Assessing and Supporting NIPI * Interventions

Transcription

1 Assessing and Supporting NIPI * Interventions Technical report November 2011 PUBLIC HEALTH FOUNDATION OF INDIA Beena Varghese (PI) Sanghita Bhattacharya Reetabrata Roy Aradhana Srivastava Somen Saha Rajmohan Panda Sudha Ramani Priya Chitkara UNIVERSITY OF OSLO Sidsel Roalkvam Jagrati Jani-Bølstad Cecilie Nordfeldt Dagrun Kyte Gjøstein Synnøve Knivestøen *Norway India Partnership Initiative 1

2 Content EXECUTIVE SUMMARY INTRODUCTION Literature review NIPI Interventions ASNI -- Goals and Objectives METHODOLOGY Study Design Data collection and analysis Limitations UNDERSTANDING DEMAND FOR HEALTH SERVICES THE YASHODA PROGRAM The Yashoda Program Operational Aspects The Yashoda program Health provider & community perspectives Summary Recommendations HOME BASED NEWBORN CARE -- EFFECT OF ASHA TRAINING NRHM & NIPI training modules for ASHAs: Comparative Review Assessment of NIPI training Community Survey -- Outcome for HBNC Indicators Summary Recommendations COMBINED BENEFITS OF YASHODA & HBNC PROGRAM TECHNO-MANAGERIAL SUPPORT & FINANCIAL RESOURCE ANALYSIS OF NIPI Techno Managerial support Financial resource analysis Summary Recommendation CONCLUSION AND RECOMMENDATIONS` ANNEXES REFERENCES

3 List of figures Figure 3.1: Research design of the ASNI project Figure 5.1: Occupational structure of sample population Figure 5.2: Time allocation of Yashoda Figure 6.1: Counseling on HBNC by ASHA, Rajasthan Figure 6.2: Counseling on HBNC by ASHA, Orissa Figure 7.1: Combined Effect of Yashoda and ASHA Figure 8.1: Year-wise fund utilization in Anugul Figure 8.2: Year-wise fund utilization in Alwar List of tables Table 3.1: ASNI methodological tool box: strengths and weaknesses Table 3.2: Sample size of community survey Table 5.1: Profile of Yashoda Alwar and Anugul District Table 5.2: Operational guidelines for Yashoda and their implementation in Rajasthan and Orissa Table 5.3: Key indicators of socio-economic characteristics of respondents Table 5.4: Key Indicators on pregnancy history of respondents Table 5.5: Median household expenditure towards maternal and neonatal care Table 5.6: Pre delivery care (Sharing of ANC card and physical examination) Table 5.7: Post natal counseling, checkup and practice, Rajasthan Table 5.8: Post natal counseling, checkup and practice, Orissa (DH) Table 5.9: Key post natal indicators for mothers who had a C-section delivery Table 5.10: Reason for coming back to facility for next delivery Table 6.1: Comparative summary of NRHM and NIPI state training modules for ASHAs Table 6.2: Frequency of home visits by ASHA Table 6.3: Counseling on HBNC by ASHA Table 6.4: HBNC- Health outcomes for Newborn Table 6.5: Information related to Referral Table 7.1: Incremental benefit of Yashoda and HBNC program Table 8.1: Key Budget head fund utilization Anugul ( ) Table 8.2: Key budget head fund utilization Alwar ( ) Table 8.3: NIPI Financial Management in Orissa and Rajasthan

4 Abbreviations ANC- Ante Natal Care ANM- Auxiliary Nurse Midwives ASHA- Accredited Social Health Activists ASNI- Assessing and Supporting NIPI Interventions AWW- Anganwadi Workers BPL- Below the poverty line BPMU- Block Project Management Unit CHC- Community Health Centers CHS- Child Health Supervisor DCHS- Deputy Child Health Supervisors DH- District Hospitals DLHs- District Level Household Survey DPMU- District Project Management Unit FGD- Focus Group Discussions FMR- Financial Management Review GoI- Government of India s HBNC- Home Based Newborn Care HBPNC- Home Based Postnatal Care HMIS- Heath Management Information Systems IASAM, University of Oslo - International Health, Faculty of Medicine IBF1- Initiation of breastfeeding within 1 hour IDIs- In-depth Interviews IMNCI- Integrated Management of Neonatal and Childhood Illness JSY- Janani Suraksha Yojana MDG- Millennium Development Goal NIPI- Norway - India Partnership Initiative NRHM- National Rural Health Mission PHFI- Public Health Foundation of India PIP- Program Implementation Plan PNC card- Postnatal Checkup card RCH-II Reproductive and Child Health Programme phase II RKS- Rogi Kalyan Samiti SNCU - Sick Newborn Care Unit SIHFW- State Institute of Health and Family Welfare SUM- Centre for Development and the Environment 4

5 ACKNOWLEDGEMENT The study team for Assessing and Supporting NIPI Interventions (ASNI) acknowledges the valuable support and inputs provided by the various cadres of staff at the Department of Health and Family Welfare and the National Rural Health Mission in Orissa and Rajasthan. Their views and experiences helped us understand the complexity of the issues being faced by the larger health system and the catalytic support provided by the NIPI interventions. Similarly, the NIPI secretariat and the state NIPI teams have provided excellent inputs and support for our work. Their perspective on the successes, challenges and learning from the NIPI interventions has helped the team gain comprehensive insight into the program and enabled us to provide recommendations to address some of gaps identified by our study. The ASNI team would like to make a special mention and express our gratitude to the various health care providers at the facilities and the community, especially the ASHAs and Yashodas who were willing to talk to us and provide us insights about all aspects of their work. Our special thanks to mothers who welcomed us into their lives and shared their personal experience with our team. Without their support it would not have been possible to present this report. We are grateful to Dr. R. M Pandey for his generous support and extensive statistical guidance in developing and reviewing the methods of the study. Thanks to GfK MODE (survey agency) and our field teams who did an excellent job collecting all required information and meeting our deadlines. The support provided by the PHFI administrative and finance staff has been valuable and appreciated. We would like to conclude with our sincere gratitude to the Royal Norwegian Embassy which provided us the funds and support to make ASNI possible. 5

6 EXECUTIVE SUMMARY The Norway - India Partnership Initiative (NIPI) is an outcome of a commitment by the Prime Ministers of Norway and India to reduce child mortality and improve child health in attaining Millennium Development Goal 4(MDG 4) by Assessing and Supporting NIPI Interventions (ASNI) is an operations research project, taken up by the Public Health Foundation of India (PHFI), the Centre for International Health, Faculty of Medicine (IASAM), and Centre for Development & the Environment (SUM, University of Oslo). This research aims to assess NIPI activities within a continuum of care approach, focusing on both demand and supply side issues, and to strengthen NIPI to achieve MDG 4 and National Rural Health Mission (NRHM) goals. Objectives The main objectives of the study were to: Understand perspectives of communities reached by NIPI interventions on childcare and birthing practices. Assess the facility based Yashoda program a cadre of lay workers who assist mothers during delivery and help with newborn care. Assess Home Based Newborn Care (HBNC) provided by Accredited Social Health Activists (ASHAs) trained by NIPI. Assess the roles, responsibilities and the value addition of NIPI techno-managerial personnel who provide support to NRHM. Provide recommendations to scale up NIPI interventions. Methods The study was conducted between November 2009 to September 2011 in Rajasthan and Orissa, two NIPI focus states in India. This was a quasi experimental design study with an intervention and control district in each of the states. The intervention districts were Alwar in Rajasthan and Anugul in Orissa; non NIPI control districts were Sawai Madhopur, Rajasthan and Bargarh, Orissa. Mixed methods of data collection ethnographic, qualitative, and quantitative (survey) --were used to collect relevant data from both the supply side (health care providers and administrators) and the demand side (community). In addition, a resource analysis was conducted to understand the fund flow mechanisms and integration with NRHM funding mechanisms. A community survey of women who had delivered in the two months preceding the survey was conducted between March and May The sample size required to show a minimum of 25 percent difference in newborn care indicators (60 percent prevalence, 80 percent power and α =0.05) was a total of 1728 mothers. Univariate, bivariate and logistic regression analyses were done to assess the benefits of the Yashoda and HBNC interventions. Further analysis to estimate the combined effects of Yashoda and HBNC programs were also done by comparing relevant indicators for mothers who were exposed to both Yashoda and ASHA with those who were exposed to just ASHAs and those who had no exposure to either the Yashoda or NIPI trained ASHAs. 6

