barefoot Auditors are looking for newer opportunities to work for an income. The voluntary nature of their work cannot be sustained for long as the work is quite demanding and requires a lot of dedication.

The groups of adolescent girls across states have proved to be the strongest link of the project. As young girls get more aware of health issues, safe practices and health services, they would take it forward after marriage, disseminating knowledge to others. This group requires minimal inputs in terms of economic capital. The project has instilled a sense of confidence amongst the girls who feel empowered as a group. Most importantly, the project has created a sense of empowerment amongst women who now sit with the men during VHSNC meetings and draft the health plans. This has been found as the most significant change that the project has ushered in, as expressed by the women, the VHSNCs and the BFAs. The project has helped overcome inertia of rest and resistance to change. A far greater energy is however required to sustain the momentum.

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T he ambit of maternal health has been expanding both in terms of theory as well for all practical purpose. While World Health

Organization (WHO) states the definition of maternal health as the health conditions of pregnant women, International Conference on Population and Development in the year 1994 augmented the concept by adding on the eligible mothers as well as their physical, mental and social well-being. This theoretical shift can be seen to be a product of the practical challenges faced while catering to the problem of maternal mortality. While efforts and resources had been devoted to the cause all over the world, maternal deaths still remain big challenge especially in the third world countries. While the global Maternal Mortality Ratio (MMR) has registered a decline of about 45 per cent, India with a MMR of 167 lags well behind the fifth goal of Millennium Development Goals (MDG) i.e. to reduce the MMR to 109 per 1,00,000 live births by 20151.

1.1. Efforts Towards Promoting Maternal Health

Maternal health has continued to remain a priority of all health programs in India for a long time, the main reason being high maternal deaths evidenced throughout the country. The commitment towards the curbing the MMR was emphasised through the launch of National Rural Health Mission (NRHM)2 in the year 2005 to exclusively cater to maternal and child health. The availability quotient was

1 UNICEF Data: Monitoring the Situation of Children and Women, http://data.unicef.org/maternal-health/maternal-mortality accessed on 22nd June, 2015

2 The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups. It now falls under the umbrella of the National Health Mission. The key features of the Mission include making the public health delivery system fully functional and accountable to the community, community involvement, decentralization, convergence of health and related programmes form village level upwards for improving health indicators. (Source: National health Mission, Mnistry of Health and Family Welfare, Government of India, 2015)

taken care of through various schemes aiming towards fulfilment of institutional and nutritional requirements. For instance, Integrated Child Development Services, (ICDS)3 supports the nutritional needs of the pregnant and lactating mothers through provision of take home ration whereas Janani Shishu Suraksha Karyakram (JSSK)4 caters to the institutional requirements of such women by making medical attention and requirements cashless. Thrust on behavioural change has been made through schemes such as Janani Suraksha Yojana (JSY)5 which provides monetary benefits to women undergoing institutional deliveries as institutional deliveries are safer and would help in reduction of MMR.

Taking into account of the lifecycle approach where today’s adolescent girl would be a mother tomorrow, schemes such as SABLA6 has been rolled out which aim to address the issue of anaemia in girls and preparing them towards a healthy motherhood. Apart from the schemes, strengthening of service providers who take health facilities to the doorstep has also been accomplished through the Anganwadi Workers (AWW), Accredited Social Health Activist (ASHA) and Aumxiliary Nurse Midwife (ANM).

1.2. Issues at Hand

Despite such efforts India is still struggling to register the intended decline in MMR. This can be

3 ICDS- Integrated Child development service is the one of the world’s largest child development programme which also includes providing nutrition through providing take home ration to the to the pregnant and lactating mothers

4 JSSK- Janani Shishu Suraksha Karyakram is a national initiative to provide completely free and cashless services to pregnant women including normal deliveries and caesarean operations and sick new born (up to 30 days after birth) in Government health institutions in both rural & urban areas.

5 JSY- Janani Suraksha Yojana is a safe motherhood intervention under National Rural Health Mission (NRHM). It promotes institutional delivery by providing monetary benefits immediately post-delivery in medical institutions

6 SABLA- it is a national initiative to take care of the health and nutrition of the adolescent girls.

1 Context

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attributed to the singularity in approach adopted to cater to maternal deaths i.e. restricting to mere availability of resources. The accessibility part of the picture has not been well catered by the implementers over the years. Ensuring maternal health not only requires addressing the health needs of a woman but it also encompasses understanding the socio-economic conditions, role and status in the society, power relations she holds within a household and every factor which affects and determines her existence. Thus, the accessibility to health programs and schemes and its consequent utilisation remains low where traces of gender disparity and patriarchy are high very similar to what is evidenced in India. States like Bihar, Chhattisgarh, Jharkhand, Rajasthan and Odisha have recorded the highest MMR accounting for nearly one third of the maternal deaths in the country.

Figure 1: Maternal Mortality in the Six States

Source: Census of India Bulletin, 2011-13

Along with a high MMR, the country also deals with issues of acute anaemia amongst women, undernourished mothers and children, incidences of home based deliveries, early marriages and high parity thus deteriorating the health of both mother and child.

Figure 2: Indicators of Determinants of Maternal Health in India by Area

Source: District Level Household and Facility Survey 2007- 08

The nexus between social status of women and maternal deaths can be proved from the very fact maternal deaths remain low in urban areas where a woman is better informed and exercise greater autonomy within the family. Marked difference in fertility rates have also been seen according to the literacy level of a woman. According to the census of India report 2013, while Total Fertility Rate (TFR) of an illiterate rural woman is 3.2, a literate urban woman records it as 1.7. With autonomy and literacy comes the power of making informed choices and exercise decisions best for their own health. However, educating the women alone would remain insufficient to address to the perceived social barriers which hinder the accessibility to health services. It requires a more comprehensive approach where each and every member of the society is made aware of the needs and requirements of a woman along with ways to facilitate the same which was when a social deterministic framework was adopted to analyse the issue.

1.3. Approach towards Improvement in Health Outcomes

Social determinant approach to maternal health takes into account the social factors which

0

100

200

300

Maternal Morality RatioMaternal Deaths

Maharasth

ra

Odisha

Rajasthan

Chhattisgarh

Bihar/Jharkhand

81

208

72 6544

222

23

104

221244

47

37.9

43.6

48

42.9

52.7

0

20

40

60

Rural India

Currently married women age 20-24 who were married

before age 18

Safe Delivery

Institutional Delivery

7

affect the health, well-being and overall life of a woman. It is understood that a person’s choices are a product of the present social factors and the past experiences. Thus, in order to explain the factors for health choices made by a woman, understanding the social construct and their social status becomes pertinent. Ensuring availability and accessibility through strengthening state services would not suffice for assuring proper maternal health. It has to team up with factors responsible for better utilisation of the provided resources which depends on her parents-in-law, husbands, parents and others especially in rural areas. Effective utilisation would require

addressing to the concerns of the social actors who can prove to be hindrance on the way of utilisation.

The project has adopted this approach to improve conditions of maternal health through community building by reviving and empowering the Village Health, Sanitation and Nutrition Committees (VHSNCs) in villages which acts as a platform to voice community demand. Also methods of advocacy and awareness generation have been employed to enhance community knowledge and participation such that they can claim their entitlements.

Determinants of Health Outcomes

OutcomesHealth System and Related Sectors

Government Policies and ActionHousehold/Communities

Health Outcomes

Health and nutritional status of women

Household Actions and Risk Factors

Awareness and use of health services, dietary, sexual practices and lifestyle etc.

Household Assets

Human, physical, financial

Health Service Provision

Awareness, availability, accessibility, quality of service

Health Policies at macro and micro level and health systems

Other government policies, example, infrastructure, transport, water and sanitation

Supply in Related Sectors

Awareness, availability, accessibility, quality of food, roads, water and sanitation etc.

Community Factors

Cultural and religious norms, community institutions, environment and infrastructure

Figure 3: Determinants of Health Outcomes

Source: World Bank, 2010

8

The initiative to improve maternal health using social determinants approach by Oxfam India through it partner Non-Governmental Organizations (NGOs), envisaged to bring about a change in the health seeking behaviour of the rural communities, focussing primarily on maternal health. This was accomplished through addressing both demand and supply side factors and bridging the gap between them resulting in smooth and hassle free medical experience. While the demand side was strengthened through awareness generation of the community of their entitlements, capacity building to claim those entitlements and as well empowering the community to sustain the change in long run, the supply side was enhanced by training the Frontline service providers and leveraging on the government programs like NRHM, ICDS etc.

The project has relied on three broad pillars of execution:

2.1. Building social capital for generating demand for health

Demand has been generated in the community at both- household and community level. At the household level, focus was more on improving individual’s awareness and knowledge on maternal health while at the community level it was looked upon as a conglomerate responsible for ensuring proper maternal health. Distinct approaches were employed to address the issues at both levels.

The first step towards stimulating the demand side

was through generating awareness about various benefits from government schemes and programs that people were entitled to. This knowledge about entitlements was imparted at the community level through meetings and training sessions. Along with guiding the community through their entitlements, awareness about different aspects of maternal health and ways of ensuring safe motherhood was explained in these meetings. While short films were exhibited in villages on issues of maternal health and family planning in almost all the intervened districts, innovative methods such as conducting small quiz sessions with distribution of small prizes at the end of each meeting ensured effective participation and learning among the community members in Odisha.

Realisation of the fact that maternal deaths are not only the function of awareness and practise among the pregnant and eligible mothers but

involves far larger number of actors and factors, has emanated in adoption of a social determinant approach while looking at the issue of maternal deaths and formulating ways to resolve them. Efforts were made to involve the entire community in the meetings and the awareness campaigns organised by the program in the villages.

For instance the intervention in Bihar and Jharkhand was initiated through organising ‘Saas-Bahu-Pati Sammelan’ where maternal health was recognised as an important issue within a

About the Project

Generating Awareness

• Householdlevel

• Communitylevel

Deploying local change agents

• Adolescentgirls

• Barefootworkers

Improving responsiveness of

supply side

• VHSNCs• ASHAs• ANMs

2

9

family and was talked about on a larger platform addressing it both- at the level of family and at the level of community. Similarly, the importance of family in ensuring proper maternal health was realised in Odisha through organising programs to strengthen the bonding between mothers-in-law and daughters-in-law.

While the community had a faint idea about the nutritional requirements of a pregnant woman, concrete information about locally available nutritious food and different ways of preparing these food was provided to the community through organising ‘WASH melas’ in Bihar and Jharkhand and ‘Jevnaar Melas’ in Chhattisgarh. These melas other than talking about nutrition also concerned itself with delivering information about maintaining sanitation and hygiene in the village. This platform was also used to bridge the gap between the community and the supply side actors like the ASHA, ANM etc. by involving them in the meetings and campaigns.

Family planning was considered to be a major component towards ensuring maternal health and formed a key component of awareness generation among women as well as facilitating supply side responses for ensuing availability of contraceptives as also facilities for safe abortion was focussed on. Special sessions on family planning and its benefits were held to make the community abreast of the procedures and the benefits thereof for couples to adopt modern temporary methods.

2.2. Revival of VHSNCs

Through the revival of the VHSNCs, health planning was brought to the grass roots where the community can make their own health plans suiting their needs and requirements. The project took VHSNCs as important elements and devised ways to make them work. The members were trained on the process of allocation and expenditure of the untied funds and the flexibility at hand in utilisation of these funds. In attempting to make the process transparent, the project also sought to

raise the accountability of these community level institutions. Mending this trust factor between the village residents and the committee provided the community with a platform to voice their demands in a more organised and implementable way.

While VHSNCs were informally established independently at the village level through the project in Bihar7, their functioning was revived in all other states inculcating a sense of responsibility towards village health and hygiene. Different programs were taken up to maintain health, hygiene and sanitation in all the states of which construction of roads and filling up of potholes were some of the primary activities. Other than that special activities to spread awareness against fatal diseases like Malaria, typhoid and dengue were done in Odisha. Also efforts were taken to disinfect mosquito nets by dipping them in mosquito repellent solution was also carried out by the VHSNCs in Odisha.

The VHSNCs were also made responsible for the Village Health and Nutrition Days (VHNDs) where they were entrusted with arranging with necessary equipment and other logistics along with providing counselling about health and nutrition to the pregnant and lactating mothers.

2.3. Harnessing the Strength of Local Change Agents

2.3.1. Adolescent Girls Group

To ensure sustainability of the project, groups of adolescent boys and girls were formed. Such group was chosen for two reasons, the first that it was young and quite receptive to changes and second that they stood at the threshold of starting a family. Greater attention was diverted to the adolescent girls who had already stepped into their reproductive age. They were trained on various aspects of maternal health as well ways to maintain hygiene and sanitation in their daily

7 In Bihar, VHSNCs are constituted at the Panchyat level and not at the village level as per the government mandates

10

life. Educating the girls with important tenets of health and hygiene was looked upon as not only resulting in personal growth and development but also creating an agent of change at the household level.

Approaches towards attending to adolescent groups varied from state to state. While Rajasthan catered to the cause of educating adolescent girls through organising ‘Kishori Melas’ twice a year where innovative and engaging activities were used to increase the awareness of the girls on the issue of maternal health, hygiene and sanitation, Chhattisgarh used posters and books for educating the young girls about reproductive health and hygiene. Odisha on the other hand held meetings and awareness campaigns where different public health officials were invited to speak about the necessity of maintaining hygiene and ways of improving maternal health.

Other than learning about the intricacies of maternal health, the girls were also educated with the demerits of early marriage and its impact on maternal health. Educating the girls is considered to have a multiplier effect addressing the concern at different levels

By inculcating the knowledge gained into personal life leads to behavioural change at individual level. Change in personal practise and perception would enable influencing others in the entire household. Such adolescent girls would not only become a role model for other girls but also lead influencing more people in the community.

2.3.2. Barefoot Auditors

Taking into cognisance the busy schedule of the ASHA which restricts her role of raising awareness in the community and attending to every woman’s need in the community, a new actor known as the

Group of Adolescent girls in Odisha

11

Barefoot Auditor (BFA) was added as a project’s feature. The BFAs are voluntary workers who were selected by the animators during the course of program. Other than generating awareness they have also been entrusted to act as a pressure group ensuring accountability from all the other supply side actors. They have also been trained with the use of community based monitoring (CBM) tools for keeping a check on the service providers.

While these BFAs were chosen from among the adolescent girls group in Odisha, Maharashtra and Rajasthan had both male and female BFAs. In many cases like that in Rajasthan, the ASHA is made the BFA due to the absence of interested female candidates which not only burdens the ASHA with more work but also steals the essence of the concept.

2.4. Towards a more responsive healthcare at the grassroots

Strengthening the supply side was a necessary measure in stimulating the demand side. Frontline Health Workers (FLW) form a vital part of the health system primarily due to their direct contact with the community. Some of these frontline workers like the ASHA and the AWW belong to the same community they are working for and possess

a better understanding of the socio-political conditions of the village. Thus empowering these workers would help overcome the social challenges towards maternal health.

The program took special efforts to ensure and enhance participation from the supply side functionaries. The ASHAs and ANMs were provided with trainings in Maharashtra, Chhattisgarh and Rajasthan. For instance, in Chhattisgarh the ASHAs are provided with drug-kit to deliver first-contact healthcare and expected to be a fountainhead of community participation in public health programmes in her village. In Odisha, the participation of the ASHAs and the ANMs was ensured to reduce the gap between the supply and demand-side and also to expose the ANMs and ASHAs to the needs and demands of the community which previously remained unheard. The project also involved the Medical officer and other state functionaries to make the complaints heard and solutions to be offered on a real time basis. Presence of the ANM was ensured on important days like the VHND and her regular visit to the villages was monitored. The increase in awareness level of the community also added to the advantage of the community where they were able to demand their due simultaneously inculcating accountability in the ANM.

An ASHA and Barefoot Worker in Chhattisgarh

12

This section outlines the overall research approach of the endline evaluation, methods of data collection and the analytical framework used in the study to measure the progress in outcome achievement and understand the nuances of the process that have led to the success in the project.

3.1. Research Objectives

The endline evaluation aims to measure project progress, understand the processes involved and document the best practices, learnings and challenges faced in the project. The overall objectives of the evaluation are:

• Tomeasure tangiblemilestones achieved andthe reasons for achievement in the project

• To assess which intervention strategies haveworked well and the reasons thereof.

To achieve the above objectives, a survey of select project villages was conducted and the impact of the project measured by a comparison of the endline estimates of the indicators with the baseline. Based on the observations from the review, study design and analytical approach for endline study was formulated to measure impact on the following four aspects:

3.2. Research Framework and Design

The evaluation framework of the study rested on the log frame indicators for the GPAF project. The overall focus of the project was to achieve improved health status of women by ensuring universal access to maternal health in six states of India. The current evaluation uses a pre-post analysis to estimate the effect of the project by comparing the baseline and evaluation figures to assess the change in the specific indicators pertaining to the project. The detailed indicators and assumptions are listed in the annexure. This study was designed to capture the change in the level of knowledge, attitude, practice & the process adopted at community level for enhancing maternal health.

A cross-section study was conducted using a mix-methods approach which employed both quantitative and qualitative methods. The fact that the GPAF project recognised the role of social determinants and therefore designed its interventions accordingly, it is deemed appropriate to use a social determinant approach to evaluate the project.

Building upon the approach as mentioned earlier, it is appropriate here to reiterate the importance of the role of social elements that determine

Research Design and Methods3

Safe Delivery Nutrition Family Planning Community Participation

• Reduction in number of incidences of serious health problems related to child birth

• Improved and increased access of women to obstetric care including referral services in the project intervention areas.

• Increased consumption of Iron rich/iron fortified food by women

• Enhanced community capacity to advocate for women’s access to a wholesome balanced diet including Iron rich supplementary nutrition provided by government.

• Increase in number of women conceiving at least one year after the legal age of marriage.

• Status of Village Health and Sanitation Committees who would able to monitor the maternal health services

Figure 4: Broad aspects to be covered in the endline evaluation

13

the health status in addition to the overarching ecosystem of policies and programmes. Specifically, for maternal health which takes into account the status of women in reproductive age, social factors like family support, her decision making capacity and norms of the community play a critical role. Some examples of such social elements relevant to our study include:

• Availability of resources to meet daily needs(e.g., safe housing and local food markets)

• Access to educational and economicopportunities

• Transportationandcommunicationoptions

• Socioeconomic conditions (e.g., concentratedpoverty and the stressful conditions that accompany it)

• Socialsupportfromthefamilyandcommunity

• Existingsocialandculturalnormsandattitudewhich may act as triggers or barriers to practices during pregnancy and child birth

To understand the link between underlying conditions or social determinants and health

outcomes, the study has looked at the role of socio- economic context and the relative position of a specific group within this context that leads to varying exposures to risk.

This framework provides a platform to integrate the data from the evaluation exercise and analyse it with the lens of maternal health outcomes prevalent in the state. For each level, the analysis will aim to establish and document:

• social determinants at play and theircontribution to social gradients

• promisingentry-pointsforintervention;

• triggersandbarrierstochange;

• whathasbeentriedandwhatwerethelessonslearned

3.3. Data Collection Methods

The evaluation used a mix of qualitative and quantitative methods for the process of data collection. In accordance with the social determinants approach, respondents for the evaluation were selected in a manner to

GovernmentPolicies/Schems

Health Facilities/Functionaries

Community

Family

Mothers

ANM’s Capabilities

Facilities at Private/Public Hospital

Presence of female doctor

Adolescent Girls

Reiligious Heads

VHSNC

ASHA

AWW

ICDS

PDS

JSY

VHND

Husband

Mother-in-law

Figure 5: Analytical approach

14

represent all categories of players that influence the health seeking behaviour of women in rural settings and their overall health status.

The following diagram represents an overall view of the adopted data collection approach along with the target group of respondents.

3.4. Sampling Approach

A multistage cluster sampling has been adopted to sample the villages for the study. The sampling was based on the list of project districts within each project state and the list of blocks and villages within each district shared by Oxfam India. The following box provides the details of the formula used for estimating the sample size.

Box 1: Formula for determination of sample size

Sample size =Deff x z2 x p x q x (1 + NRR)

d2

• Deff = Design Effect, as the sampling technique will be multi stage therefore assumed to be 2

• z=1.96(givena95%confidencelevelandthusanalphaor Type I error = 0.05)

• p = estimated or expectedminimum prevalence of thecondition or service in the target population in the project area

• q=1-p.Astheprevalenceofdifferentservicesusedbythetarget group is not known, therefore in order to maximize the sample size, 'p' would be taken as 50% i.e. 0.5.

• d= theabsoluteaccuracy (±anabsolutepercent fromthe estimated minimum prevalence) of the measurement at the given confidence level

• NRR=Non-ResponseRate,assumedtobe10percentor.1

Structured Questionnaires

Quantitative

Household Level

Pregnant women and Mothers of children <=2 years

Data Collection Qualitative

FGDs IDIsHousehold Level Institutional Level

• Pregnant women and Mothers of children <=2 years

• Husbands of women

• Mothers-in-law

• ANM

• AWW

• ASHA

• Barefoot Worker

• District and Block Medical Officer (NRHM)

• District and Block Project officer (ICDS)

• Medical Officer at PHC

• Lady Supervisor (ICDS)

• VHSNCs

Figure 6: Data collection approach including the target groups

15

Based on the above calculations for each state, a sample size of 210 respondents per state was calculated representative at the project level. Although the sample size was 210 per state, some additional surveys were conducted as buffer to maintain data quality in certain unforeseen scenarios which might lead to cancellation of surveys. The details of sample size distribution across states and villages are given in annexure.

3.4.1. Selection of Target Areas

A total of 12 sample districts (two per state) were selected out of 14 project districts for the

evaluation. The district wise list of project villages as shared by Oxfam India was considered as the sampling frame for the study. The following figure illustrates the sampling methodology adopted for the study.

3.4.2. Selection of Villages

The sample villages were selected by dividing the project villages into two strata (‘high’ and ‘low’) according to their number of households. Within each district that sample is distributed across the two strata equally (53 households in each stratum). Thus, three villages were selected using the random sampling method from each stratum.

6 states

Project States

12 districts

Stratification of each districts into 2 strata

3 villages per strata

Eligible Households

Sampled Households

Respondent

Pregnant Women or mothers who have

children aged less than 2 years

Selected Purposively

Strata 1: High (>=200 HH)Strata 2: Low (<200 HH)

Random Sampling

Household Listing in each Village

Circular systematic random sampling

6 villages per district

9 APL households9 BPL households

1 respondent per households; selection using Kish grid if more than 1 eligible respondent in a household

Figure 7: Sampling methodology

16

The list of sampled villages has been added in the annexure.

Note: Villages with a population of less than 50 households were not considered in the sampling frame. The sample size to be covered was 18 households in each village. Given that we had assumed a 30 percent probability of finding our target group (pregnant women and mothers with a child less than two years old), it effectively implied that we must list at least 60 households in each village. Considering the non-response rate and the need of a sampling frame to sample 18 households, a minimum of 70 households in each village was required to be listed.

3.4.3. Selection of Households

A systematic circular random sampling was used for selection of households. Prior to that, a house listing exercise was conducted for the selection of respondents for each subcategory of target population. Two sampling frames were created for BPL category households and APL category households separately. The eligible households were numbered in the respective sampling frames. A sampling interval8 was calculated for each sampling frame. Using this sampling interval, 10 households were selected from each sampling frame. Details of selection of households is provided in the annexure.

8 Sampling interval= Total number of eligible households/ Sample size to be covered

Limitations of the Study

• Insomeoftheprojectareas,thegovernmentofficials from Department of Women and Child Development (WCD) and Department of Health and Family Welfare (DoHFW), with whom the project had worked with, had been transferred. The new officials had not been approached by the partners as the program had ended. Thus, in some places, the study team was unable to meet the officials who had engaged with the program. These stakeholders included Child Development Project Officer (CDPO) of ICDS, Block Medical Officer (BMO) (NRHM), Medical Officer (MO), Lady Supervisor (LS) ICDS.

• In some areas the Bene-matrix tool, usedfor ranking institutions, proved difficult to be executed with mothers and pregnant women. The primary reasons for this were:

– Women were unable to identify public health institutions

– The women were apprehensive in scoring the government functionaries. Although they were willing to discuss various aspects related to the functionaries, they did not considered themselves entitled enough to score or rank them.

17

STUDY FINDINGS

19

This section will cater to the demographic profile of the households interviewed for the endline evaluation across six states. Based on household and individual data, the social and economic status of the respondents will be highlighted here. Educational profile of the respondents, their parity and age at marriage will form a part of the profile. This section will provide us a lens to look at the data in the subsequent sections. The various characteristics of individuals, households and villages will provide a base to understand the outcomes through the lens of social determinants.

4.1. Social Group

Given the nature of the intervention, the endline evaluation was carried out keeping in mind the poor and the marginalised communities. Thus, with the exception of Bihar there was a high concentration of tribal groups across the study states (34 percent). In Bihar there was a higher percentage of Scheduled Caste (SC) (30.5 percent) and Muslims (38.6 percent). The high proportion of Muslims in Bihar is primarily due to the selection of Kishanganj as a district. The population of this

district consists of 40 percent of Muslims. The report at a later stage delves into understanding some of the outcomes through the lens of religion as it is one of the determinants of practices followed during pregnancy and child birth.

4.2. Economic Status

The project villages chosen across the states are poor and marginalised with 71 percent of the households reported as poor. Almost 50 percent of the households are kaccha and over 53 percent of them have Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) job cards. Over 42 percent of the households reported farming as their main source of income and 46 percent of the households were dependent on daily wage or agricultural wage labour for their income. The others were engaged in government or private jobs or had a business of their own.

The social living index or SLI, calculated using the data on 30 household assets, indicates that almost 40 percent of the households lie in the ‘low’ category and over 57 percent belong to the

Demographic Profile4

A group of women respondents for an FGD in Bihar

20

Table 1: Household Characteristics (in %)

BackgroundCharacteristics

State

Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Total

SocialGroup

Scheduled Caste 18.1 2.1 16.5 8.4 23.3 19.2 14.6

Scheduled Tribe 0.8 77.2 26.3 67.6 57.9 48.5 46.5

Muslim 33.8 0.4 12.7 0.0 2.5 3.8 8.8

Others 47.3 20.3 44.5 23.9 16.3 28.5 30.1

Type of house

Kachha 46.4 84.9 37.7 44.9 22.8 51.0 47.9

Semi Pucca 38.8 13.0 25.0 35.7 74.0 23.0 35.1

Pucca 14.8 2.1 37.3 19.4 3.3 25.9 17.0

Ration Card

BPL 79.5 93.7 62.6 75.8 66.8 52.1 71.6

APL 20.5 6.3 37.4 24.2 33.2 47.9 28.4

MGNREGA Job Card 10.6 88.7 29.4 39.8 77.8 55.2 52.7

SourceofDrinkingWater

Piped Water 0.5 7.1 18.3 32.7 10.5 36.0 17.9

Handpump 98.4 72.1 51.3 30.5 63.7 52.1 60.6

Well 0.5 20.4 30.5 35.8 22.2 11.2 20.3

Others 0.5 0.4 0.0 0.9 3.6 0.8 1.1

Availability of Toilet Facility 7.4 0.8 6.6 19.8 5.6 19.0 10.0

CookingFuel

Electricity 0.0 0.0 3.4 4.4 3.3 2.5 2.3

LPG/ natural gas 5.9 .4 4.7 10.6 0.0 7.9 4.9

Others 94 99.6 91.9 84.9 96.6 89.7 92.9

Base: All Respondents

medium category. The method of calculation for SLI have been provided in the annexure.

4.3. Access to Drinking Water, Sanitation and Cooking Fuel

Majority (61.6 percent) of the sampled households use hand pump to draw water. Close to 18 percent of them have access to piped water. Within the states, however, disparities exist in terms of source of drinking water. For instance, in Bihar 98 percent of the households use hand pump, while only 30.5 percent households in Maharashtra use the same source. Similarly, piped water supply is reported as low as 7.1 percent in Chhattisgarh to as high as 36 percent in Rajasthan.

Overall, only 10 percent of the households reported to have a functional toilet facility within the household which is similar to that of the baseline.

A high reliance on wood (71.4 percent) as cooking fuel is seen across the states. Maharashtra and Rajasthan show use of Liquefied Petroleum Gas (LPG) as a fuel for cooking.

4.4. Respondent Characteristics

4.4.1. Age at Marriage

Close to 89 percent of the respondent women belong to the age group of 19 to 30 years. The mean age at marriage for girls at the project level is 18 years and the mean age at first pregnancy is 20 years. However, in Rajasthan, the mean age at the time of marriage for women is 15 years. Further, the mean age at first pregnancy is 17 years. In Rajasthan, early age marriages are quite common due to prevalent tradition. Therefore, the project has concentrated its efforts towards reducing early marriages. Data in subsequent sections

21

show that the incidence of such marriage are now lower that is lesser proportion of women are now getting married before the legal age.

4.4.2. Education

The states of Jharkhand (51.8 percent), Maharashtra (51.1 percent) and Odisha (43.7 percent) reported a higher level of education among the respondent where majority women reported to have studied up to higher secondary as compared to Bihar, Rajasthan and Chhattisgarh. The illiteracy level was markedly highest in Bihar (68.9 percent) followed by Rajasthan (52.1 percent).

4.4.3. Parity

Nearly 62.5 percent of the women reported to have two children or less. Almost 9 percent of the women interviewed were pregnant for the first time. It would be important to draw comparisons across groups which have more than two children and those who have two children or less. Such a comparison may provide insights on the latent factors that determine safe practices such as use of family planning methods, better access to nutritious food and getting ante-natal check-ups (ANC).

Table 2: Respondent Profile (in %)

BackgroundCharacteristics State


Age of the Women

Below 18 2.5 .8 3.0 0.0 .4 0.0 1.1

19 to 24 49.4 46.2 63.1 38.3 42.1 45.4 47.4

25 to 30 34.6 43.3 30.9 57.7 41.7 42.0 41.6

31 to 40 12.2 9.2 3.0 4.0 15.0 11.8 9.3

40 to 49 1.3 .4 .8 .8 .6

Mean Age at Marriage 17.7 18.1 18.5 20.1 19.3 14.9 18.1

Mean Age at First Pregnancy 19.7 19.7 20.2 21.7 21.2 17.3 20.0

Level of Education

Illiterate 68.9 31.1 18.3 18.9 20.6 52.1 34.4

Up to Primary 13.2 34.9 24.9 26.9 34.4 29.3 27.9

Up to Higher Secondary 15.8 33.2 51.8 51.1 43.7 17.4 35.6

More than Higher Secondary 2.1 0.8 5.1 3.1 1.2 1.2 2.2

Parity

No children 7.6 6.3 11.0 8.4 10.2 9.6 8.9

2 children or below 51.3 53.1 65.7 74.4 73.3 57.6 62.5

3 children 17.4 21.3 16.9 11.9 10.1 16.8 15.7

More than 3 children 23.7 19.2 6.4 5.3 6.5 16.0 12.9


Table 3: Standard of Living Index (in %)

SLI Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Total

Low (5 to 67) 46.0 45.1 15.7 14.3 52.5 57.3 38.5

Medium (22 to 38) 50.6 53.2 73.3 79.0 46.2 38.5 56.8

High (39 to 67) 3.4 1.7 11.0 6.7 1.2 4.2 4.7

It must be mentioned here that the findings of this section when compared to that of the baseline, show that a similar profile of the respondents have been chosen for the endline which makes the findings of further sections more comparable to the baseline.