7 Strengths and limitation of the study: The strength of the study is its multi-method approaches with ethnography, qualitative (IDIs, FGDs) and quantitative (survey) methods. One of the main limitations of this study was lack of baseline information on the selected indicators; however, this was partially addressed through the selection of control districts that most matched the intervention district. Interpretation of the findings from this study should be limited to the effect on counseling and practice indicators and not on maternal and neonatal mortality outcomes. Results Community demand The ethnographic study explored the meaning health seekers attach to acceptance and refusals of governmental health services. From a community and family perspective, the delivery of a child in a formal medical institution involves the movement of the birthing mother to an unfamiliar environment, where strangers attend woman in the absence of the physical, symbolic and social support of the family. In the communities studied, childbearing, birth and post-partum work are natural social processes that do not need the interference from medical doctors and trained personnel. The demand for facility births is voiced in cases where something appears to go wrong. In government health facilities women express that they feel vulnerable and exposed. They are not only exposed to male doctors, nurses, sweepers and ward boys, but also to evil eye ('nazar'). Government institutions are thus thought of as dangerous and potentially harmful to mother and child. These facilities are judged as intolerant to the important cultural and ritual practices surrounding childbirth. Women have minimal expectations of being treated well at health facilities and lack trust on the provider. The ethnographic study thus highlights the need to distinguish between active demand and passive acceptance in understanding health seeking behaviors. Young mothers are taken to facility for birthing motivated by the Janani Suraksha Yojana (JSY) incentives, who easily accept this because they are not the ones who set the rules. With the introduction of JSY, the incentive has become the main driver. The important questions then are: how and why does acceptance and demand for skilled and facility based births become a prevailing social condition? How flexible is the demand if the service is not up to standard, if services deteriorate or if incentives are withdrawn? It is in this context that an enabled Yashoda could provide support. Yashoda Program This study showed that the Yashoda program is functional at the district hospital (DH) and at community health centers (CHC) in Alwar and at the DH in Anugul. The profile of Yashodas (in terms of age and educational status) at the two study districts matched NIPI guidelines. In terms of remuneration, Yashodas reported preference for a mixed system of remuneration (fixed amount plus incentive). Supervision systems in Rajasthan were found to be weak compared to Orissa, especially at the CHC level where no supervisors were available. Yashodas also highlighted the need for more frequent training. 7

8 Yashodas were positioned in the health facilities to be mother's aides. However, there seemed a constant push for her to be a technical aide rather than a mother s aide. Yashodas spent majority of their time in the postnatal care (PNC) ward providing support to the mother and newborn with limited interactions with ASHAs. This was supported by the survey findings - 81 percent of mothers in Alwar DH; 41 percent in Alwar CHCs; and 93 percent in Anugul DH reported being attended by Yashoda in the PNC ward. A significantly higher proportion of mothers in the intervention districts (55 percent to 97 percent in Alwar; 87 percent to 94 percent in Anugul) received counseling on immunization, breastfeeding, family planning and nutrition compared to those in control districts (34 percent to 66 percent in Sawai Madhopur; 49 percent to 94 percent in Bargarh). Yashodas had an impact on receipt of postnatal checks at the intervention facilities mothers in Alwar DH (Anugul DH) were four to five times (1.4 to 1.5 times) more likely to receive temperature and blood pressure check than mothers in Sawai Madhopur (Bargarh). However, the absolute proportion who received basic postnatal checks was still low. Some of the neonatal care indicators (keeping the newborn warm, initiation of breast feeding and immunization), were reported by more than 90 percent of mothers in both intervention and control districts. This perhaps reflects the positive impact of the NRHM program. However, the benefit of the Yashoda program was most evident for initiation of breastfeeding among women who had a caesarian section- 76 percent of these respondents in the intervention districts reported that they initiated breastfeeding within five hours compared to 44 percent in the control districts. At the CHC level too, the Yashoda intervention showed significant benefits, however the proportion of mothers reporting benefits was lower than mothers at the district hospitals. This may be attributed to lack of supervision of Yashodas at the CHCs and other factors like lesser length of stay and fewer number of Yashodas at these facilities. The objective of the program was to enhance a joint ownership for care coordination at the facility with 'Yashoda as part of the larger system. A pregnant woman is expected to feel welcome as she enters the facility and leaves with her newborn baby with a feeling of being cared for and looked after. The study found that Yashodas both at the DH and CHC levels in Rajasthan and at the DH level in Orissa provided significant support to mothers and newborns during the postnatal period at the facilities-- mothers/families felt that the presence of Yashodas was beneficial to them and were more comfortable within the hospital environment in the presence of a Yashoda than without her support. The additional value of Yashoda program thus could contribute to the generation of demand for good maternity services and proper care for newborns. However, if the supply-chain within the health system remains weak it is indeed difficult to sustain the demand, even with the Yashoda in place. The challenge is to create a space for the Yashoda within the health system that allows her to perform her duties as a mother s aide and protect her from the technical push. NIPI supported HBNC Program The NIPI supported HBNC program is functional in both the study districts. During the study period, ASHAs had received two-day training on HBNC; the five-day skill based training had only begun in the first quarter of

9 The data from the community survey clearly showed improvement in key areas of new born care outcomes in the intervention districts: mothers in Alwar (Anugul) were twice (four times)as likely to register their newborn compared to mothers in Sawai Madhopur (Bargarh); and twice (16 times) as likely to have their babies weighed at home. Rates of zero dose immunization were above 90 percent in both the intervention and control districts. The proportion of mothers who reported receipt of counseling messages specific to newborn care (breastfeeding, birth registration, immunization) from ASHAs during their postnatal home visits were significantly higher in the intervention districts in Rajasthan and Orissa compared to control districts. The identification of danger signs and subsequent referrals including use of referral funds were higher in intervention districts than in the control, but the actual proportions reporting these were still low and have potential for significant improvement. The training methods, content, and supportive supervision including field level follow-up were perhaps the main reasons for the differences in new born outcomes observed between the intervention and control districts. The structure of the training program of NIPI with emphasis on field visits and a skill based approach thus holds promise and can play a critical role in making HBNC trainings more consistent, effective and result oriented. Yashoda and ASHA: combined benefits The analysis done to assess the incremental and combined benefits of Yashoda and ASHA on newborn care showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an incremental effect on newborn care indicators (both counseling and practice). For example, mothers in Alwar (Anugul) were almost four (three) times (Alwar OR 3.79, CI 2.57, 5.57; Anugul 2.96, CI 1.77, 4.96) more likely to have received counseling on keeping the baby warm compared to mothers in the control district. Similarly, birth registration was 2.5 (1.37) times higher among mothers who had dual exposure to Yashoda and ASHA in Alwar (Anugul) compared to mothers in control districts. These suggest that NIPI interventions on the whole have resulted in improved information among mothers and better outcomes for the newborn. Further studies may be undertaken to understand the impact of these two program components on neonatal mortality. Combined Effect of Yashoda and ASHA (Odds ratios with 95 percent confidence intervals) Rajasthan Orissa 9

10 Techno managerial support The techno managerial support of coordinating and providing technical support for maternal and child health issues in the districts needs strengthening. Recruitment through government channels and retention of staff remained challenging. However, support provided in managing the Yashoda and HBNC programs has been significant. Another important achievement has been the on-ground post-training support provided by child health managers to ASHAs on HBNC. Fund utilization NIPI funds contributed to about six percent of total NRHM district allocation for The utilization of these funds has been around 40 percent in both Anugul and Alwar, a significant improvement from utilization in the first year of the program. Across Rajasthan and Orissa, maximum fund utilization was for Yashoda and HBNC components. Frequent revisions of financial guidelines, financial monitoring, follow-up, and lack of coordination were some of the reasons for low fund utilization especially for the ASHA referral and untied funds.. NIPI should be acknowledged and appreciated for integrating its programs under the NRHM. This is a significant contribution to secure sustainability of the program. However, some of the biggest challenges faced in the implementation of NIPI programs were also intrinsically linked to procedures in the NRHM such as recruitment, fund-flow, retention of staff, and procedures in procurement. Conclusion The assessment thus showed that the Yashoda and HBNC programs supported by NIPI in Rajasthan and Orissa have resulted in significant improvements in the knowledge and practice of important maternal and new born indicators. These interventions could be scaled up in rest of the districts in the state and perhaps in the country in a phased manner with due considerations to the various recommendations provided below. These could have an impact on both maternal and neonatal outcomes. However, it is important to have active participation of communities as a non-negotiable precondition for such programs to be sustainable and have long lasting impact. Recommendations Active demand for institutional births supported by Yashoda should be promoted by building in strategies for community participation and involvement of local communities (through increased awareness). Branding of the Yashoda through her clothing and work as a mothers aide perhaps with supply of newborn kits to support the mother and new born would be important. Yashoda s role as a mother s aide to be made specific and clear during recruitment (keep education level below tenth grade) and training and to keep her identity distinct from that of nurses or other staff. Increase focus on normative behavior (dignity, ethical norms, human rights, protection) in the training modules for both ASHA and Yashoda. 10

11 Weak supervision of Yashodas has serious implications on discharge of duties by them, and therefore supervision needs to be strengthened, especially at the CHC levels. Supportive supervision through appropriate support at the facility and encouraging their role as mother s aide is important. To improve continuum of care, the presence of ASHAs at registration provides an excellent opportunity for Yashodas to interact with them and take over the mother s care (through sharing of the ANC card information) at the facility. Similarly, at discharge, Yashodas could provide similar information about the mother to the ASHAs to continue care through postnatal visits at home. Counseling on danger signs, facilitation of postnatal checks, and use of supplementary feed could receive further focus and attention. Customized, field based, and frequent training that emphasizes on these topics should be considered. HBNC training should be customized further in terms of local content, imparted through more field level demonstrations. Continued focus on supportive supervision, regular refresher training, performance monitoring and feedback are integral and should be emphasized. ASHAs should be provided more information and training on the identification of danger signs for the mother and new born and appropriate referral along with availability of referral funds for transport should be strengthened. Guidelines for utilizing untied funds should suggest a list of possible and permissible activities. Program managers should be adequately sensitized about the guidelines. NIPI program should attempt to implement uniform system of financial reporting based on activitywise resource allocation and expenditure and reporting of efficiency in incurring of expenses by blocks. 11

12 2.1 Literature review 2. INTRODUCTION In contemporary debate concerning maternal and child health care, provisions of health care services are increasingly understood as a dynamic system of entitlement and obligations between people, communities, providers and governments. Community participation, health promotion, social support and empowerment of individuals (especially of women) are seen as critical to achieving sustainable improvements in maternal and child health care. While governments should make quality reproductive services and information accessible, women and families should be encouraged to articulate what they need and expect in terms of services. In the report on Macroeconomics and Health the substantial barriers to access that exists for the poorest members of society became abundantly clear 1. Although the reasons for why the poor do not make use of services is driven by both supply and demand factors related to health care services, the focus of much health interventions has been on reducing supply side barriers 2. Yet, whether and where to utilize health services starts well before arrival at the clinic and requires myriad and often conflicting choices on behalf of the health seeker. In 2004, the government of India launched the National Rural health Mission (NRHM) to address both the supply and demand side issues in public health care services in rural India. The government introduced a conditional cash transfer program, a demand side financial incentive --Janani Suraksha Yojana (JSY) to increase the level of institutional births in the country. This central government sponsored scheme links cash assistance with delivery and post-delivery care, taking into account the pregnant woman s need for escort, transport, and in case of complications, referral services. JSY has succeeded in increasing the number of institutional deliveries in the country 3,4. However these have not adequately addressed the quality of care and counseling needs of mother and infants within the facility. This dramatic increase in facility births and has now put tremendous pressure on the institutions. Maternity wards at the DHs and sometimes at the CHCs are overcrowded and staff overstretched. The doctors and nurses -- routine caregivers in a facility, are often unable and not equipped to provide emotional support to mothers and non-medical support for newborns. Besides, vacancies in the health sector necessitate the optimal use of specialized skills of the workforce like doctors and nurses. Raising expectations at the demand side was not met adequately by supply side factors and this could result in both cynicism and despair among both providers and users leading to a serious setback for what the Government of India intended to achieve. Global policies encourage rational re-allocation of less specialized but important tasks to less-trained cadres of health workforce. 5 International evidence points towards the usefulness of birth companions who provide support to women during childbirth, ranging from psychosocial support to assistance with information and procedures. 6,7 Birth companions were traditionally community women or family members who comforted and supported a woman emotionally as she went through the extremely stressful experience of childbirth. However, with technical advancements in modern medicine and the stress on facilitybased births with skilled birth assistance, the role of traditional birth companions was gradually sidelined. But research since the 1970s has proven the presence of a birth companion as being 12

13 extremely beneficial in easing the trauma of childbirth for the mother and in helping her cope with her experience. 8 The lack of emotional support or empathy by birth attendants can in fact make the whole process of childbirth a dissatisfying and painful experience for the mother. 9,10 Birth companionship is now accepted as a low-cost intervention beneficial to labor outcomes, giving birth companions a renewed acceptance in the modern scenario as well. 6 The professional birth companion or Doula emerged consequently in the Americas. They are paid companions who accompany mothers during delivery and provide her the necessary support, guidance, information and encouragement. Besides providing emotional support, birth companions help improve patient-provider communication, assist the mother in getting the requisite delivery care, advice regarding coping techniques, comfort measures (comforting touch, massages, promoting adequate fluid intake and output) and advocacy. 6 There is a possibility of the role of birth companions clashing with those of obstetric nurses, but this could be minimized by ensuring that their roles are complementary and not conflicting. 11,12 Birth companionship was found to be positively associated with reduced length of labor and improved maternal-infant interaction. 13 A Cochrane review of sixteen trials involving female birth companions found that women who had continuous intra-partum support were likely to have a slightly shorter labor, were more likely to have a spontaneous vaginal birth and less likely to have intra-partum analgesia or to report dissatisfaction with their childbirth experiences. 14 Birth companions presence is also likely to lead to fewer newborn complications. 15 In India, the Government of Tamil Nadu initiated a birth companion scheme in 2004 in all public hospitals in the state, under which women getting admitted to facilities could nominate a female family member to be their birth companion. The companion should be aware of the labor process and should stay with the mother without interfering in the medical procedures. 6 One of the positive effects of the intervention was observed in a study on maternal care in Tamil Nadu which showed that the presence of a birth companion in the labor room may have reduced the likelihood of abuse by providers of women in labor. 16 Most women agreed that a birth companion would not only support the woman in labor but could also act as her advocate and demand better quality of services on her behalf. Another critical concern relates to ensuring the survival of newborns and infants. HBNC has been recognized as an effective low-cost strategy for reduction of newborn and infant mortality and morbidity in resource-poor countries where there is lack of availability of facilities and preference for home births, and where hospital-based interventions are often not practical, appropriate or affordable. 17 It has been observed by various studies on newborn care that the knowledge and practice of simple newborn care (such as the identification of danger signs in the newborn, and care-seeking) is generally poor. 18,19,20 In order to ensure care at home, there should be a continuum of care between the hospital and the community. Many studies in the past have proved the efficacy of the role of community health workers in continuum of care. 21 The Gadchiroli study demonstrated that neonatal and infant mortality can be reduced by 50 percent 22 through counseling and management of some basic newborn complications, provided by trained village health workers during home visits. Similar improvements in newborn and peri-natal outcomes have been observed in other studies on home-based care in countries like Pakistan and Bangladesh. 23,24 13

14 Owing to its critical role in complementing institutional care, HBNC as a key element of the continuum of care approach, and has become an integral part of Government of India s (GoI) neonatal care strategy under the Integrated Management of Neonatal and Childhood Illness (IMNCI) approach, introduced in the Reproductive and Child Health Program phase II (RCH-II). Home visits by health workers (Auxiliary Nurse Midwives (ANMs), Anganwadi Workers (AWWs), Accredited Social Health Activists (ASHAs) and other link volunteers) help mothers and families to understand and provide essential newborn care at home and detect and manage newborns with special needs due to low birth weight or sickness. 25 According to GoI guidelines five home visits are to be provided to every newborn starting with the first visit on the day of birth followed by visits on days 3, 7, 14 and 28. Services to be provided include advice on keeping the child warm, covered, skin and eye care, initiation of breastfeeding immediately after birth and counseling for exclusive breastfeeding. The training includes recognition of illness in newborn and management and/or referral and immunization. A recent evaluation of HBNC conducted by National Health Systems Resource Center (NHSRC) in eight states of India reported that 73 percent of the respondents received advice on early initiation of breastfeeding, 65 percent consulted ASHA during illness of a sick child. But at the same time the study reported that ASHAs are not as effective in influencing critical health behaviors such as breastfeeding, adequacy in complementary feeding with the same intensity, which undermines her effectiveness in bringing about changes in health outcomes. This has been identified as a core area for improvement by the fourth common review of the NRHM, which stresses on the need for all ASHAs to imbibe skills in home-based newborn care including inter-personal behavior change NIPI Interventions NIPI was designed to provide three main areas of catalytic support to NRHM, first in terms on providing support to mothers and infants in select health facilities through voluntary birth companions called Yashodas; support for the HBNC program to address the post natal needs of mothers and newborn; and provide techno managerial support at district and sub-district levels to improve the functioning of the health system. These activities are expected to reduce child mortality, improve child health and help attain MDG 4 by The Yashoda program: This program is designed so that local volunteers from the community assist mothers with their post-natal requirements and provide support for newborn care in the maternity and post-natal wards of DHs and select CHCs. NIPI envisages Yashodas to provide the following support: 1. Receiving and supporting pregnant women at the facility. 2. Counseling the mother on immediate and exclusive breast feeding, nutrition for self and newborn, immunization and family planning choices and informing them about accessing child health services after leaving the hospital. 3. Ensuring overall cleanliness of the beds and ward including toilets; ensuring dignity and privacy of mother by avoiding crowding around the bed. 4. Drawing the attention of the doctor or nurse if the baby is found sick. 14