22

Birth preparedness can be referred to the series of activities undertaken to promote safe motherhood. It involves the timely usage of skilled maternal and neonatal care thus reducing the risk of complications on the health of both mother and child. It includes regular antenatal checkup, intake of nutritious food right dosage of Iron Folic Acid (IFA) tablets and Tetanus Toxoid (TT) injection etc. Generating awareness about the benefits of Ante-Natal Care (ANC) remained one of the primary objective of the project as it remains the first and a deciding factor towards safe motherhood. The project has worked towards raising awareness of women to ensure safer practice of women on adoption of birth preparedness measures.

This section delves into the aspects of ANC and nutrition. Data pertaining to the number of ANC visits that women have undergone and what does ANCs mean to the community after theintervention has been presented. Emphasis has been laid on how the project has brought about a change in ANC through promotion ofVHND. Availability and consumption of iron richfood has been explained keeping in mind thatconsumption is an issue at the individual level, while availability is a supply side issue. The social determinants of health entail both sides to converge for better outputs. At the same time, PDS supply has also been evaluated under the survey to understand whether community finds PDS more accessible now. Roles of VHSNC,ASHA,AWW and ANM have been brought to the forethroughtheir involvement inVHNDwhich isoneplatform connecting these players.

5.1. Antenatal Care

5.1.1. Awareness

The knowledge about the minimum number of antenatal check-ups to be done during pregnancy are quite high across Chhattisgarh, Jharkhand, Maharashtra and Odisha though we do not have a baseline figure to compare it with. In Bihar and Rajasthan, more than half of the surveyed women were aware of the required number. This high level of awareness among women can be attributed to the rigorous awareness campaigns and meetings conducted at the village level and involving the entire community in the process.

The program has particularly targeted the VHNDs for increase in the knowledge and practice towards ANCs. Earlier, VHND in all the states were held at the panchayat level. Though mandated at the village level, often ANMs would not go to the village or only go for a couple of hours to mark their attendance. Moreover, the community was not aware of any such day where pregnant and lactating mothers could get their check-ups done. In most of the areas, VHND was considered as

Birth Preparedness5

Table 4: Proportion of women who reported to have knowledge regarding at least 3 ANCs (in %)

State Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Overall

Women (15-49 years)

54.9 71.4 85.6 92.5 85.4 57.3 74.4


IEC Material indicating the time period of ANCs

23

immunization day when children could get their vaccination.

The program worked on reconstitution of the VHSNCs, mobilization of the ASHAs and the BFAs to ensure that VHND is conducted as mandated by the government policy. Slowly, the VHSNCs started demanding from the ANM to come to the village and auditing the time that she stayed and the check-ups that she did. On the other hand, they also created awareness amongst the community to join the VHND for their check-ups. The ASHA would go to each household to inform the pregnant and lactating mothers about the time and venue of the VHND.

It was observed during the field work, that with the effort of the project, women in some places have demanded an anganwadi centre in their own hamlet within the village so that they did not have to walk too far on VHND. The distance being a major reason due to which they often did not attend VHND. Now, the VHNDs happen regularly and most of the women attend it. In many villages, it was observed that the VHSNCs have bought a table and curtain to enable abdominal check-ups during the VHNDs. Further, some health plans showed that the VHSNC was

eager to buy a machine to test Haemoglobin as the ANMs do not bring it on the VHNDs on account of it getting broken during travel.

5.1.2. Information regarding ANC

ASHA and ANM were reported to be the most important source of information in generating awareness among the women regarding ANCs.

0

10

20

30

40

50

60

OthersFamily Members

AWWANMASHA

53.1

24.9

10.28

3.9

Figure 8: Source of Information regarding ANC (in %)

24.127.4

96.9

83.3

10095.9

78.7 80.381.9 84.2

40.8

60.4

Indicators of Determinants of Maternal Health in India by Area

66.263.4

0

10

20

30

40

50

60

70

80

90

100

EndlineBaseline

OverallRajasthanOdishaMaharashtraJharkhandChhattisgarhBihar

Base: All Respondents who reported awareness regarding ANC

Figure 9: Proportion of women undergone three or more ANCs by states (in %)

Base: All those who reported to have been registered with ASHA or ANM

24

While 53 percent of women reported to be made aware by the ASHA regarding the benefits of ANCs, 25 percent of women stated that the task of awareness generation was done by the ANM. The AWW seemed to have complemented the work of ASHAs and ANMs where 10 percent of women reported to have known about the ANCs from the AWW. The share of family members as source of information though small at 8 percent is still significant as family forms the first point of contact and a support system essential for ensuring maternal health.

5.1.3. Number of ANCs Received

All the states recorded an increase in the proportion of women who had undergone three or more ANCs. Except in Bihar, all other states have shown a remarkable increase. In Bihar, only 27 percent of the women reported to have had three or more ANCs.

This improvement in behaviour can be seen as a function of the increase in awareness about the benefits of the ANCs and its contribution in ensuring safe motherhood. It may be observed that the increase in awareness of 3 or more ANCs, is not as high as compared to the practice. This can be attributed to the fact that the VHNDs are now happening in the villages and not at the panchayat level. There is an increase in put by the FLWs in ensuring more women go for the ANCs. For instance the ASHA and the BFA go door to door to remind women of their ANC dates which have resulted in greater turn-out of women for ANCs. However, some women may not necessarily know that minimum of three ANCs are required but they go for the check-ups as other women in the village are also doing the same. This is a multiplier effect of one woman’s behaviour translating into other women in the village also following the same.

Another feature of the VHNDs is collection of take-home ration (THR) from the anganwadi centre which happens on the same day. Thus, women anyway go to the anganwadi centre to collect their ration and therefore also have their check-

ups. Here, VHND shows a tandem converging two aspects of birth-preparedness.

In Bihar, however, only eight pregnant and eight lactating mothers receive the take-home ration in a month. The AWW finds it difficult to choose the 8 women as it often creates a fight amongst the community towards receipt of the same. Women feel that all pregnant and lactating mothers are entitled to the THR when the government mandates are different. For this reason the AWW, does not distribute the THR on the same day as VHND and does it separately. Thus, women do not have an added incentive to go for the VHND unlike other states.

Observations from qualitative discussions indicate that many women from the Muslim community and those from the maha-dalit community amongst the SC groups, still need more encouragement to attend the VHNDs. The ASHA worker in Sitamarhi mentioned that women from SC households would often not accept her advice as she came from a different community. The barefoot worker also mentioned that she cannot go and talk to the women from other communities as easily as their own. Women from far flung and poorer hamlets often do not pay attention to her advice.

Further, amongst the Muslim community, TT injections or vaccinations are still not accepted completely due to religious beliefs. The barefoot worker in one of the villages in Kishanganj mentioned that some of the beliefs are very strong and furthered by the strong patriarchal nature of the community where women do not do anything without permission from there family. However, she was positive that the adolescent girls were now more informed and slowly creating awareness amongst the younger generation of mothers. It is interesting to observe that in Bihar out of the 27 percent of the women who had more than 3 ANCs, over 67 percent are in the age group of 19 to 25 years. Clearly, younger mothers are leading the way towards a better preparedness for birth.

25

5.1.4. ANC from Numbers to Meaning

While the quantitative figures show high number of women going for at least three ANCs, the definition of what remains the constituent of ANCs varies in some places. In most places, ANC meant only the receipt of IFA tablets and TT doses as observed in Bihar and Rajasthan. However, the notion cannot be generalised to all states as women in Maharashtra, Chhattisgarh, Odisha and Jharkhand were aware of other constituents of ANC like abdomen check, blood pressure and weight check etc. This is evident as the VHSNCs in the villages have been striving to get beds, curtains and blood

pressure measuring apparatus to be used during the VHNDs.

Women who had not received any ANC or less than 3 ANCs were asked for the reasons of the same. In Bihar, 57 percent of the women reported that their family members advised them to not go for the ANC due to fears of disclosing the pregnancy or that they did not feel it was necessary. About 20% of the women reported to be dependent on their husbands for ANC visits which speaks about their dependence on the family both in terms of exercising preference or power in terms of decision making. However, the decrease in the proportion of such women depicts a behavioural change in women where more importance have been attached to the ANCs.

5.1.5. Counselling by ANM or ASHA

The proportion of women reported to have received counselling from the ASHA/ANM have increased during the project period. It must be noted that across states, the project partner NGOs and the Medical Officers mentioned that the role of ANM is slowly transforming into that of a service provider than a counsellor. ASHAs therefore, through their trainings are increasingly taking up the role of counselling women. Thus, the project has aptly targeted the ASHAs to also play an active role in informing women of safer practices during pregnancy and child-birth.

It must be noted here, that in Bihar while the number of women who had undergone 3 ANCs is low, the proportion of women counselled is comparatively higher. The information captured here is from women who were counselled by ANM

IEC Material indicating the features of ANCs

Table 5: Proportion of women who have received counselling from ANM/ASHA on care during pregnancy (in %)

Women(15-49 years)


Baseline 15.5 28.0 39.0 62.6 41.3 31.1 36.5

Endline 63.3 96.2 84.7 84.6 85.8 64.9 79.9

Base: All respondents

26

or ASHA during their entire pregnancy. Thus, even women who reported to have gone for atleast one ANC reported to have been counselled by the ANM or ASHA.

The active participation of the FLWs in ensuring better maternal health can be attributed to the training programs done with the ASHAs for optimizing her duties like that observed in Maharashtra and Rajasthan. Also involving the ASHAs and ANMs in the community awareness programs have not only made them more aware of the problems faced by the women but also made them accountable as people were now aware of their entitlements and services to be received from the FLWs.

5.2. Nutrition and Consumption of Iron Fortified Food and Supplements

Women reported to have received information on their status of anaemia as well. A higher proportion of women (68 percent), compared to the baseline, reported to be aware of the same.

Campaigns towards fighting against anaemia, generation of awareness through the adolescent girls and repeated counselling from ASHA and Barefoot auditor has been responsible for the increase in awareness regarding the status of anaemia amongst the respondents. Chhattisgarh particularly owes the increase to it partner NGO, which also runs an alternate facility from where trained health workers and doctors are invited to counsel women on issues of health.

Further, the program has held nutrition fairs across all states with a local flavour that focus on

the nutritional requirements of a pregnant woman. These fairs have been held at the village level in some states and at panchayat level in others that focus on the locally available iron rich food for the women and highlight the ease with which they can be availed. For example, one of the locally grown green leafy vegetables (bathua) was not eaten in the area of Jharkhand. However, after the nutrition fair, women have started adding it to their diet. They have mentioned in the discussions about the ease of access to these vegetables which are grown in their own backyard. Various other pulses and millets were also displayed and their values described. Duringthediscussions,womenvividlydescribed the activities in these nutrition fairs which means that visual demonstration is very helpful for creating awareness.

5.2.1. Receipt and Consumption of Take-Home Ration (THR)

Close to 95 percent of the women were aware of the availability of the component of ICDS scheme where women are provided Take Home Ration (THR) from the anganwadi centre. In all the states, the women are either provided with packaged food or raw material that is rich in iron content. In Bihar, however, only dal and rice is provided to the women as THR.

The proportion of women who reported to have received THR has increased in Chhattisgarh and Rajasthan. In Maharashtra and Odisha, the receipt of THR was already high since baseline and shows no significant change. In Bihar as well, there is no significant change in uptake of THR due to the feature of the policy which provides only eight lactating and pregnant mothers with the

Table 6: Proportion of women who reported to be informed regarding their status of Anaemia (in %)

Women(15-49 years)


Baseline 24.8 34.5 26.1 37.0 34.0 44.8 33.5

Endline 30.4 98.3 72.9 68.7 86.2 51.0 68.0


27

ration. However, in Chhattisgarh and Rajasthan, this figure has shown a dramatic increase, which has been through the efforts of the project. The community’s awareness regarding the THR has increased in the project period across the two states and therefore, they have started to demand the THR from the AWW making her more accountable for the entitlement.

In Jharkhand, the state has replaced the earlier THR (including rice, dal, jaggery and soya beans) by processed food packets. These packets are not liked by the pregnant women or mothers who complain of their poor taste and high salt content. Therefore, the decrease in the receipts.

The evaluation has tried to capture the proportion of women who consume the THR alone considering

the assumption in the log-frame that there is change in cultural practices and women have fair share of food in the family and sit with family to eat food. It was observed that there is an increase of 15 percent from the baseline in the proportion of women who consume the THR alone. Most of the women explained in the discussions that they tend to share it with their child or family as they are not comfortable eating it alone. However, they did mention that they eat adequate share of food in the household. The younger women especially reported that they were comfortable in eating food with the rest of their family.

This change has been more from the end of the mothers-in-law who explained that with the information received from the ASHA and the project animators, they are now aware that nutrition of the

37.7 39.0

98.7

85.7

96.5 97.4

78.781.0

94.198.4

44.8

73.6

97.5

67.1

0

10

20

30

40

50

60

70

80

90

100

EndlineBaseline


Figure 10: Proportion of women who reported to have received iron rich/ iron fortified food by states (in %)


Table 7: Proportion of women who consumed iron rich/iron fortified food alone (in %)

Women(15-49years) Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Total

Baseline 6.0 1.9 2.5 7.0 3.0 12.1 5.4

Endline 7.6 15.3 8.9 34.2 12.6 44.9 21.3

Base: All Respondents who reported to have received THR

28

mother is essential for the child to be healthier. Hence, they feel that their daughters-in-law should be eating adequate share of food in the household.

In Jharkhand, however, women were not comfortable consuming the new packets given as ration. They mentioned that however, they might cook it, the salt content is too high for it to be consumed. The government’s change here is not acceptable to the women. Further, there have been few incidents when a pebble or pieces of glass were found in the packets. This, has considerably reduced the consumption of THR. Instead, the women feed it to their cattle.

However, across other states, satisfaction from THR has shown an increase from the baseline with close to 88 percent of the women reporting being satisfied with the food provided.

5.2.2. Receipt and Consumption of Iron Folic Acid (IFA) tablets

Awareness regarding consumption of atleast 100 IFA tablets has increased over the project period by 11 percent. Close to 53 percent of the respondents are aware about the number of IFA tablets to be consumed during pregnancy. Further, women were also aware about the benefits of IFA tablets and recounted that it fights against anaemia, prepares the women for blood loss during child birth and helps the baby be stronger.

It was observed that receipt of atleast 100 IFA tablets has increased during the project period across all states with the exception of Bihar. In Bihar, for over 10 months in the last financial year, distribution of IFA tablets had not happened due to lack of stock with the health department.

In the other states, the increase in the proportion of beneficiaries receiving requisite number of IFA tablets can be attributed to the distribution of IFA tablets every month during the VHNDs which are now regularly held at the village level.

An increase in consumption of IFA tablets across all states can be observed during the project period. However, in Bihar, due to the poor distribution of IFA, the consumption is also affected. Consumption of IFA tablets is extremely high in Chhattisgarh due to JSS’s (partner NGO) efforts in providing them through their own health centres. They have focussed their efforts through capacitating the ASHA and the BFA to monitor the consumption. In other states counselling done by the FLWs have also contributed in the increase in consumption of IFA tablets among women.

0

50

100

EndlineBaseline

Rajasthan

Odisha

Maharasth

ra

Jharkhand

Chhattisgarh

Bihar

10.44.6

23.8 26.8

77.9

54.3

80.5

13.5

89.7

35.9

57.9

34.7

Table 8: Proportion of mothers who consumed atleast 100 IFA tablets (in %)

Mothers(15-49years) Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Total

Baseline 11.2 22.1 18.4 54.7 34.4 11.6 27.4

Endline 4.1 74.6 24.8 54.5 41.9 25.1 37.6

Base: All women excluding currently pregnant women (zero parity)

Figure 11: Proportion of women who reported to

have received at least 100 IFA Tablets (in %)

Base: All women excluding currently pregnant women (zero parity)

29

It must however, be noted, that women during the discussions pointed out that they have heard about IFA syrups being available, however, very few of them reported to have consumed it. With the increase in awareness, the women know that if they want, they can access the syrup as well. However, due to supply side issues, these syrups are not available. Thus, it is essential to note the change in discourse towards demand for the IFA syrups from the tablets which may in future be the reasons for a higher consumption and thus, lower incidence of anaemia.