15 5. Keeping records of all mothers and children born. HBNC component: To establish the continuum of care by strengthening the HBNC component, NIPI builds on the presence and competency of the ASHA to create a structured follow-up system for both the mother and the newborn in the community. The three pronged approach that NIPI employs to achieve this are: 1. A special training module (2+5 days) on HBNC 2. An incentive of Rs. 100 to ASHAs for completing five to six PNC checkups 3. A referral fund to ensure that sick newborns and mothers can be referred to a facility where proper care is available. Newborn care includes the provision of warmth, umbilical cord care, cleaning of mucous, proper airway resuscitation, feeding, basic hygiene, identification of danger signs, and seeking help from health personnel when required. ASHAs under the HBNC program are supposed to provide: A. PNC visits: The ASHA does five to six post natal visits per mother, generally visiting three or four households a day. The first post natal visit is on the day of discharge after coming from hospital. Subsequent visits are on 3 rd, 7 th, 14 th and 28 th day. A visit on the 42 nd day is also made in Rajasthan. The activities focus on checking the health of baby and mother, nutrition of mother, counseling on breast feeding, family planning and immunization, and examining the baby for danger signs. The ASHAs are required to fill a Postnatal Checkup card (PNC-card) during the visit, and submit it for validation and payment after the requisite visits have been completed. B. Referrals: ASHAs are trained to identify danger signs in mothers and newborns during their home visits. On identification of danger signs that require referral, the woman and/or newborn must be sent to the referral hospital in the locality, the block hospital (CHC) or the DH. There are a total of nine danger signs for newborns and four for mothers in the post delivery period, which require urgent attention. Proper and timely identification skills for such danger signs and referrals are given to the ASHAs during their training. ASHAs must tell the woman and family member about the hospital where to go and how to go. They should assist the family in finding a suitable transport facility. The referral card should be filled up appropriately and given to the family. NIPI s Techno-managerial support to NRHM: This contributes towards enhancing the overall quality and effectiveness of the program and strengthening of systems. The overall framework for this is: 1. National, state, district and block level planning and implementation of child health activities. The new techno-managerial support takes into account existing support mechanisms at various levels and extends them to current initiatives under NRHM as well as new innovations. 2. Technical support at all levels for development, adaptation, sharing and dissemination of tools, including those for ASHAs and all child health activities. 3. Catalytic action to galvanize and motivate teams, and support training activities, including those for ASHAs and all child health activities 15

16 4. Gap management and problem-solving related to technical solutions, planning, budgeting, management, and financial issues. 5. Innovative solutions, action research, identification of best practices, and refinement of approaches. 6. Streamlining communication and referrals in the ASHA chain. 2.3 ASNI -- Goals and Objectives The current study--assessing and Supporting NIPI Interventions (ASNI) is an operations research project, taken up by the Public Health Foundation of India (PHFI) and the Centre for International Health, Faculty of Medicine (IASAM, University of Oslo) and Centre for Development and the Environment (SUM). The aims of the study are two-fold: 1) To understand the functioning of three thematic areas under NIPI activities: facility based Yashoda initiatives; HBNC provided by ASHAs; techno managerial support and their convergence with NRHM. 2) To identify key obstacles/problems if any in the effective implementation of these initiatives so as to provide recommendations to improve the program. It also aims to assess NIPI activities within a continuum of care approach focusing on both the demand as well as the supply side, and to strengthen NIPI to achieve MDG 4 and NRHM goals. The main objectives of the study were to: Understand perspectives of communities reached by NIPI interventions on childcare and birthing practices. Assess the facility based Yashoda program a cadre of lay workers who assist mothers during delivery and help with newborn care. Assess Home Based Newborn Care (HBNC) provided by Accredited Social Health Activists (ASHAs) trained by NIPI. Assess the roles, responsibilities and the value addition of NIPI techno-managerial personnel who provide support to NRHM. Provide recommendations to scale up NIPI interventions. Currently, evidence from India on establishing a facility based health worker system for maternal and child health care is limited. Hence, the innovative Yashoda program under NIPI provides an opportunity to assess their additional value. Similarly, the improved HBNC program through NIPI and the technomanagerial support to NRHM are innovative additions to the existing system and an assessment of the same would provide valuable information to NIPI and to the state governments. 16

17 3. METHODOLOGY 3.1 Study Design Research design and selection of study area To assess and document the additional benefits of NIPI interventions, the study used a quasiexperimental design, wherein the intervention district (where NIPI is functional) was compared to a non- NIPI district (control district). The differences between the intervention district and control district in processes and in intermediate outcomes related to maternal and child health are assessed at the facility level and the community level. Figure 3.1 depicts the research design of the project. Figure 3.1: Research design of the ASNI project Intervention district (NIPI focus) Control District (Non NIPI Focus) Observe, Assess and identify barriers Formulate recommendation At the start of the ASNI study, NIPI interventions were operational in three districts each of Rajasthan and Orissa -- Alwar, Dausa and Bharatpur districts of Rajasthan and Anugul, Sambalpur and Jharsaguda districts of Orissa. Thus, for this study, one intervention district out of the three was chosen in each of the study states. The choice of the intervention districts for this study was done on the basis of inputs from NIPI program personnel and program data provided by the NIPI teams. In Rajasthan, Alwar was chosen since NIPI interventions such as the Yashoda program, training of ASHAs for HBNC and Sick Newborn Care Unit (SNCU) were fully functional. A similar rationale was used in Orissa where Anugul was chosen as the NIPI intervention district. The choice of the control district was done based on a comparison of various socioeconomic and epidemiological indicators across districts within a state. The main indicators that were used for comparison included population density, economic profile, literacy rates and health indicators relevant to maternal and child health such as Ante Natal Care (ANC), immunization rates, rates of institutional delivery. These were obtained from the District Level Household Survey (DLHS) III, census data, and supplemented using state-level Heath Management Information Systems (HMIS) data (See Annexure 1).The control districts were Sawai Madhopur in Rajasthan and Bargarh in Orissa. The assessment study looked at the Yashoda program s norms of appointment, operational issues in implementing the model viz., recruitment, training, supervision, integration of Yashodas into the existing NRHM model and the benefits of having such a cadre of workers from a provider and mother s perspective. 17

18 It also assessed the training received by ASHAs on HBNC, the usefulness of this training, their workload and implication for HBNC. It also reviewed the referral mechanisms and linkages with Yashodas and the techno-managerial component of the program. The study methods were a combination of both qualitative and quantitative techniques. Implementation research and other forms of research in health have moved increasingly from single method to multimethod approaches 27. Although cross sectional sample surveys are still common, they are now often combined with qualitative methods. As each key method has its own strengths and weaknesses (see Table 3.1) they are increasingly selected for use together. As a result, multi-method combine studies are now able to benefit from the advantages of sample surveys and statistical methods (quantification, representativeness and attribution) and the advantages of the qualitative and participatory approaches (ability to uncover approaches, capture the diversity of opinions and perceptions, unexpected impacts etc.). Qualitative tools, used in the first phase of this study, focused on largely programmatic and implementation perspectives, while the quantitative survey in Phase II aimed to measure benefits of the two NIPI interventions through a community survey of recently delivered women. Review of various government and NIPI documents combined with a literature review of birth companions and HBNC programs was carried out, which facilitated the development of quantitative survey and qualitative tools (In-depth Interviews (IDIs) and Focus Group Discussions (FGDs)) for data collection. Table 3.1: ASNI methodological tool box: strengths and weaknesses Criteria/ Method Survey Qualitative studies/rapid appraisal 18 Ethnographic studies/ participant observation Scale of applicability High Medium Low Representativeness High Medium Low Ability of isolate and measure nonintervention High Low Low causes of change Ability to capture qualitative Low Medium High information on maternal-child health Ability to capture non-causal Low Medium High processes of utilization and vulnerability Ability to elicit views of women Low Medium High Ability to capture unexpected Low High Very high impacts Time scale High Medium Very high Human resource requirement Large with special supervision Skilled practitioners Long-time commitment, good supervision Study Timeline: The study began in December 2009 with the literature review. This was followed by development of the qualitative data collection tools. The qualitative data collection was done from March to May 2010, and the report writing was completed between June and September 2010.

19 Subsequently for the community survey in Phase II of the study, the questionnaire development, selection of survey agency and formalization of data collection plan spanned from November 2010 to March The field data collection was conducted between March and May 2011, followed by data analysis from May to August The study obtained ethical clearance from PHFI s institutional ethics committee. Informed consents were obtained from study participants and to ensure confidentially during data collection identification of respondents were not recorded. The access to data was limited to the study team. Qualitative research design (Phase I): In-depth interviews with various health care providers and health administrators helped collect information regarding the additional benefits of NIPI interventions. In addition, they also focused on identifying road blocks and issues related to the successful implementation of the NIPI program. Interviews and group discussions with mothers were also conducted to understand the community level perspective. A total of 100 IDIs, 20 FGDs, and 26 days of observation were undertaken. Additionally, 532 structured interviews were conducted among mothers, Yashodas and ASHAs. (See Annexure 2) An observation study of the hospital wards focused on documenting the tasks done by Yashodas and other staff at the DH during the pre-delivery, delivery and post-delivery periods. Facility surveys among mothers focused on their delivery experiences at the facility. The surveys done among Yashodas and ASHAs collected information related to their knowledge, training, and tasks performed by them. Ethnographic studies: The ethnographic team embarked on their fieldwork in January 2010 and lived in two communities in the following 6 months. Unrecognized in most health research that is designated qualitative but which relies mainly on interview based methods, is the difference between what people do say and what people do. This method of participation and observation helped distinguish between normative statements (what people say should be the case) and actual practices (what really happens). It follows from the mandate of an ethnographer to see the object of study from as many angles as possible and a presupposition and experience within the discipline that all people, things, ideas or events (i.e. all social facts ) are socially and culturally situated and contingent 28. This is an empirical based grasp of the context specific nature of the NIPI intervention. In documenting complex details of everyday life an important corrective can be made to misleading generalizations and abstractions. Therefore, this report also emphasizes the importance of cultural and social specific description of some detail for the NIPI interventions. Ethnographies achieve generalizability through logical rather than statistical inferences and seek statistical inferences by feeding issues raised through qualitative and ethnographic data into a larger survey. Fund flow analyses: A fund flow analysis was undertaken in one NIPI intervention district each from Rajasthan and Orissa. It focused on: Analyzing the fund flow system from center to state and district level 19

20 Understanding the utilization and absorptive capacity of state and districts to utilize the fund, through some basic financial performance indicators Identifying bottlenecks in the financial management of NIPI. Quantitative research design (Phase II) For the community survey, study participants were defined as Mothers who have delivered in the last two months preceding the survey and who reside in a community where ASHA is present and active. To estimate the sample size required for this group, indicators with the least differences expected in the intervention and the control districts was used. The sample size calculated using this method would ensure that the differences for all other variables are adequately captured between the intervention and the control areas. To calculate the required sample size for the community survey, initiation of breastfeeding within one hour (IBF1), immunization, receipt of postnatal care within 48 hours and similar newborn care indicators were considered. The prevalence of these indicators was based on data from DLHS III ( ). Assuming a prevalence rate of 60 percent for IBF1, to demonstrate at least a 25 percent difference between the intervention and control groups (with 80 percent power and α=0.05); the minimum sample was estimated to be 216 mothers. A design effect of two was assumed, increasing the sample size to 432 each in the intervention and control districts of Orissa and Rajasthan, generating a total sample size of To ensure a fair distribution of the study sample across facilities and home and to be able to capture the benefits of the Yashoda program that is most functional at the DH level, the following distribution of the sample was envisaged: 1. DH: 50 percent 2. CHC: 30 percent 3. Home based and others: 20 percent The procedure followed for listing and identification of respondents is explained in Annexure 3. In the second phase, against an estimated sample of 1728, the survey included a total of 1698 mothers; 46 responses were found to be invalid and excluded yielding a total of 1652 valid responses of women who had delivered in the two months preceding the survey across the four study districts (Table 3.2). The sample size in Rajasthan was larger because of the requirement to cover the requisite number of deliveries in CHCs where Yashoda was placed. This was not required in Orissa, where no Yashodas were available at the CHC level. Table 3.2: Sample size of community survey State District Number of respondents (Mothers who delivered in last 2 months preceding the survey, valid responses) Rajasthan Orissa Alwar 451 Sawai Madhopur 489 Anugul 359 Bargarh 353 Total

21 A detailed questionnaire was developed for the community survey, divided into thematic sections. The primary indicators for which data was collected for the Yashoda program included initiation of breastfeeding within one to five hours after delivery, weighing of the baby, immunization (Polio + BCG), counseling on exclusive breast feeding, family planning, nutrition, danger signs, cleanliness and length of stay at the facility after delivery. Primary indicators for the HBNC program included five PNC home visits by ASHAs, counseling during home visits on various important newborn care issues and referrals of mother and child. Explanatory variables included in the questionnaire were indicators of demographic and socio- economic status and maternal and child outcomes. Details of pregnancy history and birth experience were also collected, including antenatal, intra-natal and postnatal care, quality of care (cleanliness, availability of toilet & drinking water), trust and emotional support, cost of care and awareness and receipt of Janani Suraksha Yojana (JSY). 3.2 Data collection and analysis Phase I The study team visited the NIPI intervention districts between March and May 2010 in Orissa and Rajasthan to conduct the qualitative research. They met key district staff including the Yashoda Coordinator, District and Block Maternal and Child Health (MCH) Officer, District Accounts Manager responsible for NIPI fund management, State Program Manager (NIPI) and Finance and Accounts Controller of NRHM. To get an understanding of the financial management systems in place, IDIs with the block MCH Coordinators and Block Program Managers responsible for NIPI financial management were conducted in five blocks each from Alwar and Anugul. The topics covered included frequency of fund transfer, delays in fund transfer, fund utilization, adequacy of financial guidelines, and NIPI review process at block and district level. Apart from IDIs with the key staff, the team reviewed financial documents to analyze approved budget, released fund, utilized fund, and performance of the district in utilization of funds. To assess the techno managerial support provided by NIPI to NRHM, IDIs were conducted to understand issues of recruitment, roles, value addition and convergence/integration with NRHM. Interviews were conducted with NIPI staff at the center, state and district levels and NRHM staff. In addition to the interviews documents on recruitment processes, job descriptions of NIPI staff at various levels were also studied. The data was collected by investigators from the State Institute of Health and Family Welfare (SIHFW), Orissa, Department of Anthropology, University of Rajasthan and the PHFI team. IDIs and FGDs with the health care providers especially those at the nurse level and below were conducted in native languages (Hindi and Oriya). Some of the interviews with medical doctors and administrators were in English. All those in the native languages were translated into English and then transcribed and coded manually. Broad thematic analysis of IDIs, FGDs, and the observation studies were done. The themes were initially 21

22 analyzed in the form of role-ordered matrices, based on qualitative frameworks suggested by Miles and Huberman. 29 Quantitative data from the facility and provider surveys were analyzed using SPSS. The ethnography study was conducted in two communities in Alwar. The two communities were similar in that the majority of the population was living below the poverty line and had similar access to health care services. They differed clearly however in utilization of services. Community 1 was referred to as well performing with a well performing ASHA in its midst. Community 2 was, on the other hand referred to as a low performing regards uptake of governmental services. The ethnographic method implied long-term fieldwork in the two communities (6 months in each community). The fieldworkers lived, observed, and participated in community life. They participated in numerous childbirths at facilities and at home. They accompanied ASHA and Yashoda in their daily tasks as well as accompanied mothers to the facilities. In addition to observational and participatory data, fieldworkers conducted indepth interviews with mothers, family members and health workers, held focus group discussions and examined documents and records. The study design covers the entire referral system as an ethnographic site with a clear demand side approach. Phase II The community survey of recently delivered women was conducted during March-May A professional survey agency was identified and contracted for data collection, entry and tabulation. It was ensured that all investigators and majority of supervisors were women. ASNI team members prepared the questionnaire and participated in the training of investigators on administering the questionnaire and monitoring of field data collection. Spot checks of forms on many of the important questions were carried out to check accuracy of data collection. The team also conducted checks for data quality on a regular basis for about five percent of the sample answered questionnaires every two to three days. Final analysis of the data and report writing was also carried out by ASNI team members. A senior national level expert on biostatistics was consulted in finalizing the questionnaire and designing the analysis plan. Data consistency and accuracy was checked through range checks and conditional checks. For all important indicators frequencies were checked to ensure data consistency. Univariate analyses was followed by binary logistic regression to check for the effect of Yashodas and NIPI trained ASHAs on maternal and newborn indicators controlled for possible confounding factors of age, education, income and type of deliveries, and number of ANC visits. To analyze the specific effect on mothers who had cesarean sections, only nonparametric tests were used, odds ratios were not calculated as the sample sizes of these mothers were less than fifty. To analyze across income groups, the respondents were divided into quartiles based on monthly incomes and using monthly expenditure data-- quartile one referring to the poorest and four to the least poor groups in this sample. This classification was used for further analyses of various indicators across socioeconomic groups. The survey collected information on both medical cost (fees, drugs, supplies, laboratory diagnostics, total costs) as well as non-medical costs (transportation, stay, food, and informal payments) related to ANC, delivery and PNC in the intervention and the control districts. The cost 22