5.2.3. Access to Public Distribution System (PDS)

The project has specifically worked through the VHSNCs and the adolescent groups, to ensure that the PDS shops are efficiently working in the target villages and villagers have access to the food distributed under the government program. Across all states, the issue of selling of PDS ration by the private dealers to the markets had been rampant. When asked about the low or no

supply, the dealers would cite lack of supply from the government’s end. Further, the dealers would often give less ration to the beneficiaries than that they were entitled to and write the requisite amount in their books.

Table 9: Proportion of households with status of PDS consumption and satisfaction

Households Baseline Endline

Proportion of households that procure food items from PDS

54.4 78.5

Proportion of households satisfied with PDS supply system

47.8 72.9

During the project period, with a rise in awareness, the community have taken measures to ensure that the PDS supplier provides to them as per their entitlement. The BFA has specifically worked in this area ensuring the projects achievement in increasing access to the PDS and increased satisfaction since the baseline.

In Discussion with the Adolescent Girls from Noniabasti, Kishanganj, Bihar

30

Community fairs as a step towards creating awareness on importance of nutrition for pregnant mothers – Reflections from Chhattisgarh

Poor connectivity restricts the tribal communities to consume locally available food which makes it all the more necessary to make them conscious of the food they consume and their nutritional benefits. Understanding the topographic and economic limitation of the tribals of Chhattisgarh, JSS came up with the unique idea of promoting locally available vegetables.

To make these awareness campaigns more effective, Jevnaar Melas (meaning Food Fairs) were conducted by the local NGO JSS. At these melas, the target groups under the Oxfam-GPAF project were made aware of the locally available vegetables and exhibitions were done on the different traditional methods of preparing these vegetables. These platforms also provided a peer learning opportunity where women shared on traditional ways of cooking these vegetables to retain the nutritional ingredients. JSS has now helped identify 56 types of locally available green leafy and iron rich vegetable which may be beneficial for pregnant

Using Jevnaar Melas as platform for information dissemination has made the entire process of educating the community more interesting and receptive. Large presence of women at these Melas reflects the receptivity of the local community to these occasions as a step towards improving the intake of nutritious food both among all members of a family and the pregnant women in particular.

Leading the Way for Food Security

The adolescent girls group in Noniabasti, Kishanganj in Bihar, with their heads covered in a Hijab may look like a group of shy girls. But this group of girls has stopped a van full of grains being taken away to the market for sale by the PDS dealer. The group leader, Sabiya Khatoon, explained, “The dealer was taking away the food entitled to us by the government. Why should have we let him go?” They stopped the van with the help of village elders and forced the dealer to put it back in the PDS shop and distribute it as per the mandates set by the government.

Another time, the girls had caught the dealer writing five kilo-gram in their ration card and instead giving only four kilo-gram of rice. They took up the matter in their hands and spoke to the VHSNC regarding the same. The dealer had to admit his corrupt behaviour and has been honest since.

The girls have mentioned how the project animator has helped them become aware of their rights and they feel empowered as a group, thanking the NGO partner. They sing a song in their local Surjapuri dialect that echoes the thought of their fields growing maize and all of them having enough food that no one goes to bed hungry.

5.3. Good practices on birth preparedness- Reflections from the states

Bihar

Chattisgarh

31

Using supply side interventions to stimulate effective demand for maternal health services

Providing role clarity among Frontline functionaries has proven to be an effective step in reducing the demand-supply gap through supply side interventions in Maharashtra.

Both partners (AAA and Janarth) in Maharashtra have concentrated their efforts on strengthening the supply side of health care delivery as key measure to stimulate the demand side. Front Line workers such as ASHAs, AWWs and ANMs were routinely targeted for trainings and information dissemination. Since these FLWs belong to the same community they are working for, they possess a better understanding of the socio-political conditions of the village and empowering these workers helped overcome the social challenges towards maternal health. FLWs now report that trainings by the partners have helped them to better understand the importance of their role and also equipped them to be more sensitive in dealing with pregnant women and mothers.

Leveraging strength of symbolism for awareness generation

Uchhab has been working with CYSD, a local NGO for the last fifteen years and had been associated with the project since its very inception. Working in the area for such a long time has provided him with the added knowledge of the terrain, culture and socio-economic condition of the area. He speaks about high rate of illiteracy and strong belief in symbolism as key features of the area. CYSD decided to use this belief to their advantage and use it as a medium to spread their message more effectively.

The intervention areas being predominantly tribal are dependent on locally available vegetables and fruits owing to their poor economic conditions due to undulating terrain and lack of irrigation facilities. Along with limited diet options they also remain clueless about nutritional benefits of locally available vegetables. Understanding the fact that these poor tribals could not be asked to consume something which is beyond their budget and reach, CYSD decided to project the locally available nutritious food beneficial for pregnant women.

Symbolic approaches, which are more coherent and permeable were used to inform the community about locally available nutritious food. ASHA and the AWW turned out to be the key actors in the process as they are the first point of contact in case of any pregnancy in the village.

In the event of any pregnancy in the village, a small symbolic ceremony was performed in the woman’s house by planting leafy vegetables in the courtyard. This helped in not only setting a positive attitude towards ensuring iron rich diet to the expecting mother within the household but also generated a community concern towards her health.

Maharashtra

Odisha

32

Key Summary Points

The program has particularly targeted the VHNDs for increase in the knowledge and practice towards ANCs.

Now, the VHNDs happen regularly and most of the women attend it. In many villages, it was observed that the VHSNCs have bought a table and curtain to enable abdominal check-ups during the VHNDs. Further, some health plans showed that the VHSNC was eager to buy a machine to test Haemoglobin as the ANMs do not bring it on the VHNDs on account of it getting broken during travel.

ASHA and ANM were reported to be the most important source of information in generating awareness among the women regarding ANCs.

Increase in the proportion of women who had undergone three or more ANCs (60 percent in the baseline to 80 percent in the endline).

Women in Maharashtra, Chhattisgarh, Odisha and Jharkhand were aware of constituents of ANC, apart from receipt of IFA tablets and TT injection, like abdomen check, blood pressure and weight check etc.

The proportion of women reported to have received counselling from the ASHA/ANM have increased during the project period by 43 percent.

Nutrition fair across states were vividly described by women during the FGDs. This indicates that visual demonstration is very helpful for creating awareness.

The proportion of women who reported to have received THR has increased significantly in Chhattisgarh and Rajasthan.

In Jharkhand, due to the poor taste and high salt content of the food packets the receipt of THR by women has decreased.

Receipt and consumption of IFA tablets has increased across all states except Bihar. In Bihar, for 10 months in the last financial year, distribution of IFA tablets had not happened due to lack of stock with the health department.

33

The project has aimed to contribute towards increase in access to public health facilities for deliveries with an aim to reduce out of pocket expenditure. With public health systems being the priority option for the poor and the marginalised, the project has felt the need of making the same accountable, accessible and deliver quality care. High incidence of anaemia and low body mass index are indicative of poor nutritional intake by women. Thus, the project has tried to leverage the government programs and schemes and make the community aware of their entitlements which include the distribution of TH) and IFA tablets.

Further, through the reconstitution of the non-functioning VHSNCs, capacity building of ASHA and creating a cadre of barefoot auditors, the project has generated awareness and demand regarding advantages of institutional delivery over home based delivery, benefits under JSY and mandates under VHND. The project has oriented VHSNCs on

the critical need for safe deliveries and abortion services in the public health system developing their capacity for audit and demand for quality care in health institutions and campaign for referral transport.

6.1. Complications during Pregnancy and Childbirth

Respondents were asked about their knowledge regarding danger signs during pregnancy and complications that may arise during or after child birth. Further, they were also questioned if they faced any problems during their pregnancy and the measures that they had taken to treat themselves.

6.1.1. Awareness of Complication during Pregnancy

Over 47 percent of the women reported to know at least two danger signs of pregnancy and at least two complications during and after child birth. This

Safe Delivery6


43.3

62

55.5

44.5 44.140.7

35.6

47

31.5

2124.1

29.931.328

0

20

40

60

80

100

EndlineBaseline


Figure 12: Proportion of women aware about incidences of serious health problems due to pregnancy or childbirth (in %)

34

awareness has increased in all the states from the baseline. Most of the women reported that ASHA and the BFA were their source of information. Further, if anyone in their neighbourhood or community had any such complications, they would talk about it, which was also a source of information.

6.1.2. Incidence of Complication during Pregnancy

This indicator was not captured in the baseline, however, it is essential to look at the health seeking behaviour of women in case of any health issues that they face. It was observed that over 40 percent of the respondents had noticed some danger signs during pregnancy.

Some of the problems faced by the women included dizziness, excessive vomiting, severe abdominal pain, and blurred vision. Close to 12 percent of the women reported that they were anaemic at the time of pregnancy which was observed to be

highest in Odisha. It is important to notice here that women are aware about the problems that they had faced. Reporting of anaemia is crucial to the project which has particularly worked on increasing access to nutrition. In discussions with mother-in-laws, they mentioned that earlier, women did not know that certain symptoms were actually danger signs including paleness in the skin. Their ignorance would often lead to the death of the mother or child. However, with an increase in the VHND and the activity of the ASHA, women are now more aware of the symptoms during pregnancy that could be danger signs.

Amongst women who had faced any issues, only 5 percent did not report it to anyone. Dataindicatesthat women are communicating about their health problems during pregnancy with their husbands and mothers-in-law. Further, contact with ASHAandANMovertheseissueshasalsobeenreported.Over 64 percent of the women reported to have told theirhusbandsaboutitand30percenthadspokento their mothers-in-law regarding the same.

Further, 76 percent of the women had sought treatment for the problems faced. In Bihar, Chhattisgarh and Jharkhand, higher proportion of women had gone to the private facilities for treatment. In Maharashtra, Odisha and Rajasthan, women had sought care in the public health facilities. In the discussions, with women, it was reported that in the former three states, private facilities were more accessible and perceived to have better treatment and care than government hospitals. In Maharashtra and Odisha, Community Health Centres (CHCs), situated at block level, were given a higher preference and in Rajasthan, district hospitals were approached more. The facilities in the government hospitals in these three states was reported to be better with more care provided from the health staff.

Table 10: Percentage distribution of women who reported to have a problem by states (in %)

States Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Total

Women (15-49 years) 44.3 43.7 49.6 26.0 39.0 51.9 42.5


IEC Material indicating the danger signs during

pregnancy

35

Data indicates that 82 percent of the women reported these issues within a week which sets a positive trend to identification and reporting of the danger signs during pregnancy. The project through the efforts of ASHA and barefoot worker has created awareness regarding the importance of reporting incidents and seeking treatment for complications.

6.2. Institutional Delivery

Women were asked about the place of their last delivery. It was observed that home based deliveries have reduced over the project period. Deliveries in public hospitals in Maharashtra, Odisha and Rajasthan have shown a significant increase from the baseline. A small proportion of women have delivered on their way to the hospital which remains unchanged from the baseline.

Table 11: Danger signs reported by women (in %)

Dangersigns Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Overall

Fever in the 3rd Trimester 11.2 3.0 2.7 3.0 23.7 7.1 8.5

Severe Headache 14.8 2.0 4.4 4.1 38.4 20.8 14.5

Severe abdominal pain 52.1 4.2 21.7 8.1 37.8 28.0 26.5

Swollen hands and feet 22.9 25.6 20.8 37.7 44.1 5.3 24.2

Vaginal Bleeding 3.2 1.5 2.8 2.0 6.0 13.6 5.3

Paleness/Anaemia 5.9 12.1 11.6 3.1 31.0 7.6 12.1

Difficulty in breathing 7.4 2.7 2.1 0.0 16.4 4.6 5.7

Convulsion/loss of consciousness

18.6 4.4 0.5 0.0 1.2 1.8 4.6

Reduced Foetal Movements 2.1 3.7 3.1 0.0 3.1 1.4 2.4

Dizziness 68.6 39.4 48.4 31.7 41.5 64.1 50.8

Excessive Vomiting 47.2 52.1 47.6 56.9 36.8 29.8 43.9

Blurred Vision 37.8 3.7 6.0 3.0 6.2 3.9 10.5

Foul smelling vaginal discharge

1.6 0.5 0.0 2.0 0.0 0.7 0.7

Base: All respondents who reported to have faced danger signs

0

20

40

60

80

100

End LineBase Line

Others

Private

Hospital

Public Hospita

lHome

31.924.6

5.812.4

0.7 0.9

61.5 62.1

Table 12: Place of treatment for complications during pregnancy by state (in %)

Place of treatment Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Overall

Public Hospital 13.3 21.9 20.7 89.8 83.2 66.1 45.5

Private Hospital 43.8 50.5 39.7 8.5 3.2 6.5 26.7

Home 11.4 5.7 0.9 0.0 4.2 0.8 4.0

Not treated 31.4 21.9 38.8 1.7 9.5 26.6 23.8

Base: All respondents who reported to have faced danger signs

Figure 13: Place of Delivery (in %)

Base: All women excluding pregnant women (zero parity)

36

Discussions with women revealed that in the past two years there has been an increased tendency to delivery in the hospital due to safety concerns. Women spoke of how the project animator, BFA and ASHA have time and again spoken to them regarding delivery in the hospital. Moreover, during VHND, ANM has also advised them to deliver at the hospital. Further, JSY benefits were an added incentive to visit the public hospitals for deliveries.

If we look at state level disaggregated data, we can see that there is an increase in deliveries at the private hospitals Bihar, Chhattisgarh and Jharkhand. In Maharashtra, Odisha and Rajasthan, there is a significant increase in deliveries at public hospitals.

The reasons were found in the qualitative discussions. Many women in Bihar, Jharkhandand Chhattisgarh, reported that they had notreceived the benefits of JSY in the hospitals.The infrastructure in public health facilities is poor, referral is an issue and care provided is not adequate. So, in such a scenario, if they don’t even receive the benefits that they are entitled to, why go to public hospitals. Instead, they prefer to pay some money and deliver at the private facilities which provide them with adequate care and have requisite amenities. In Maharashtra, Odisha and Rajasthan, these issues did not surface. Women were happy with the services provided in the public health facilities and also mentioned receiving their benefits from JSY on time.

However, for the extreme poor and marginalised women, who cannot afford private facilities, deliveries happen at home. The local village doctor is called for these deliveries who does a check-up and provides a prescription for medicines. The traditional birth attendant (TBA) or Dai conducts the deliveries. It is interesting to note that in Bihar, amongst women who reported to have a homebaseddelivery,41percentwereMuslims. In Kishanganj, women in the discussions mentioned that many women amongst the

Sirshawadi community, which is considered to be more orthodox in its beliefs, still do not go to the hospital for delivery. The Surjapuri community which is more open to ideas, has however, started going to the hospitals for delivery. The NGO partner in Bihar, working in Kishanganj, had mentionedhow earlier, women would not even take IFAtablets or TT injections. Thus considering their past practices, it is a welcome change to see that women have started going to the hospital for deliveries.With safer outcomesof childbirthatthe hospital, the BFA had mentioned, that more womenwerelikelytofollowsuit.

6.2.1. Availing Benefits of JSY

It can be observed through data, that there has been a decline in the proportion of women who have received benefits from the JSY scheme in Bihar, Jharkhand and Chhattisgarh.