23 information for ANC, delivery and informal payments in facilities were restricted to those mothers who had delivered at public facilities and cost data for PNC and referral included all mothers in the sample. Median expenditures along with 25 th and 75 th percentiles were calculated. To further understand the incremental and total value of a dual exposure to Yashodas and ASHAs compared to just NIPI trained ASHAs and the control group, key counseling and practice indicators were analyzed across three sub-groups of the sample women who had exposure to both Yashodas and HBNC (mothers who delivered at DH and CHC in Alwar and DH in Anugul); women who had exposure to only HBNC (mothers who delivered at home/facilities other than DH/CHCs in Alwar and at home/facilities other than DH in Anugul) and women with no exposure to the NIPI program (control districts). The study was, however, not designed to show significant differences between the two groups (Yashoda + ASHA vs. ASHAs), but only to compare differences between a NIPI intervention and nonintervention district. To understand the effect of gender on newborn care, four key indicators length of stay in facility, initiation of breast feeding, immunization at the facility and referral were analyzed by sex of the newborn. For both phases, data on the Yashoda component was collected from both DH and CHCs in Alwar where the Yashoda program was functional. In Anugul data was collected only from the DH level as the Yashoda program was not functional at the CHC level. In Sawai Madhopur, women delivering in DH were not included as Yashodas were introduced there in June 2010; instead data was collected from Sub District Hospitals (SDH) where Yashodas were not placed. 3.3 Limitations The following limitations can be identified for the study methodology and field data collection: Implementation research design does not enable collection of baseline information on the selected indicators. This affects the selection of a true control sample and thus potentially results in biased findings. However, this was partially addressed through the use of DLHS data to compare maternal and newborn care indicators across all districts of the study states and selecting a control that most matched the intervention district. Final sample size was slightly less than the estimated required sample size for the study. The analysis on mothers who had a cesarean section delivery was limited due to small sample size as unexpectedly, the number of C-section were not very high at district hospitals. Thus benefits of Yashodas for this subgroup could not be analyzed completely. There is a possibility of recall bias among women regarding Yashodas, as many times they were not able to differentiate the Yashoda from the staff nurses. In Alwar district, the sample was largely from urban areas as the DH in Alwar served the large urban as well as rural population surrounding it. Exposure and awareness levels of women in urban areas are quite different from women in rural areas, and could thereby affect their responses. Certain sections of the questionnaire, such as relating to sexual intercourse or family planning, could not be spot-checked by male supervisors as respondents were not comfortable answering such questions in their presence. 23

24 4. UNDERSTANDING DEMAND FOR HEALTH SERVICES The term demand side appears with increased frequency in pro-poor health planning and policy. The drivers behind this interest are located both in the economic and institutional crisis of the national health sectors. The health sector has seen an increased marketization and provider pluralism. Many countries have experienced a collapse of public sector services alongside a limited success of supply side demanding health sector reforms to improve health service delivery. The renewed focus on maternal and child health mortality and morbidity enforced by the MDG 4 & 5 has highlighted the lack of demand for governmental services. These poverty reduction strategies and related aid instruments have led to renewed focus on the voices of the poor and a greater understanding of the powerlessness of the poor in relation to responsiveness of service delivery. Poor people tend to underutilize health services. The determinants of this are complex and encompass not only cost factors but also indifferent treatment, rude behavior from providers, gender barriers within household and a host of other cultural and social constrains. The prominence of unorganized markets in health care and the associated provider pluralism pose major challenges to the reform of health systems. Individuals and household face an unregulated environment in which the boundaries between public and private become increasingly blurred. They also face this market from a position of information inequality. The recent slogans of public health reform availability, quality and access rests on a substantial body of research showing that supply side factors such as cost of care substantially reduce the health care utilization by the poor. Demand for care rises significantly with increasing proportion of qualified medical staff. In addition, the probability of seeking care from any formal provider decreases with the increase in distance to that provider. Yet ensuring demand is not only a matter of adequate supply side. An intriguing and very important social phenomenon is women, men and families acceptances of governmental facilities as the best and safest place to give birth. Within a field of medical pluralism they need also to accept bio-medicine as the best way to ensure their and their children s health. Social scientist has understandably emphasized the social and cultural factors that could explain low utilization. Now with introduction of JSY and consequently a tremendous increase in facility based birth, important questions remain to be answered: how and why does acceptance and demand for skilled and facility based births become a prevailing social condition? How flexible is the demand if the service is not up to standard, if services deteriorate or if incentives are withdrawn? When and why do some sections of the community still not utilize government health services? In this chapter we investigate acceptance of governmental facilities and we discuss variations across contexts. We explore the meanings health workers and families attach to acceptance and refusals of governmental services. We need to understand demand in its local situated context. Below we discuss how social inequalities, such as gender, caste and class shapes people s experiences of the health services offered them. Instead of focusing upon characteristics of individuals as being educated, knowledgeable and modern, to give a few examples of labels frequently used in explaining demand and health seeking behavior, we highlight a relational and contextualized approach to demand. We close this chapter by discussing briefly the community foundation for lay-health worker programme like the 24

25 Yashoda and the ASHA and let this serve as a background for our assessment of the NIPI interventions to be discussed in the following chapters. Acceptance for facility based births in contexts The female disadvantage in less-developed countries with regard to health and well-being has been documented abundantly 30. The health status of both women and children, particularly female children, suffers in relation to that of males in areas where system of kinship and authority limit women s autonomy. Research that explores the relationship between women s autonomy and health outcomes shows that women s status is a general term with many connotations; its definition necessarily changes from one setting to another. Second, some aspects of women s status are far more significant than others with regard to specific outcomes. Decision making processes and gender empowerment - who decides? Women s life in rural north India is rooted in the domestic sphere and family and kinship are key factors defining the parameters of their experiences. Maternal and child health nests within families and households. For rural women perspectives on the state, governmental institutions and public health interventions are first and foremost shaped in the local moral world that has daily bearing on women through their household and farm work and through their own child bearing histories and the stories of their neighbors and kin 31,32. Women s utilization of services are heavily dependent upon women s roles, rights and responsibilities as defined by household structure and their relationship to in-laws and natal kin. The organization of the kinship structure around property, ownership and rights ultimately marginalizes daughters in north Indian societies. In this part of India the kinship system is patrilineal and with few exceptions patrilocal. A daughter marries and moves in with her husband s family. She earns her rights in this household by giving birth to a son that will maintain the family lineage. The flow of resources is also unidirectional, from the wife s father to the husband. Anthropologists have observed, however, that the frequency of contact with natal kin after marriage is a powerful mediator after marriage. Women with close ties to their parents and brothers have greater ability to realize their needs and desires. After marriage natal kin provides both material and emotional support to their daughters. Our observations also shows that women prefer to give birth to their first child in their natal home. Among Hindus the transformation from daughter to bride is particularly intense since she is arrives as a stranger to her groom s family. A Muslim daughter is usually married closer to home and to a family that has known her for years. The ability to keep up a relation to natal kin thus heavily affects married women s autonomy and hence also their ability to utilize the services they feel they need or want. Whereas women can express a longing for good and safe delivery care she is not the one to decide where the delivery is to take place. In most cases these are decisions made by the mother-in-law. The mother-in-law is very often also the one who accompanies the daughter-i- law to the facility or even may deliver the baby at home. With introduction of the JSY scheme birthing mothers express that they are brought to the facility because of the money. In theory the JSY incentive should cover the actual 25

26 cost. In practice, there are ongoing maximizing strategies so that the incentive also should provide some fresh household cash. There are several strategies to achieve an extra income however meager. Mothers-in-law bargain with ASHAs and facility personnel (both eager to achieve their targets) on showing home deliveries as institutional deliveries in the records, or even manipulating the number of home deliveries. This reflects there is an active demand for the JSY incentive, but not necessarily for giving birth at the facility. If women themselves had the choice, what would their choice be and why? Contrasting homebirths and facility births I feel too shy to go the hospital, so I had my baby her at home. In my village all the deliveries of children are at home, it is best to stay home with your family, they can help you. I preferred to stay at home. Everyone in the village calls the dai for delivery. Pregnancy and childbirth are universally associated with culturally based ceremonies and rituals 33,34. All cultures have beliefs about appropriate behavior during pregnancy, labor and the postpartum period. Culturally described rules concerning foods to eat, activity to avoid and care and behavior during delivery and the postpartum period guides choices and behaviors. The cultural contexts in which childbirth occur provides the norms that influences attitudes, values and interpretations of personal and interpersonal experiences of birthing as well as mothering behavior. It is a common understanding in the communities studied that childbearing, birth and post partum work are natural social processes that does not need the interference from medical doctors and skilled personnel. The demand for facility births and the interference of skilled personnel is only voiced in cases where something appears to go wrong. When mother and child is at risk there is indeed an active social demand. Safety and familiarity of the home environment are important factors in women s decision to have home births. The work of bringing a child into the world is delineated between those who assist in deliveries and those who perform the healing, cleansing and symbolically critically tasks during the most vulnerable post-partum period when, mother and child is spatially located outside of their normal social webs. The latter work is often done by Dalit and falls into the scope of Jajmani, (social and economic arrangements between families of different castes within the community) while labor and delivery are most often handled by family members. Birth specialist does not do post partum tasks. The delineation of post-partum work involves the social ordering of polluting bodily substances. On the one hand this is a stigmatized form of labor, on the other hand it involves tasks aimed at recovery and healing as well as a range of symbolically vital transitions. The Dai accompanies mother and child through a phase of vulnerability and seclusion. It is said that a new born baby has no Jati, i.e. no structure of belonging and identity. In this post partum process healing parallels the re- integration of mother and child. While all these acts can be understood through the idiom pollution taboos to think about the post partum period solely in these terms would undermine its symbolic, physical and social value. Women prefer to utilize the services of the Dai not only to keep childbirth in their local environment, but also 26

27 A pregnant woman came in to the CHC early in the morning. She was accompanied by her ASHA, her mother in law and her husband. She was wailing in pain. The Nurse on duty checked her and observed that the umbilical cord had come out The patient had been told that she might need to go to the District Hospital due to possible complications. In the afternoon they were still waiting and they had not received any further attention by the medical staff present. The fieldworker suggested to the ASHA that they needed to go to the district hospital immediately. The ASHA explained that the family was too poor, and that it would be too costly. What about their PBL card probed the fieldworker, and told them about the free ambulance and hospital-medicines that should be provided to the holder of such cards. On this information they decided to go but suggested that they should speak to lady doctor at the CHC firs. The lady doctor was no were to be found in the hospital so the ASHA and the labouring woman went to her home. There when on the front steps the delivery started. Nurse and staff were called with equipment and the delivery was performed there on the porch, in full view for everyone to see, neighbors as well as children. The child, a full grown good looking boy, was stillborn. The medical staff gave him s injections but with no success. The boy-child was declared stillborn and handed over to the father, who carried him around, crying loudly. The mother was not told that the child was stillborn. The staff explained that she would not heal if she were to be told now. Later in the evening the father passed the stillborn baby on to some friends or relatives so that they could bury him somewhere outside the fields in order that its inauspiciousness would not be disturbing to life. because important rites of cleansing, protection and social integration are well taken care of. This is one of the main reasons for why women giving birth at the facility want to return home as soon as possible after delivery. The delivery of a child in a formal medical institution involves the movement of the birthing mother to an unfamiliar environment, where strangers attend the woman in the absence of the physical, symbolic and social necessities the family and the Dai offers. In governmental facilities women express that they feel vulnerable and exposed. They are not only exposed to male doctors, nurses, sweepers and ward boys, but also to nazar (evil eye). New born babies are particularly vulnerable to nazar. Governmental institutions are thus thought of as dangerous and potentially harmful to mother and child. Governmental facilities are furthermore judged intolerant to the important cultural and ritual practices surrounding childbirth. These practices are crucial as they are seen to protect both mother and child during the vulnerable stages of birth and post partum period. Apart from being ignorant or intolerant of cultural and social needs and necessities, health facilities and their personnel are referred to as negligent in their services when they really need them as well as rude in attending to birthing women and the family members accompanying them. Women are seriously afraid of being subjected to forced sterilizations as well as being told of and blamed for stupidity and negligence in full public. Women have minimal positive expectations of being treated well at health facilities. Numerous stories circulate in local communities about mistreatment, negligence and rude behavior and reinforce the relation of mistrust existing between governmental facilities and community members. 27

28 Shared histories and shares notions Shared notions emerge when relatives and neighbors exchange accounts of their birthing experiences. Bad treatment by health workers; a doctor that did not appear when needed, or asked for bribes in order to attend to them; painful birthing process and stillbirths are stories that travel and stories that have impact on utilization over a long period of time. The population campaign in the 1970 is still hampering the Indian health system. There are number of stories about intimidation and coercions that raises serious human rights issues. Memories of these rigorous procedures have become part of community understanding of governmental facilities. Sadly, these memories are very much kept real and alive with present day behaviors. Importantly here is that the ANM and the ASHA are involved in both curative and preventive care with the most aggressive targets set on family planning. Observational data and stories told give evidence to a prevailing practice of misinformation, and brute force in order for health personnel to meet the targets set. When people actively express distrust to the health system, this is not only because of history it is also because of present day practice. Issues of social inequality and relation to the nation state Acceptance and demand behavior needs to be understood in their local situational context. The ethnographic study in our two different villages shows how inequality in the form of caste and class may interfere with utilization and demand. Social inequality may coerce people to adhere to rules. Like the young mothers referred to above that are taken to facility births because of the JSY Incentive. They easily conform because they are not the ones who set the rules. The ASHA of the well performing village was chosen from one of the elite families in the community. At community level then the local governmental structure could operate through the village elite in mobilizing villagers for health activities. In this she had success. The downside of her elite position was that she refused to enter the households of the scheduled caste to perform her duties. There was a lot of resentment in these households about this but they felt unable to protest as the ASHA was an upper caste person with influential family and in this they were not the ones who complained and set the rules. An interesting feature with Community 1 was that the Brahmin caste dominated it, with only 10 households belonging to a scheduled caste Meena and 3 Saini households. Yet both Scheduled castes and the Brahmin referred to themselves as modern by the fact that they appreciated and utilized governmental services of immunization and facility based births. For the scheduled castes there was indeed an active demand, but due to local system of inequalities they had limited access. In village 2, referred to as low performing community with regards to uptake of governmental services, this situation was different. Village 2 is a hard to reach community in terms of conceptualizations, not geographical distance. The village had a population of 1553 people predominantly Muslims (Meo) and Hindu low caste. Several of the elder Meo in the village had parents or family who fled to Pakistan during the partition. The distrust towards governmental facilities was far more pronounced in Community 2 than in Community 1. Although here too the JSY scheme had its followers, this was a community were home births was clearly voiced as preferred. The pronounced mistrust uttered by this community brings yet another perspective to what influences demand. Public health programs, such as the JSY can be defined as regulation, surveillance and control of bodies by the state. For communities 28

29 public health interventions can therefore also have profound political meaning. It can be understood as the human and benevolent intentions by the state towards its subject. But it can also be seen as a tool for control and surveillance and hence met with fierce resistance, refusal and mistrust. At a micro level then refusal of a governmental health program can be an occasion to express political or religious differences. Acceptance, social demand and trust In this chapter we have brought attention to the part of the ASNI project that attempts at understanding demand. We have argued that demand needs to be understood in its local situational context. We have focused upon how the complexities of social relations affect demand. There is not one single definition of what fosters demand. Demand is socially situated and contingent. We have pointed to how the interactions of various dimensions of social inequalities, such as gender caste, class shapes peoples experiences of the health services offered them. Instead of focusing upon characteristics of individuals as being educated, knowledgeable and modern, to give a few examples of labels frequently used in explaining demand and health seeking behavior, we have highlighted a relational and contextualized approach to demand and traced the consequences of caste, class and gender for lived experience. In the field of service provision and utilization, we need to be aware of the seemingly unrelated factors that can influence a person's life experience and response to services. For instance, national health policies urging all women or even paying poor women to give birth in governmental facilities does not take into account how the extraordinary coerciveness of India s family planning programs targeting the poor segments of the population has fostered deep mistrust to the public health system. Neither does it capture the fine distinctions between active demand and acceptance. Passive acceptance denotes compliance by a public that yields to recommendations and social pressure by community leaders and health workers. The young wife accepting the rule of the mother in law is an act of passive compliance. A community referring to themselves as modern by choosing facility births, likewise. Neither does it take into full account how marginal conducting life below the poverty line can be. There is indeed a demand for the JSY incentive. But it is not necessarily an active social demand that entails adherence to governmental health programs by an informed public that perceives the benefits of and the need for safe facility births with skilled attendance. We have argued that trust is fostered at the point of service. Attitudes of personnel and quality of services offered are of crucial importance. The key positions in the health system are thus the frontliners : those dealing directly with the birthing mothers. The role of this new cadre--the Yashoda at the facility and the ASHA doing the community HBNC program - in fostering trust to the public health system and raising an active demand is important. We close this chapter with some reflections on the role of lay health workers as change agents and as builders of trust. 29