Table 13: Percentage distribution of place of delivery by State (in %)

State Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan

Place of Delivery Baseline Endline Baseline Endline Baseline Endline Baseline Endline Baseline Endline Baseline Endline

Home 42.8 51.1 46.2 55.8 35.1 12.0 39.4 16.9 12.8 3.6 14.8 6.5

Public Facility

51.6 39.7 52.3 17.4 45.3 53.6 50.7 77.8 87.0 93.6 83.3 92.1

Private Facility

4.6 8.7 1.2 26.3 17.0 34.0 9.9 3.9 0.2 0.9 1.4 0.9

Others 0.9 0.5 0.2 0.4 2.5 0.5 0.0 1.4 0.0 1.9 0.5 0.5


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The reasons cited for these has been delay in receipt of cheques inspite of having accounts in their name. Some of the ASHAs mentioned thateven they have not received their payments. IssueswerecitedbyoneoftheMedicalOfficersataPrimaryHealthCentre(PHC)inBiharandtheNRHM Block Manager in Jharkhand as lack ofavailabilityoffundsforJSYpaymentsinthelastfinancial year. Thus, there have been extreme delay in payments of these beneficiaries. As some households do not receive benefits, others in the village are discouraged and prefer going to private facilities or have delivery at home. These are supply side bottlenecks created due to poor management from the government officials who tend to blame the hierarchy through which the transfer of funds happen. Quite a few VHSNCs reported to have spoken to the PHC doctors who only give them false hopes that the money will be transferred in the coming month.

6.2.2. Awareness regarding JSY

What is important to be noted here, that the program has created awareness regarding the scheme amongst the community who now well understand the features of the scheme and have opened their accounts to ensure the receipt of cheques. Further, they are now capacitated to demand for their rights as they know clearly about them. Data shows that over 90 percent of the women are aware of the JSY scheme including the

states where the scheme performance is low due to supply side issues.

There have been instances when women have not been given the JSY cheque even though she has not been registered. Women have now started asking for them as they are aware of it and are also strong enough to demand for the same. Thus, the project has enabled the community to raise their voice against such issues. However, larger supply side problems, such as fund availability can only be treated at the level of the government through wider advocacy and continued engagement with the officials.

The project period was that of three years and the NGO officials have engaged with the concerned government offices for advocacy. However, once the official is transferred, the new incoming official has to be met again and a new rapport has to be created. Within three years, the process has to be repeated at least once which does cause a loss of goodwill from the incumbent to the new officer who may or may not support the program.

6.2.3. Transport and Payment for Institutional Delivery

Transportation and payment for the same form an important part of the process of a delivery at the hospital. Under JSY, the public hospitals send an ambulance to pick up the pregnant women

Table 14: Proportion of women who reported to have benefited under the JSY scheme (in %)


Baseline 41.4 41.7 51.0 35.2 56.8 72.4 49.7

Endline 30.7 35.0 23.9 62.5 62.9 73.5 48.1


Table 15: Percentage distribution of women who are aware about the scheme (in %)


Baseline 62.7 60.1 84.1 55.5 64.6 79.8 67.8

Endline 99.6 92.0 97.5 79.7 91.5 84.5 90.9


38

in labour after a call has been made. It can be observed that the proportion of households who went to the hospital by an ambulance, has increased from the baseline across all states.

The project through its campaigns and Information Education and Communication (IEC) material has informed the community of the facility of the ambulance and the number of the same. The ASHA calls the ambulance in time of need. However, in absolute terms, the proportion of people going by private or public vehicles is higher than those who have availed the services of the ambulance. The main reason cited for this was again supply side issue where only one ambulance caters to seven to ten panchayats and sometimes even more. In Kishanganj, Mahismara panchyat, there are 22 villages. Only one ambulance is provided for the panchayat which is unable to reach the beneficiary on time. Thus, people arrange for their own vehicles to reach the hospital on time for the delivery.

For private or public vehicles, households have paid on their own, however, they were also asked, if they had to pay for the ambulance used to reach the hospital. As compared to the baseline where 51 percent of the households reported to have paid for the ambulance, only 13 percent of the households in endline reported the same. Earlier, community was not aware of the terms of payment for the ambulance. Now, they are aware of the free ambulance service and thus, the payments for the ambulance have reduced drastically. Payments made at the hospital were also reported to be lesser than that during the baseline. The proportion of respondents who had to make a payment shows a decline of 28 percent from the baseline.

In Mukaru, the village adopted by the current MP of the area, close to 66 women have not received their JSY cheques. The ASHA, Manju Devi, who is also the barefoot worker, spoke strongly about it and has been working towards writing to the authorities over the past 3 months. Through her efforts, 4 women have received the cheque in May. She said, now we are aware of our rights, and all of us women will go and demand for our rights from the government authorities.

-Hazaribagh,Jharkhand,

as reported on 3rd

June, 2015

Table 16: Percentage distribution of women who availed an ambulance from the hospital (in %)


Baseline 12.3 41.7 9.5 33.5 22.0 12.3 21.1

Endline 20.8 58.2 31.5 56.2 73.8 33.8 47.0

Base: All women who had institutional delivery during their last child birth

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6.2.4. Deliveries Attended by Skilled Birth Attendants

It was observed that the proportion of women whose last child birth was attended by a doctor has increased across all states with close to 55 percent of deliveries being attended to by doctors. In Odisha and Rajasthan, there has been a significant increase in deliveries that have taken place in CHCs and the district hospital as compared to the baseline. At this level of health facilities doctors are present for attending to deliveries.

In Bihar, it was observed that the quacks or local doctors, especially in Kishanganj, are reported as doctors by the respondents. Thus, while the deliveries are conducted by Dai (at home) or ANM, the local doctor, called by the family, is present for any help. In Jharkhand and Chhattisgarh, compared to baseline, a higher proportion of women reported to have visited the private health facilities for deliveries as a doctor is present there.

In Maharashtra, deliveries at the PHC have shown an increase as compared to the baseline. Thus, more ANMs (who are also trained as birth attendants) are conducting the deliveries. This shows the better functioning of the public health facilities and capacity building of the ANMs who are capable of conducting deliveries on their own.

While most of the home based deliveries are still conducted by TBAs or Dai, there is an increase in the number of doctors who conduct the delivery from the baseline in the states of Bihar, Odisha and Rajasthan. In, Chhattisgarh, this proportion has reduced as more people conduct deliveries through the trained birth attendants. In Maharashtra and Jharkhand, women mentioned during the discussions that they call the ANM to conduct some of the home based deliveries in the villages where the women is unable to reach the PHC. Payment is made separately to the ANM for the same.

21.1

33.3 32.3

48.8 48.1

91.0

75.8

54.9

50.9

77.4

46.2 44.640.4

31

0

20

40

60

80

100

EndlineBaseline


Figure 14: Proportion of women whose last child birth was attended by skilled health personnel (in %)


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6.3. Post-Natal Care

The project components do not particularly focus on the aspects of Post-Natal Care (PNC) which also reflects in the data from the survey. It was observed that only 21 percent of the women had knowledge regarding the minimum number of PNCs to be conducted. While baseline data does not cover this information, the value indicates that the awareness regarding the same is quite low. However, data does indicates 70 percent of the women had received their first PNC within one week of delivery as compared to the baseline incidence of the same was 60 percent.

Women did talk about their nutritional intake that has increased in the past two years post-delivery as well. The program had worked towards availing of THR during pregnancy and held campaigns or melas at village and panchayat level to inform the community of locally grown nutritious food that must be eaten by a pregnant woman. The women mentioned that earlier, after the child was born, their health was not paid attention to. Now, with the information obtained from the health melas, they are conscious about their food intake and continue with a similar diet as during pregnancy.

Table 17: Percentage distribution of home deliveries assisted by health professionals (Doctors)


Baseline 8.6 28.8 17.4 13.4 7.1 23.4 17.1

Endline 22.3 0.0 4.2 5.6 62.5 78.6 13.8

Base: All women who had home based delivery during their last child birth

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6.4. Strategies that worked- Glimpses from the states

Mobilising communities for safe delivery

Women in Mahin village in Kishanganj district of Bihar mostly had child birth at home due to lack of a health facility within their reach. The health sub-centre (HSC) had been dysfunctional for the past two years in the village. Either the ANM was not available at the health centre due to other mandated services or it was under a lock. Neither was the community aware of the reasons of absence of the ANM nor did they know that they were entitled to free health care at the HSC. Often deaths were cited due to poor facilities and care of women who delivered at home. While some could afford private health facilities, majority of the women risked their life during child birth by delivering at home without a skilled birth attendant.

Oxfam India, along with its partner NGO, BVGA, has slowly, with the efforts of the community, has brought about a drastic change in the dystopian scenario that was two years ago. With the formation and empowerment of the VHSNCs at the village level, the project has created a demand amongst the community for health care services which they are entitled to by the government. The project has used VHND as a platform to raise awareness of the community towards the importance and benefits of institutional delivery.

Awakened about their rights by the project, the village head wrote to the Medical Officer In-Charge at the PHC, the Chief Surgeon and the District Magistrate explaining their predicament related to the dysfunctional HSC. On 29th June, 2014, through strong efforts the village welcomed the reopening of the HSC. Today, there are two ANMs at the HSC. One of them is responsible only for attending to deliveries and patients while the other ANM conducts house visits, reports at VHNDs and other mandated duties.

The case brings to the fore, the project’s untiring efforts in generating awareness amongst the community, helping them understand the advantages of a delivery at the health centre and also strengthening the village based institutions to seek responsiveness from the supply side.

Bihar

42

Overcoming constraints to access to health care facilities - the Jan Sunwai experiment in Chhattisgarh

Jan Swasthya Sahyog (JSS) has been engaged in the last mile service delivery on health care, particularly maternal and child health in remote locations of Chhattisgarh for the last 15 years. Focusing on Bilaspur and Mungeli districts (with a recent expansion in Korba), the JSS has of late also adopted methods of public hearing providing an interface of the communities with the local administration. Infrastructure gaps, particularly roads linking the villages with the blocks or district HQs have continued to constrain the access to various health facilities. The best of awareness generation on MCH and birth preparedness were not yielding the desired outcomes through reduction in maternal deaths or improved institutional delivery. Limited mobile networks were found to limit attempts at seeking emergency medical care among pregnant women in most of the project villages in these districts.

However, the Jan Sunwai (public hearing) facilitated under the Oxfam –GPAF project by the local NGO JSS has begun to bring about a small change in the positive direction. Senior administration and health officials called for these meetings and apprised by the women members of the community about difficulties faced by then in absence of ambulance facilities have responded favourably. To begin with, a dedicated ambulance for the Bamhani centre of JSS in Mungeli district has been made available to cater to a catchment of approximately 50 villages. Given that basic infrastructure such as roads and electricity may take some time to reach to these villages, the Mahatari Express -108 (ambulance service) now chugs along the village roads to the nearby hospitals bringing cheer to pregnant women and their families for its assurance of easy access to health facilities and safe delivery.

Chhattisgarh

43

Realising change through enhancing knowledge

Nishi Kullu has been a live witness to the change in health seeking behaviour of women in the past two years. She has been working as ANM for the last twenty three year and in Hamirpur (project intervention area) for the last 8 years.

Nishi speaks about the hesitance women used to show towards institutional delivery prior to the project delivery. The pregnant women had more or less no say in choice of delivery facility, her mother-in-law and husband were the decision makers. The mothers-in-law going by their own experience would choose home as the best place of delivery completely ignoring the quotient of safety of both mother and child.

However, the situation seemed to have changed remarkably in the last three years. Repeated awareness campaigns in the village not only made the pregnant women conscious of their own health, but also enhanced the knowledge of the community especially mothers-in-law and husbands about various complications which can arise during delivery and can prove fatal to both mother and child. The campaigns inculcated a culture of caution not only among mothers but also mothers-in-law. Whilst it empowered the young pregnant women to make their choices of place of delivery, it also convinced the mothers-in-law and the husbands on medical institutions being the safest place of delivery as it remains well equipped to handle cases of complication if arises during delivery.

Prayas’ novel PRAYAS… towards improved governance

Prayas, the partner NGO has taken long strides in ensuring women receive their entitlements in time. JSY scheme in Rajasthan entitles a cheque of Rs. 1400 and 5 litres of ghee at the time of first delivery. However, these entitlements were rarely received by the women before Prayas intervened. Ganga Devi, a mother of two in Chittorgarh district recalls the hurdles she faced in getting her entitlements. She was even hassled by the bankers when she questioned about the delay in opening her account required to avail the monetary benefits of JSY. There were many others who spoke about facing delays at the healthcare facility in getting Ghee. The present situation speaks about the efforts taken by Prayas to not only provide support to the community but also strengthening the community to claim what is rightfully theirs.

Field animators and the Barefoot Workers have played an important role in actively supporting ASHA and ANM in their daily call of duty. In the absence of FLWs, Prayas has taken an active role in not only listening to the complaints but also taking steps to address them through conducting Jan Sunwai - triggering a public dialogue between the community and the responsible officials. The results of the efforts have been inspiring, which include transfer of erring bank managers and raising the issues at the district level by the community itself. The faith in importance of civil society organisations acting as a support mechanism to the government level institutional delivery mechanism is yet again strengthened with the positive outcomes seen in the district in the last three years of NGO’s operation.

Odisha

Rajasthan

44

Key Summary Points

Increase of 17 percent over baseline in proportion of women who were aware of at least two danger signs of pregnancy and at least two complications during and after child birth. Most of the women reported that ASHA and the barefoot worker were their source of information.

Over 40 percent of the respondents had noticed some danger signs during pregnancy. With an increase in the VHND and the activity of the ASHA, women are now more aware of the symptoms during pregnancy that could be danger signs.

76 percent of the women had sought treatment for the problems faced. The project through the efforts of ASHA and barefoot worker has created awareness regarding the importance of reporting incidents and seeking treatment for complications.

7 percent decline in home based deliveries from baseline. Women spoke of how the project animator, barefoot workers and ASHA have time and again spoken to them regarding delivery in the hospital. Moreover, during VHND, ANM has also advised them to deliver at the hospital.

In Maharashtra, Odisha and Rajasthan, there is a significant increase in deliveries at public hospitals.

There has been a decline in the proportion of women who have received benefits from the JSY scheme in Bihar, Jharkhand and Chhattisgarh. Issues were cited by one of the Medical Officers at a PHC in Bihar and the NRHM Block Manager in Jharkhand as lack of availability of funds for JSY payments in the last financial year.

Over 90 percent of the women are aware of the JSY scheme.

The project has enabled the community to raise their voice demanding their entitlements as JSY beneficiaries. However, larger supply side problems, such as fund availability can only be treated at the level of the government through wider advocacy and continued engagement with the officials.

Proportion of women whose last child birth was attended by a doctor has increased across all states with close to 55 percent of deliveries being attended to by doctors.

45

The program has worked towards creating awareness towards spacing and limiting measures for family planning. Through promotion of use of temporary methods of spacing and encouragement of access to various forms of contraception, the program has aimed at increasing awareness and access of couples towards contraceptives. Further, the programme has worked towards supporting the planning, budgeting, provisioning and reporting of safe abortion services. The project strategy was to increase awareness towards public health facilities that have safe abortion services and thus increase access of the women to the same.

Moreover, the program has worked extensively through the groups of adolescent girls against marriage at early age. Awareness towards legal age of marriage and disadvantages of early marriage has been created amongst the community through the medium of street plays and door-to-door visits

by the adolescent girls and the barefoot worker in the village.

7.1. Age at Marriage

7.1.1. Knowledge about Legal Age of Marriage

The legal age of marriage for girls and boys in India is 18 years and 21 years respectively. Over the project period, the knowledge of legal age of marriage has increased significantly from the baseline across all states. This increase has been a result of efforts of the adolescent girls, the barefoot worker and the VHSNCs towards raising awareness about the legal age at marriage along with the disadvantages of early marriage.

Over 87 percent of the women were able to articulate the disadvantages of early marriages.

Family Planning7

Table 18: Percentage distribution of women who are aware of legal age at marriage (boys) by states (in %)


Baseline 43.1 65.7 44.9 57.5 16.7 50.3 46.4

Endline 67.1 94.2 89.0 71.4 86.2 57.7 77.7


Table 19: Percentage distribution of women who are aware of legal age at marriage (girls) by states (in %)


Baseline 64.1 69.7 78.5 67.4 44.1 55.7 63.3

Endline 73.5 96.7 98.7 97.4 95.5 67.4 88.2


Table 20: Percentage distribution of women who are aware of disadvantages of early marriage by states (in %)


Women (15-49 years)

78.1 93.3 97.0 86.8 96.7 71.1 87.2


46

Amongst the disadvantages, ‘physical and emotional stress’, ‘mother becomes weaker’ and ‘inability of mother to take care of the child’ were the ones that were cited by most of the women.

Further, it was also observed that the reported mean age at marriage for girls was 19 years and that of the boys was 23 years. A lower proportion (as compared to baseline) of men and women were now getting married before the legal age. This has been possible through sustained efforts of the project animators, the barefoot workers and the adolescent groups who have continuously talked about the issues related to early marriage through IEC materials that have been used extensively for the same.

Table 21: Proportion of men and women married before legal age

Characteristics Baseline Endline

Proportion of women married before 18 years

65.4 21.3

Proportion of men married before 21 years

93.9 17.6

In district Kishanganj of Bihar, the community mostly consists of Muslim where marriage at an early age was a norm. The adolescent girls reported that over the project period they have realised the issues of marriage at an early age and have found a voice through their group to stop such marriages. They mention that while even now such marriages take place, their incidence has reduced. Moreover, parents with continued pressure from such groups are giving in to their demands and not marrying their girls before 18 years of age. The girls mentioned that this group had given them the strength to fight for themselves as now they were not alone and had a support group.

Quite a few cases in Bihar and Jharkhand were observed where young girls had reported to the barefoot worker or the village animator that they were supposed to get married even before 18 years of age and it was against their will. Groups of young girls, the barefoot workers and members of the VHSNCs reported to have visited the parents of these girls to talk them out of such a decision. Many such successful cases were cited in the field during the discussions.

7.1.2. Age at Conception of First Child

Data shows that a higher proportion of women reported to have conceived at least one year after the legal age of marriage. This can be linked to the fact that the awareness of availability of contraceptives has increased over the project period. More women are taking decisions regarding family planning along with their husbands.

7.2. Safe Abortion

Abortions are still seen as a taboo in the community unless necessitated by a problem during pregnancy. Women were not very open in talking about the issue or their willingness to have an abortion for an unwanted pregnancy. However, through the project, the awareness about the availability of this service in public health facilities has increased. Earlier, women were mostly aware of private facilities for safe abortions but now a

IEC Material at village health resource centres

47

59.0

67.6

80.885.5

96.992.4

85.7 84.786.191.6

79.3 77.2

62.4

84.4

0

50

100

EndlineBaseline


Figure 15: Proportion of women who conceived at least one year after the legal age of marriage (in %)

significantly higher proportion of women are also aware of the same in public health facilities.

The study did not capture the practice of the women under this component, but discussions with ANMs and ASHA revealed that few women would come to them wanting an abortion. This was supposed to be a quiet affair not to be mentioned

3.0

54.4

45.0 47.0

85.0

49.6

36.4

52.6

20.0

7.1

23.7

15.3

26.1

11.7

0

50

100

EndlineBaseline

TotalRajasthanOdishaMaharashtraJharkhandChhattisgarhBihar

Figure 16: Proportion of women aware of availability of safe abortion services in public health facilities (in %)

openly. In Kishanganj, Bihar particularly, where religious beliefs do not allow women to have an abortion or adopt family planning methods, the ANM was quite discreet about the issue of abortions. She mentioned that women did come to her for counselling and she took them to the private hospital nearby for the abortion.


48

It was observed that proportion of women who knew about the period of safe abortion (within 3 months of pregnancy) has also increased from 26 percent to close to 70 percent at an overall level.

7.3. Family Planning Methods

Use of contraceptives depends on awareness of different methods, access to them, social norms towards usage of these methods, desired fertility and decision making power of the women. While

72.5

83.5

95.4 94.199.1

88.283.3

90.5

54.6

66.4

78.2

68.8

81.9

59.9

0

50

100

EndlineBaseline


24.1

59.9

73.971.2

84.6

34.1

44.8

61.1

17 18.7

30.426.8

60.1

10.5

0

50

100

EndlineBaseline


Figure 17: Proportion of women who were aware of the time period for safe abortion (in %)

Figure 18: Proportion of eligible couples in the intervention area with knowledge of temporary method of contraception (in %)



the endline objectives did not cater to capturing practice related to family planning, the report does present data on knowledge of women regarding the methods and their availability.

7.3.1. Awareness of Temporary Methods

As compared to the baseline, there is a significant increase in the proportion of couples who reported to have knowledge of at least one temporary method of contraception. These temporary

49

methods include modern methods of spacing namely, male and female condoms, oral pills, emergency pills, Intra Uterine Devices (IUD) and injectable. IUD and oral pills are most commonly referred to by women as they are more accessible and easy to use. However, some incidents related to infection in the uterus caused by the IUD were mentioned by the women during discussions. Such incidents do create a ripple effect, with more women not wanting to use IUDs as contraceptive measures.

Discussionswiththewomen,duringfocusgroup,revealed that younger mothers wanted only two children and did not have any sex preferences for the child. Younger mothers mentioned thatsince they are educated and more informed of the temporary methods, they are also deciding their plan of family along with their husbands. Amongst older mothers, preference of a male child still remains, which is a decision made by the family. In the focus groups, these mothers expressed their desire to not have more children but that it would not be accepted in their family.

Table 5 shows that close to 75 percent of women (along with their husbands) are now taking decisions regarding planning of their family. However, it must be noted that qualitative findings showed that family planning was more defined as limiting than spacing. It is interesting to note that 60 percent of the women who are takingthese decisions belong to the age-group of 18-25 years. This indicates, that there is a change in the program period in the behaviour of the younger mothers. It was observed that younger mothers had visited the ASHA and the BFA on their own to inquire about methods of spacing and limiting.

Moreover, groups of adolescent girls in every village are also a source of information. They speak to the women regarding this issue and provide them with knowledge regarding family planning and the need of it. The group mentioned that they found it easier to speak with the younger mothers whom they were more comfortable with. Older women, would often not take the girls seriously on these issues.

Table 23: Proportion of women with knowledge regarding terminal and spacing methods of Family Planning (in %)

Characteristics Baseline Endline

Knowledge of at least 2 terminal methods of Family Planning

43.2 66.7

Knowledge of at least 3 spacing methods of Family Planning

45.1 74.2

Further, data shows that proportion of women who have knowledge regarding male and female sterilization and at least three temporary methods has increased during the project period. It can be observed that while knowledge regarding male sterilization is high, women mentioned in the discussions, that female sterilization was more prevalent as a practice across all states. Secondary data, points to similar findings, where in India, 37 percent of women compared to 1 percent of men who reported to have undergone sterilization (IIPS and ORC Macro, 2000).

7.3.2. Awareness of availability of contraception and safe abortion services

There is an increase in the proportion of women who are aware of availability of contraception

Table 22: Percentage distribution of women who reported to be taking decision regarding family planning by states (in %)

States Bihar Chhattisgarh Jharkhand Maharashtra Odisha Rajasthan Overall

Women (15-49 years)

75.1 99.2 52.5 82.4 73.6 67.8 75.1


50

and safe abortion services. Women have reported PHC and CHC as centres where they can avail contraceptives. They have mentioned that ASHA also has a stock of male condoms which can be taken from her if required.

Out of the 51 percent women who knew about the availability of contraceptives and safe abortion services, 79 percent were those who took decision regarding their family planning along with their husbands. Further, amongst the 51 percent, 71 percent are those who have two or lesser number of children.

Table 24: Percentage distribution of women aware of availability of contraceptives and safe abortion services


Baseline 3.0 11.4 24.0 18.1 4.6 21.8 13.9

Endline 54.4 44.5 46.6 84.1 44.7 35.1 51.3


This clearly indicates that knowledge about availability is not a standalone indicator. Women who want to limit their families, are more aware of these services. Thus, generating willingness towards family planning is an essential component towards creating awareness regarding family planning methods and their availability. This willingness is dependent upon women’s education, their awareness regarding issues due to a large family and their decision making power within a household.

79%takedecisionregarding family

planning

71% with 2 or lesser number of

children

Womenawareof availability of

contraceptives and safe abortion

51

7.4. Approaches towards family planning- Vignettes from States

Family planning in Maharashtra: No more a taboo.

Couples in Maharashtra prefer to have a small family, with the average family having less than three children. Many families opt for a permanent sterilization of either the wife or husband to prevent further conception once at least one or two sons/male children are born. The average spacing between two pregnancies varies from one to three years with a high awareness and acceptance of temporary contraception methods such as IUDs. Over the project period the acceptance of temporary contraception as an effective means of delaying subsequent pregnancies has increased. Women today know about the Copper-T, oral contraceptives and condoms, using at least some of these modern methods to effectively plan their pregnancies.

While temporary methods have gained prominence, there has been a steady increase in the uptake of permanent methods as well. In Gadchiroli district for example, the proportion of men undergoing family planning operation is almost equal to that of women. This gender neutrality can be attributed to the predominant tribal culture that has remained aloof of the normative, patriarchal judgments associated with the mainstream in these matters. People have realized the advantage of having a small family size which reduces the burden on incomes and resources of the family.

Raising voices and expanding choices

Surekha and Kishori are neighbours and live in a small village called Birkaldehi in Balisankara block of Sundergarh. Both in their early twenties have become first time mothers. While Kishori has a boy of eight months, Seurkha’s daughter is of seventeen months. Surekha’s family has been pushing her for another child as her child has been past one year now. However, Surekha speaks about maintaining required gap before she gives birth to another child.

Surekha has studied till class 11th and had no knowledge about family planning till she attended the awareness campaigns on family planning conducted in the village. these campaigns not only equipped her with the knowledge of different family planning measures but also help her in choosing what suits her needs the best. She has been using Copper T as birth control measure since a year after discussing it with her husband. Apart from putting the knowledge gained to her own benefit, she has also proved to be an inspiration for Kishori, convincing her about the safety of using such measures. Kishori and her husband were convinced on planning their family and like Surekha she has also been using CopperT. When they were asked about whether their families know about it, they shyly reply that it was their decision and supported by their husband.

These campaigns on family planning are not only making people aware of benefits of planning their family but has provided the women with a voice in family planning which previously was entirely dependent on men. Many women like Surekha and Kishori are able to choose independently methods of family according to their needs along with convincing their husbands about planning their family.

MAHARASHTRA

ODISHA

52

Using a Social Determinants lens is producing the nut-cracker effect

Villages of Rajasthan are dotted with several cases where women have given birth as frequently as within 14 months of previous child despite being aware of benefits of spacing between children. The primary reason being lack of choice and participation in decisions regarding family planning or spacing within the family. While the women remain the child bearer, the decision of number of children to bear usually remains with the husband and the mother-in law. Under such circumstances, counselling the family and addressing the family’s concern on family planning measures remained a major issue which was well realised by the partner NGO- Prayas. Adoption of such an approach i.e. addressing the social concerns and using them as measure to ensure safe maternal health was evident after meeting Shyama devi.

Shyama Devi from Devgarh narrated her experience of sterilisation after having two children. Her husband not only supported her decision, but was also vigilant about her health post procedure. She credits the efforts of the NGO and the frontline workers to reach out to her family members for counselling which made this possible. Not only was she able to speak about her preferences but was also able to put it into practise by deciding the family size.

Shyama Devi has further strengthened the NGO’s belief on adoption of the social determinants approach. The fact that family support remains a major factor influencing a woman’s decision was aptly realised and prospective hurdles were resolved. Addressing social concerns and issues not only makes it sustainable but also results in empowering women to make their choices.

RAJASTHAN

Key Summary Points

Over the project period, the knowledge of legal age of marriage has increased significantly from the baseline across all states. Over 87 percent of the women were able to articulate the disadvantages of early marriages.The reported mean age at marriage for girls was 19 years and that of the boys was 23 years. A lower proportion (as compared to baseline) of men and women were now getting married before

the legal age.These results have possible through the efforts of the adolescent girls, the barefoot worker

and the VHSNCs towards raising awareness about the legal age at marriage along with the disadvantages of early marriage.Close to 75 percent of women (along with their husbands) are now taking decisions regarding

planning of their family. 60 percent of the women who are taking these decisions belong to the age-group of 18-25 years.Proportion of women who have knowledge regarding male and female sterilization and atleast

three temporary methods has increased during the project period.Increase in awareness of 37% from baseline regarding availability of contraception and safe

abortion services. Out of the 51 percent women who knew about the availability of contraceptives and safe abortion

services, 79 percent were those who took decision regarding their family planning along with their husbands and 71 percent are those who have two or lesser number of children.

53

The fundamental rationale of the social determinants of health approach is not only that social determinants shape health outcomes but that it is possible to improve health outcomes and reduce health inequities by analyzing and acting on the most influential of those social determinants9. The current project has identified components of nutrition, safe delivery and family planning as its core factors at play that are instrumental in reduction of MMR in India. It has taken the route of community based mobilization in voicing their demand for the entitlements under the existing public programmes and schemes. A variety of government policies are targeted towards the improvement of health outcomes for poor. However, lack of awareness towards their rights, supply side bottlenecks and certain religious and social beliefs act as barriers on the path towards improved maternal and child health. Thus, the project has particularly worked towards harnessing the strength of village based institutions and individuals including the VHSNCs, the adolescent girls and frontline workers towards this end.

This report has analysed quantitative data to draw comparisons on various indicators from the baseline. Given the approach of the study, it is essential to look at the key social determinants that have been influential in bringing about the change that has been described in the earlier sections. The project had worked with social groups that were comprised mostly of SC and ST groups. Thus, the evaluation was also conducted with these groups to asses a change using pre-post analysis. However, the homogeneity of the groups that were visited during the endline survey tend to be a limiting factor to look at a causal analysis or understand latent factors at play

9 A social Determinants Approach to maternal Health, Discussion Paper, Roles for Development Actors, Bureau for Development Policy, UNDP, October, 2011

instrumental in the change, through quantitative data at this stage. The current analysis, therefore, will draw upon inferences from qualitative findings of the discussions in the field.

8.1. Augmenting Birth Preparedness

Birth preparedness under the ambit of the project, can be disaggregated into three components namely, undergoing ante-natal check-ups, improvement in nutrition and reduction in incidence of anaemia amongst women. With an increased awareness of VHND amongst beneficiaries on one hand, the project has also capacitated the village institutions into monitoring the VHND. With increased awareness about the features of VHND mandated as per government rules, the VHSNCs have made the frontline workers accountable towards provision of adequate check-ups during pregnancy, information regarding care to be taken during pregnancy and the nutrition supplements that are provisioned for the women.

The success of VHND across states is attributed to a supply side that has responded towards the demands of the community. Poor attendance in VHND earlier, was due to limited availability of the ANM at the VHND, distance of the place of VHND from the villages as it was held at the panchayat level in some states or due to irregularity of the organization of VHNDs at the village level and inadequate facilities and medicines. However, now the VHND is organized within the village, reducing the problem of access due to distance. Moreover, the ANM can no more be absent on the day as she is now held accountable by the VHSNCs who have realised their rights and powers.

Women are more aware of the benefits of IFA tablets and the supplementary nutrition made available to them. Thus, they ensure their presence in the anganwadi centre where the VHND is held. This effectively, underscores the convergence

Explaining Outcomes through the Lens of Social Determinants

8

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of health and nutritional aspects of mother and child health where one day every month, pregnant and lactating mothers can receive health check-ups and receive nutritional supplements that help reduce incidents of anaemia. This model has worked under the project as the efforts have brought a synthesis of the work of the community based institution and the service providers to benefit the individual.

8.2. Steps towards Safe Delivery

The project has worked towards an increase in access of public health facilities for institutional childbirth, receipt of benefits under JSY and delivery in presence of a doctor. It must be understood at the outset that all three components are interlinked and sometimes dependent on

each other. The data indicates that there is not significant increase in deliveries at public health facilities. However, a close look at the data indicates an increase in deliveries in public health facilities in Maharashtra, Odisha and Rajasthan. In Jharkhand, Bihar and Chhattisgarh, deliveries at public health facilities has dropped. Moreover, In Chhattisgarh and Bihar, the deliveries conducted at home have shown an increase. What really has happened in each state that such varied results have emerged? How has the project helped in the increase and why has the strategy not worked across states?

The schematic represents the linkage between the JSY scheme, the place of delivery and the birth attendant during the delivery. Here, the larger policy environment is mainly responsible for the

VHND

AWWANM ASHA

Monitor VHND activities and

services

Provision of ANC and counselling

Provide THR

Women

Receive Health and

Nutrition Benefits

Responsible for generating awareness

regarding day of VHND and counsel women on benefits

Act as citizen watch groupVHSNCs

Act as the link between supply and demand sides

COM

MUN

ITY

INST

ITUT

ION

SERV

ICE

PROV

IDER

SIN

DIVI

DUAL

Figure 19: Roles played by different Actors in provision of VHND services

55

outcomes observed which have direct effect on the household and individual behaviour. Further, the health system’s capacity and infrastructure has also made an impact on the observed practices.

The discussions with women revealed that all of them preferred a delivery in the hospital as it was safer for both mother and children. However, private facilities are given a preference over public health facilities in terms of infrastructure and care provided. But, deliveries at public health facilities have an added incentive of INR 1400 as per the JSY scheme. In Maharashtra, Rajasthan andOdisha, there has been an increase in proportion of beneficiaries who have availed JSY. This isbecauseofwell-functioningPHC,CHCanddistricthospitals with adequate infrastructure. The JSYpaymentsareon timeandensured.Withanincrease in institutional deliveries, the deliveries conducted by the skilled birth attendants hasincreased.

Now, the program has specifically raised awareness of the community regarding the JSY benefits that they are entitled to. However, supply sidebottlenecksinBihar,ChhattisgarhandJharkhandhave led to non-payment of the monetary benefit under JSY. While awareness about the schemehas increased in these states, the supply side has not conformed to its mandates. Thus, poor responsiveness from the service providers has led

to a decline in the deliveries that happen at public health facilities. Many efforts across the three states, in petitioning for the entitlement have been made but they have not resulted in significant outcomes. Thus, a larger advocacy with the state level officials of the concerned departments is needed for the effects to be observed at the ground level. Moreover, lack of presence of female doctors in these states has been an issue raised by the community many a times. This is confirmed by the medical officers at the PHC who report to be helpless in the situation.

It is interesting to note here, that in Jharkhand,non-state service providers (NSP) have beenpresent traditionally across the state due to the missionary interventions. These NSPs are notexpensive and accessible to the community with adequate infrastructure and trained staff. These hospitals thus, provide a last mile delivery for the health outcomes in the state.

8.3. Self-Efficacy in Family Planning

The project has harnessed the strength of the adolescent girls in the villages who have received training regarding the legal age of marriage, disadvantages of early marriage and temporary and permanent methods of family planning. The idea of a life cycle approach here, has worked extremely well as across states, women have

Delivery at Home or

Private Facility

Delivery attended by a Skilled

Birth Attendant

Not Available

Delivery at Public Health Facility

Available

JSY

Bihar and Chhattisgarh- Increase in Home based delivery

Jharkhand- presence of non-state service providers

Figure 20: Effect of JSY on Institutional Deliveries

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reported an increase in awareness regarding age of marriage and access to safe abortion services and contraceptives.

Here, the services at public facilities were already available, however, knowledge regarding the same and a discussion amongst women was what was lacking. The project through the empowerment of girls has brought about an increase in awareness. Thus, the barrier of discussions around family planning have been reduced as younger women being more active are discussing it in their community with the women in the reproductive age. However, discussion have revealed that religious beliefs and patriarchal nature of the society, are obstacles that have a huge impact on the women’s ability to make decisions. While 75 percent of the women are planning their family, along with their husbands, these social norms govern their behaviour.

Here, the program’s approach to work with young girls have triggered a huge change as girls have found a platform to talk and they feel empowered as a group. Their thoughts and behaviour can be influenced at this stage when they are at the threshold of starting a family. Their empowered status will continue to influence other members in their own family.

8.4. Demand Creation versus Service Delivery

The projects outcomes when seen in the light of the interventions indicate the depth at which the activities have been conducted. The latent social factors at work that are instrumental in bringing a change to the health outcomes have been very aptly chosen in the form of behaviour or institutions and the individuals. The project has faced numerous challenges in terms of the social groups that they have worked with. Across states, these groups have varied and the partners have engaged continuously with the community to start and continue the project.

While the context of each state has been different, in responsiveness of the supply side and the efficacy of demand from the community, the outcomes have shown progress across various indicators of maternal health. The social determinants at play particularly the community’s attitude, their capacity and the social norms have been very well captured in the project. However, supply side bottlenecks, including the health care facilities and the policy environment need special attention and perhaps stronger lobby towards a better service delivery mechanism. The demand for the entitlements has been raised, the community is aware and mobilised as they await a responsive service delivery system from the state.

57

The project’s progress across the chosen themes indicates an increase in awareness regarding safe practices of motherhood amongst the beneficiaries. This awareness has shown a translation into a move towards safer practices such as increase in consumption of minimum number of IFA tablets, uptake and consumption of THR and counselling from ANM and ante-natal check-ups. Further, access to contraceptives and safe abortion facilities has increased with women now taking decisions regarding family planning along with their husbands.

However, certain aspects of safe delivery including institutional delivery and availing benefits of JSY have seen varied results across states. Due to poor service delivery JSY benefits have not been made available to the poor in Bihar, Chhattisgarh and Jharkhand. This has led to a fall in deliveries at public health facilities in these states. On the other hand in Maharashtra, Odisha and Rajasthan, there is a significant increase in the deliveries at public health facilities owing to improved infrastructure, staff and care along with timely payment of JSY beneficiaries. Limitations of the public sector health delivery system have been taken care of by the emergence of the non-state service providers in Jharkhand. However, In Bihar and Chhattisgarh, the poor are resorting to home based deliveries attended to by local doctors and the traditional birth attendant.

An increase in awareness and access to family planning methods and safe abortion services is a positive outcome of the project. However, what is required is to understand whether the awareness has translated into better practices. While limiting is understood well by the women, the need for spacing is yet to be well absorbed. Safe abortion services at public health facilities may be known to the women, but they indicated a preference towards the private services given the social norms that underline the taboo around the subject.

9.1. Empowering Women

Across all states, it was observed that women have started voicing their concerns to their family, the village institution and frontline workers. The project has provided a space for the women to seek knowledge on safer practices, demand for their entitlements from the government health workers and understand their rights as a citizen. The project has created a sense of empowerment amongst women who now sit with the men during VHSNC meetings and draft the health plans.

9.2. Bringing VHSNCs to Life

The VHSNCs now realize their role in the health status of the village. They have started developing health plans with a component of maternal health

Conclusion9

On paper committees reconstituted

Membersmadeawareoftheirtaskas a committee

VHSNCslearnedmethods of conductingCBM

Helpinginawarenesscreation towards VHND

Planning for effective use of untied funds

VHSNCsexpressedneed for guidance from the NGOs

CapacityBuildingofsilent members.

Mostofthehealthplans yet to capture component of maternal health

Form

atio

n

Stre

ngth

enin

g

Sust

aina

bili

ty

Figure 21: Project’s efforts towards strengthening VHSNCs

58

in it. Women are now an integral part of the committees and in some areas heading them. ASHA worker has slowly realized her role in developing health plan and is now confident to use the funds. VHND are slowly seeing more involvement from the villages due to awareness created by VHSNCs.

In some areas, VHSNCs have started making health plans and are awaiting the untied fund to execute it. However, awareness towards planning for the untied funds is still required. Regular meetings of VHSNCs have started happening which are now being conducted without the project animators, but this exit has to be slow as VHSNCs expressed their need of further guidance at this stage.

It was observed that the VHSNCs have slowly moved towards better understanding and planning of their work, but they are still at a nascent stage of their work and may need some handholding to make them into sustainable institutions. The project support in execution of health plans with effective use of the untied funds is still required in all the states.

9.3. Walking the Last Mile of Service Delivery

Barefoot Auditors have been instrumental in the progress of the project especially in raising awareness and monitoring supply side delivery of services. On one side, the project has capacitated a cadre of women in understanding health issues and generating awareness amongst women, on the other, they have generated help for the ASHA who is assisted in her work as a health activist. However, while the auditors are happy with the work that they do, they have often mentioned that their workload is high and have requested for a salary to continue their work. The BFA are young and educated and on the lookout for economic opportunities to support themselves and their families. As the project has withdrawn, they are looking for newer opportunities to work for an income. The voluntary nature of their work cannot be sustained for long as the work is quite demanding and requires a lot of dedication. Thus, the project may consider some method of payment to these volunteers. Alternatively, one of the adolescent girls may be chosen to be the BFA which can change yearly.

9.4. Sowing the Seeds of Change

The groups of adolescent girls across states have proved to be the strongest link of the project. A life-cycle approach has been adopted to start with knowledge of safe practices leading to a change in attitude. As young girls get more aware of health

Highlights of the work of VHSNCs

In Jharkhand few VHSNCs continue to monitor the VHNDs, have written letters to the officials requesting money for JSY to be given to the mothers, arranged for vehicles when vans have failed to come.

In Maharashtra, a VHSNC had used untied funds to sponsor an ultrasound and additional scans of a pregnant woman with complications

In Bihar, VHSNCs are constituted at the panchayat level. The village level committees are not recognized. Members want it registered. They see the committee as their right and a space to voice concerns.

“We still need a lot of guidance. Now ASHA and Sarpanch have become active but we still need support in terms awareness. We will need another 6 months to stand on our feet”

-VHSNCmemberinKandhamal,Odisha

59

issues, safe practices and health services, they would take it forward after marriage, disseminating knowledge to others. This group requires minimal inputs in terms of economic capital. The girls are extremely happy to have a platform that belongs to them and the support group created has helped them fight issues related to PDS, stop marriages before the legal age and secure their rights as rightful citizens.

The project has instilled a sense of confidence amongst the girls who feel empowered as a group.

They are more receptive to the health issues that occur during maternity and encourage young mothers in their villages to follow the advice of the ASHA and ANM and adopt safe practices during pregnancy and child birth.

As the older girls get married or grow out of the group, younger girls join it and are trained by the other members. These groups are effective in communication, active in their work and sustainable given their group dynamics which have minimal interference from the other villagers.

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Annexures

I. Log-frame Indicators

IMPACT Impact Indicator 1 Assumptions

Ensuring Universal Access to maternal health to achieve MDG-5 by the year 2015 in Six states of India

Maternal Mortality Ratio Government committed about reducing Maternal Mortality through its flagship program "National Rural Mission" and MDG goals. 2. No reduction on Government’s health budget,

OUTCOME Outcome Indicator 1 Assumptions

“Improved women’s health status in the six poorest states of India”.

(Direct Beneficiaries- 186686 in the six poorest states on India) State wise direct beneficiaries are: 39750-Bihar, 87700-Chattisgarh, 1 1 2 9 6 - M a h a r a s h t r a , 12400-Jharkhand, 13390-Orissa, 22150-Rajasthan

Number of women aware about incidences of serious health problems due to pregnancy or childbirth

Government's commitment to increase institutional delivery.

Outcome Indicator 2 Assumptions

Number of women conceiving at least one year after the legal age of marriage

Government’s commitment to strengthen legal framework to avoid early child marriage. Community is aware about the ill effects of early pregnancy which would lead to changes in cultural practices.

Outcome Indicator 3 Assumptions

Number of women consuming iron rich/ iron fortified food

There is sufficient nutrition available and there is change in cultural practices that women have fair share of food in the family and sit with family to eat food.

Also here it is assumed that number of women receiving are consuming the supplementary nutrition from AWC

OUTPUT 1 Output Indicator 1.1 Assumptions

Community capacity to advocate for women’s access to a wholesome balanced diet.

Number of community institutions equipped to demand the promised entitlement under the Public Distribution System (PDS) /Integrated Child Development Scheme (ICDS) at right frequency

There is no corruption in the PDS and ICDS distribution system and there is increased accountability. Governments own regulatory structure functions optimally.

Output Indicator 1.2

Number of VHSCs/Citizens bodies able to prepare community score cards on the performance of ICDS and PDS


Women have improved and increased access to obstetric care including referral services in project intervention areas

Number of women benefited under the Janani Surkasha Yojana (JSY) scheme

Government's flagship programme the National Rural Health Mission (NRHM) has a framework of service guarantees with emphasis on maternal health services

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Number of PHCs with referral services for complicated pregnancy


Number of PHCs and CHCs having at least a monthly stock of essential drugs for maternal health


Number of women having access to contraceptive and safe abortion services

Output Indicator 2.5 Assumptions

Number of births attended by skilled health personnel

Assuming that births assisted by Skilled Birth Attendants reduces the incidences of the post-partum/child birth related complication among women


Number of women who have received counselling from ANM on care during pregnancy


Women with increased awareness and knowledge on legal age of marriage and contraception methods.

Number of women able to articulate different disadvantages of early marriages

Assuming that the Government’s legal machinery supports to stop child marriages and community supports the same and community understands the benefits of spacing , delay in child birth and importance of girl child. Here the women who have information that abortion facility is available in their nearby health facility are considered as women who have access to safe abortion facility.

Number of women aware about the availability of contraceptive and abortion services at various levels of public health system


Number of eligible couples in the intervention area having knowledge of temporary method


Increased engagement of Civil Society Organisations (CSOs) in monitoring and planning of the Government health delivery services through identification of policy gaps at \all levels

Number of Village Health plans with focus on maternal health

Government and community supportive about instituting VHSC , community based monitoring under the NRHM and increased spaces for CSO participation


Existing policy gaps are identified by doing community based monitoring of maternal health services through VHSCs/ citizens bodies


State/ national level policy briefs published and number of dialogues with the high level officials


Number of VHSCs/Citizens bodies able to monitor the performance of ICDS and PDS

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II. Data Collection Approach

The evaluation used a mix of qualitative and quantitative methods for the process of data collection. The tools were developed keeping the log frame indicators as the focal areas. The quantitative component involved collection and analysis of empirical data at household level which provides information related to the extent and type of impact created by the project. The answers to ‘why’ and ‘how’ of the impacts were captured by the qualitative tools which delve deeper into the nature of and the reasons behind change. Trends in practices were encapsulated by involving in discussions at community and institutional level.

Level Target Group

Household Level Mothers with children aged two years or less

Pregnant women

Mothers in law

Husbands

Village Level ANM

Village Health Sanitation and Nutrition Committees

ANM

ASHA

Anganwadi Worker

Barefoot auditor

Block/District Level Block Medical Officer (BMO) / Chief Medical officer (CMO)

Child Development Project Officer (CDPO) / District Project Officer, ICDS (DPO-ICDS)

Lady Supervisor

Medical officer in-charge (MOIC)

a. Tools and Techniques

Under the quantitative component, a survey using structured questionnaire was conducted with pregnant women and mothers having children aged 2 years or below. It was divided into the following sections:

i. Household questionnaire

ii. Antenatal care, including nutrition and care at home

iii. Delivery and post partum care

iv. Safe abortion

v. Early marriage and family planning

vi. General awareness of and use of schemes and feedback mechanism

Under thequalitativesegment,FocusGroupDiscussions(FGDs)andIn-DepthInterviews(IDIs)wereconducted with another set of stakeholders to get a wider perspective of the situation. The qualitative discussions were conducted at two levels:

i. FGDswith pregnantwomen andmotherswith children aged two years or below,mothers-in-law and husbands. Particularly for the group of mothers and pregnant women, Benematrix tool

63

was used in addition to main discussion for ascertaining perception about various institutions of health. The familymembersofthewomenarekeydecisionmakers who determine various practices existent in the community. Conducting qualitative exercises with groups of husband and mothers-in-law led to an understanding of their role, their perceived attitude towards different components of maternal and newborn health care, issues in accessing services, their behaviour and support towards the mother etc. FGDs were also conducted with VHSNCs members to understand their perception of the roles and responsibilities of the committee.

ii. IDIs were conductedwith frontline healthworkers– Auxiliary Nurse Midwife (ANM), Accredited Social Health Activists (ASHA), Anganwadi Worker (AWW)), Barefoot Auditor (BFA) and Village Health Sanitation and Nutrition Committees (VHSNCs) to understand their role, functions and support in determining health at the village or community level. Discussions were also held with government functionariessuchas,ChildDevelopmentProjectOfficer(ICDS)(CDPO);DistrictProjectOfficer,ICDS(DPO-ICDS);BlockMedicalOfficer(BMO);andChiefMedicalofficer(CMO)tounderstandthehealthservice delivery mechanism in the district and the issues faced.

b. SampleSizeCovered

SampleSizeTargetedandAchievedforQuantitativeComponent

States/Districts

TargetedSampleSize

perState

SampleSizeCovered

Number of pregnant

women interviewed

NumberofMothers

interviewed

TotalSampleSize

Bihar 210 17 220 237

Kishanganj 7 112 119

Sitamarhi 10 108 118

Chhattisgarh 210 21 216 235

Bilaspur 10 109 117

Mungeli 11 107 118

Jharkhand 210 25 217 242

Hazaribagh 12 109 121

Ranchi 13 108 121

Maharashtra 210 20 224 244

Gadchiroli 12 106 118

Nandurbar 8 118 126

Odisha 210 24 216 239

Kandhmahal 12 108 119

Sundergarh 12 108 120

Rajasthan 210 25 215 240

Chittorgarh 12 108 120

Pratapgarh 13 107 120

Grand Total 1260 132 1308 1437

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SampleSizeTargetedandAchievedforQualitativeComponent

Category Targeted SampleSizeperState

Samplesizecovered

Bihar Jharkhand Rajasthan Chhattisgarh Maharashtra Odisha Total

Mother 2 2 2 2 2 2 2 12

Mother-in-law 1 1 1 1 1 1 1 6

Husband 1 1 1 1 1 1 1 6

ANM 1 1 1 1 1 1 1 6

ASHA 1 1 1 1 1 1 1 6

AWW 1 1 1 1 1 1 1 6

Barefoot worker 2 2 2 2 2 1 2 11

VHSNC 2 2 2 3 2 2 2 13

CDPO/DPO 1 0 0 1 0 0 1 2

BMO/CMO 1 0 1 1 0 1 0 3

MOIC 1 1 0 1 0 1 1 4

LS 1 0 0 1 0 1 1 3

Total 15 14 13 16 11 13 16 83

In addition to the above mentioned stakeholders, adolescent girls were also interviewed in Bihar, Jharkhand and Odisha.

c. SelectionofVillages

The following steps were followed to select the villages:

1. The population in each village was divided by five to derive the number of households in each village.

2. The villages were then sorted in an ascending order based on the number of households.

3. The villages were divided into 2 strata- ‘High’ and ‘Low’. The villages with 200 or more than 200 households were in the first stratum (high) and the villages with less than 200 households were in the second stratum (low)10.

4. The sample size at the state level was distributed equally across two districts in each state. Within each district that sample is distributed across the 2 strata equally (53 households in each strata). Thus, 3 villages were selected using the random sampling method from each strata.

5. Unique codes were then generated for the districts, blocks and the villages.

Sampledistributionatvillage,districtandstatelevel

Sample size per state 210 households

No of sampled project districts per state 2

Sample Size per district 105 households

No of strata per district 2

Sample size per stratum 53 households

No of villages per strata 3

Sample size per village 18 households

10 It was observed that most of the villages have a relatively low population, especially in Rajasthan, Odisha and Jharkhand. Therefore, 200 households was observed to be a cut-off point for the two strata.

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Note: Villages with a population of less than 50 households were not considered in the sampling frame. The sample size to be covered is 18 households in each village. Given that we have assumed a 30 percent probability of finding our target group (pregnant women and mothers with a child less than two years old), it effectively implies that we must list at least 60 households in each village. Considering the non-response rate and the need of a sampling frame to sample 18 households, a minimum of 70 households in each village is required to be listed.

d. SelectionofHouseholds

The following steps were followed to select the households:

1. A house listing exercise was conducted to generate the sampling frame for the selection of respondents for each subcategory of the target population. Details including the age of the youngest child, the poverty status and few other demographic details of the households were recorded during listing. These details were noted to decide the eligibility status of the household.

2. After the listing, all the sheets were combined and two sampling frames were created. The first sampling frame comprised households in the BPL category. All the households in this sampling frame were given running numbers starting from 1. Similarly, the second sampling frame comprised households in the APL category which will also be numbered.

3. A sampling interval was calculated for each sampling frame (total number of eligible households/ sample size to be covered).

4. We selected 10 households from each category using systematic circular random sampling. A random number will be generated between one and sampling interval and addition of the sampling interval to the same will be continued until we select nine households under BPL and APL households.

5. Within each household, if more than one eligible woman was present, one respondent was selected randomly.

6. If a sampled household refuses for the survey or is vacant, the household was replaced with the household next to it in the list.

A Note on House Listing Exercise

1. Approximately 200 households were listed in each sampled village

2. All villages which had approximately 200 or less households were listed completely.

3. Villages with 200-400 households were divided into segments with approximately 50 households in each segment. Four segments were randomly selected to be listed.

4. Villages with more than 400 households were divided into 2 quadrants. Within each quadrant, segments of approximately 50 households were created. In each quadrant 2 segments were randomly selected and listed completely.

5. It was ensured that BPL or marginalised segments are selected (purposively if not randomly to ensure their representation in the sample)

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III. Quality Assurance Mechanism

A team of four field enumerators and one supervisor was deployed in each sampled project. It was ensured that the teams had adequate survey experience in social research. In addition to this, the enumerators and supervisors were:

• Hiredfromlocalareaswithknowledgeofthelocationsbeingsurveyed

• Fluent in the local language to enable smooth administration of the questionnaires to thebeneficiaries.

A state coordinator was assigned to each state to ensure smooth implementation of the field work. The state coordinator was responsible for development of team movement plan, monitoring of the field work, provision of clarifications on the questionnaire, respondent groups and other research related queries to the field teams, scrutiny of one percent of questionnaires and overall management of the field issues.

The following diagram illustrates the quality assurance procedure followed at different stages of data collection and processing.

� Recording values lower or higher than the end values

� Inconsistency in recorded information

� Skipping issues and missing questions

� Incomplete questionnaire

� Pre-testing of tools

� Household and respondent Identification

� Range Checks

� Consistency Checks

� Validation Checks

� Completeness of Tool

� Field Supervisors - 100% scrutiny

� State coordinators - 10% scrutiny and superise visit

� Researcher Associates - 5% scrutiny and back checking

� Senior Team - 1% spot checking

� Usage of new codes in close ended questions

� Multiple responses for open ended questions

� Procedure Error

� Data Omission

� Finger Error

� Code Error

� Listing other codes appearing in pre-coded Questions

� Preparing of code lists for open ended questions

� Scrutiny and Coding of Pre-coded and open ended Questions

� Double data entry

� Physical verification 10% Tools

� System based Range Checks

� System based Cosistency Checks

� System based Validation Checks

� Comparison of 2 data sets

� State Coordinator

� Research Associates

� State Coordinator

� Research Associates

Data Collection LevelStage

PtentialChallenges

Typical QAAcivities

Responsibility

Pre-Data Entry Post-Data Entry

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IV. Calculation of SLI

The NFHS 3 Supplemental Documentation has been referred for Standard of Living Index. Computation of the Standard of Living Index (SLI) involves a scoring system where the house, facilities associated with the house, and physical items belonging to the household are given scores. These scores are then summed and the result measured against a static set of SLI cut-offs. Once the data entry is completed, the minimum and maximum scores will be arrived at. Then the frequencies would be defined as Low, Medium and High SLI. For example, Households with a score 5 to 21 are classified as having a Low SLI, a score of 22 to 38 is a Medium SLI, and scores 39 to 67 is a High SLI. As with House Type, if any of the variables from which the scores are drawn are missing, don‘t know, or other, the SLI for that household is then set to missing.

The variables used and the scores assigned are as follows:

Q.No Question Codingcategories SLIscore (followingNFHS3)

120

Household goods Mattress 1

Chair 1

Cot or bed 1

Table 1

Pressure cooker 1

Electric fan 2

Radio or transistor 2

Television (B&W) 2

Television (Color) 3

Sewing machine 2

Mobile 3

Telephone 3

Computer 3

Refrigerator 3

Watch or clock 1

Water pump (domestic use) 2

Thresher 2

Tractor 4

Bi-cycle 2

Two wheeler 3

Car/ jeep 4

121 Type of house Kachha house 0

Semi-pacca house 2

Pucca house 4

122 Ownership of house Rent 0

Own house 2

Do not own but not paying 0

123 Source of lighting Electricity 2

Kerosene 0

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Q.No Question Codingcategories SLIscore (followingNFHS3)

124 Source of drinking water

Piped water into dwelling/yard/plot 2

Piped water outside dwelling/ yard/plot 2

Public tap/standpipe 1

Hand pump inside or outside dwelling/ yard/ plot

1

Well inside or outside dwelling/ yard/ plot 1

Protected spring/River water/ Pond water/ Rainwater

0

125 Type of toilet facility Own toilet with water seal 4

Own toilet without water seal 2

Shared/ public toilet of any type 2

No facility/ bush/ field 0

127 Type of cooking fuel Electricity 2

LPG/ natural gas 2

Bio gas 1

Kerosene 1

Kerosene 1

Coal/ lignite 1

Charcoal 1

Wood 1

Straw/shrub/grass 1

Agriculture crop waste 1

Dung cakes 1

128 Place of cooking In the house, separate room 1

In the house, no separate room 0

In a separate building 1

Outdoors 0

111 Household own any agricultural land

Yes 4

No 0

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v. Key Indicators Sheet

KeyIndicators Baseline Endline % Difference

P values

Households having access to safe drinking water 80.4% 79.1% -1.3% 0.171056

Availability of toilet in the household 11.2% 10.0% -1.2% 0.1156

Households having separate place for cooking 47.0% 52.0% 5.0% 0.001203

Households having Job card for MGNREGA 48.6% 50.1% 1.5% 0.181675

Household procure food items from PDS? 54.4% 78.5% 24.1% 0.00001

Household satisfied with PDS supply system? 47.8% 72.9% 25.1% 0.00001

Knowledge on at least 3 ANC should be taken by a pregnant mother

NA 74.4% NA NA

Received at least 3 ANC check-ups 60.4% 80.3% 19.9% 0.00001

No ANC at all 6.0% 5.6% -0.4% 0.312421

Information obtained from any type of health workers (ASHA, ANM, AWW) on necessity of ANC checkup

NA 88.2% NA NA

Counselling from ANM 36.5% 79.9% 43.4% 0.00001

Knowledge on consumption of 100 IFA during pregnancy by a pregnant woman

42.9% 54.4% 11.5% 0.00001

Knowledge on at least one benefits of IFA tablet NA 89.3% NA NA

Percentage of women consuming requisite amount of IFA tablets

27.4% 37.6% 10.2% 0.00001

Knowledge on at least 2 TT should be taken by a pregnant mother

NA 90.2% NA NA

Received 2 TT during last pregnancy NA 84.4% NA NA

Awareness on availability of supplementary food at Anganwadi centre

NA 95.4% NA NA

Received supplementary food from Anganwadi during last pregnancy?

73.6% 81.0% 7.4% 0.00001

Consumption pattern of THR among women (eat alone)

7.5% 21.2% 13.7% 0.00001

Satisfaction on supplementary food provided by Anganwadi centre

88.5% 73.4% -15.1% 0.00001

Awareness on atleast 2 complications during pregnancy and childbirth

29.9% 47.0% 17.1% 0.00001

Percentage of women with incidences of serious health problems during pregnancy

NA 42.5% NA NA

Sought treatment for danger signs of pregnancy NA 72.2% NA NA

Delivered at public health facilities 61.6% 62.1% 0.5% 0.384379

% of institutional delivery 67.3% 74.5% 7.2% 0.00001

In case of institutional delivery mode of transportation- ambulance sent by hospital

21.1% 47.0% 25.9% 0.00001

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KeyIndicators Baseline Endline % Difference

P values

Who paid the cost of transportation -self for any transport

74.1% 44.4% -29.7% 0.00001

% of Home delivery 31.9% 25.4% -6.5% 0.00015

% of home deliveries assisted by health professionals 17.1% 13.8% -3.3% 0.087073

Percentage births attended by skilled health personnel

44.6% 54.9% 10.3% 0.00001

Aware regarding JSY scheme 67.8% 90.9% 23.1% 0.00001

Percent women availing the benefit under JSY scheme 49.7% 48.1% -1.6% 0.172074

Aware regarding JSSK scheme NA 49.8% NA NA

Availed benefits of JSSK scheme NA 72.0% NA NA

Percentage of women with incidences of serious health problems after child birth

78.2% 37.4% -40.8% 0.00001

Knowledge on PNC (minimum 3) NA 20.7% NA NA

Received PNC within one week of delivery (whether home visit made by ASHA/ANM or women make a visit to the health facility)

61.3% 70.3% 9.0% 0.00001

Knowledge of safe abortion period 26.8% 61.1% 34.3% 0.00001

Percentage of women aware of availability of safe abortion services

15.3% 52.6% 37.3% 0.00001

Knowledge of legal age at marriage for girls 46.4% 77.7% 31.3% 0.00001

Knowledge of legal age at marriage for boys 63.3% 88.2% 24.9% 0.00001

Percent women reporting disadvantages of early marriage

NA 87.2% NA NA

Knowledge of at least 2 Terminal methods of FP 43.2% 66.7% 23.5% 0.00001

Knowledge of at least 3 spacing methods of FP 45.1% 74.2% 29.1% 0.00001

Percent couples aware about temporary methods 68.8% 90.5% 21.7% 0.00001

% of women who could decide the FP method they should use (women alone or with their husband)

NA 75.1% NA NA

Percentage women reporting access of contraceptive 93.7% 97.0% 3.3% 0.00001

Percentage of women aware of availability of contraceptives and safe abortion services

13.9% 51.3% 37.4% 0.00001

% of women married before 18 years 65.4% 21.3% -44.1% 0.00001

% of men married before 21 years 93.9% 17.6% -76.3% 0.00001

% of women becoming pregnant before 19 years of age

22.8% 15.3% -7.5% 0.00001

Number of women conceiving at least one year after the legal age of marriage

77.2% 84.7% 7.5% 0.00001

Knowledge on VHND 52.2% 84.3% 32.1% 0.00001

Knowledge of at least 2 services provided in VHND 58.9% 76.2% 17.3% 0.00001

Note: P values calculated at 5 percent level of significance (Those indicated in bold are significant)

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