30 Lay-health workers: change agents and a builder of trust? Interventions aimed at modifying individual, household and community behaviors have been a salient factor in public health interventions. In the literature of medical anthropology there has been a counterview that health beliefs and practices have their own integrity and should be understood in their own right. The truth and falsity of this is beside the point as traditional birthing practices, as illustrated above, fulfill other potential health promoting as well as sociological, psychological and emotional needs. JSY is a demand side financing (DSF) scheme transferring purchasing power to particular defined target groups. It is an attempt to change demand side behaviors by removing costs by giving purchasing power to the targeted populations. International experience suggests that these schemes have been most successful in increasing coverage to poorer and vulnerable groups. However, demand side financing have been less successful in raising the quality of service provision. Schemes work best in relation to easy defined targets and where the service offered are standard and predictable. Enson 2004 therefore suggests that demand side financing schemes are not a quick fix in an institutional sense. Most of the detailed examples we have of these financing schemes comes from developed countries were institutional and informational requirements are already met. This includes population registration, functioning bureaucracies, strong regulatory frameworks and robust mechanisms for accountability. Neither of these are recognizable traits of the Indian health system. In contexts where these are lacking, the political bureaucratic, regulatory and accountability deficits that undermine the supply side interventions will affect the demand side interventions as well. In the paragraphs above, we discussed how demand and lack thereof is not a matter of knowledge and education. We have shown how, bio-medicine beckons with promises of health also for poor women, at the same time as institutions repel with a range of threats. The choice of seeking care is thus taken within a delicate balance of longing and mistrust. It is within this complexity that the lay health-workers as the Yashoda and the ASHA are set to develop and navigate their roles and responsibilities. The lay worker denominated Yashoda 1 is meant to be the caregiver to the mother and respective newborn at the facility. The Yashoda is conceptualised to be the mothers friend at the health institution, to give comfort, maintain hygiene in the mother s surroundings, to explain and assist the mother with basic newborn care, to motivate the mother to early and exclusive breastfeeding and to encourage the mothers to stay in the facility 24-48h after delivery. The ASHA is a community health mobilizer situated in the communities in order to mobilize for health and healthcare choices. The ASHA is responsible for bringing the mother to the facility, the Yashoda is responsible for making her stay comfortable at the same time as she initiate good child health care. The ASHA under NIPI program is responsible for the 5 HBNC visits (after delivery) to the mother and newborn in community. NIPI intervention thus attempts to assure mother and child care within the frame of continuum of care. Placing the Yashodas in the maternity ward as a mother s aide and as a support worker for improving quality of care, addresses some of the gaps that surfaced with the implementation of JSY scheme. A UNFPA assessment in selected Indian states raised several issues about the benefits of JSY for women 1 Named in respect of the foster-mother to Krishna in Hindu mythology 30

31 and newborns. In order that JSY should contribute to lower maternal and newborn deaths, increasing the number of facility-based births was not enough. Reduction in maternal morbidity will be achieved when women coming to the facility receive quality delivery and post partum care services the UNFPA report concluded 35. The quality of care at the facility, the services available there, the safety of mother and child in the facility and lastly the availability of counseling for newborn care; breastfeeding, immunization, and diarrhea management, needed also to be addressed and improved 35. NIPI designed the Yashoda intervention in order that these gaps could be addressed. Nevertheless the human rights organizations in India argue that to persuade women to give birth at facilities with such a poor quality of care is indeed a human rights violation. A study by Singh and Gupta (2004) addressing quality of care and utilization of health services in Rajasthan public facilities, paints a rather bleak picture. They conclude bluntly that the public services are abysmal, unregulated and underutilized. Unqualified private providers provided in fact the bulk of healthcare in the area studied. Interestingly they argue also that although the quality is appalling, villagers seems content with what they are getting, perhaps the authors suggest, because they have come to expect very little. There is thus a challenge to build trust in public facility as well as strengthen the voice of the poor to demand good quality of services. A well trained lay health-worker could if trained accordingly play a role in giving voice to the demand for better quality of care. Decisions women make with respect to maternity and where to give birth are neither governed by a purely religious tradition nor the result of free choice from a range of traditional and modern At the maternity ward, a puerperal mother and her mother-in-law were crying. Family members and other patients were gathering around them. The Yashoda intruded gently, and asked the mother if everything was all right with the child and if she had breastfed. But the mother was all in tears and did not respond. The mother-in-law explained that she had not given breast milk yet, as she was still tired and crying. The mother had given birth to a girl. It was her third daughter. They were both very disappointed. She was also scared of the reaction of her husband, explained the mother-in-law. The new mother s mother stood by the side of her daughter, listening and nodding. The mother herself was not paying much attention. The Yashoda smiled and shook her head, asking why they were so sad. She told them, to look at herself and at the female visiting researcher how they as women were free to move around, work and contribute to the society. Patients and their family members on the other beds gathered to listen. The mother also turned her head and listened. The Yashoda continued, and told them that she herself only had one sister, and that the two sisters took care of their parents, maybe better than any sons would have done. She said that girls take better care of parents than boys, since girls are more compassionate. At this, other people in the room agreed, and told the mother not to cry; others told stories of successful women, and said that these days, girls can have good educations and do better than boys. 31

32 private and public options. The family decisions whether or not seek medical care during pregnancy and birth are based on a finely tuned appreciation of the ways in which class and case power shape their experience of medical institutions. Whatever the social class or caste of staff they are not likely to identify with poor women giving birth. The withering scorn of hospital staff towards birthing women are frequent observations. The lack of cleanliness in the hospital is explained as due to the lack of cleanliness of patients. Anguish for women were also the harsh attitudes towards pain-- why are you making such big noise now, shut your mouth. Within the tradition pain incurred in pregnancy and birth are seen as integral parts of woman- and motherhood. Expressed pain thus also understood as opportunities for other women to give comfort and care. The village midwife or the dai see their task as an extension of these virtues and stress that what they offer the birthing woman are the qualities of patience and endurance. They contrast this with facility based births were hospital staff is seen as impatient with the mothers. Impatience is also experienced when the baby is overdue, often explained as resulting in a forced caesarian section or an episiotomy. Another issue to them is the lack of protection and sheltering of her body and herself. The crowdedness and the degree of exposure of the female body stand in sharp contrast to the seclusion and protection experienced at home. To solidify the friendship between the mothers and Yashodas, a disposable birthing kit was designed. The kit was intended to strengthen the bond between the Yashoda and the expectant-mother, and support principles of cleanliness and hygiene inside maternities. The distribution of such Kits would create a friendly atmosphere for the mothers to initiate and continue habits of good cleanliness. Such contributions could help prevent infection and hypothermia of the newborn baby. The birthing kit includes: a bed sheet for the mother, a flannel blanket for the baby, rubber/oil cloth for the baby, a sterile baby sheet, cotton diapers, and a maternity pad for the mother & newborn baby. Additionally the kit contains material for the health provider such as gloves, a cap, a plastic gown, a mask and an umbilical clam A well trained Yashoda can help fill the gap of care in institutional deliveries by on the one hand placing emphasis on the emotional and comfort aspects in the delivery process inside busy maternity services and slowly change clinical practice towards a more humanized and gender sensitive approach. Her comforting role, her ability to shelter, protect and give voice to needs is of crucial importance for her to fulfill community expectations of a mother s aide. One of the main challenges however in all lay-health worker programs is while lay-health workers are set up as change-agents they are often experienced as being an extension of the formal health system. 36 Community participation is crucial for the success for of lay-health worker programmes. Although today s discourse is more pragmatic and technical compared to the concern in the 1980, it is widely acknowledged that the sustainability and impact of these programmes require ownership and active participation of communities as a non negotiable pre condition. 32

33 To conclude For the past 20 years lay health workers has been key players in primary health care models because of their knowledge of the community and its socio-cultural belief system. A well trained lay health-worker can serve as an important negotiator between traditional practises and facility-based care. She can negotiate birthing practises, give comfort and care when the birth of a baby girl results in grief, as well as gently support the change of traditional mother and child health care practises seen as harmful to mother and child. Likewise she can help pinpoint community resources and practises beneficial to the health of mother and child. The ethnographic study highlights however that one of the most important roles of these new cadres is to be enabled to slowly change the way in which people engage with the health system and perceive their entitlements to health and health care. There is a clear demand for god quality services. The lay health workers, the Yashoda and the ASHA, should adapt their role to this present community concern. 33

34 5. THE YASHODA PROGRAM 5.1 The Yashoda Program Operational Aspects Yashoda Profile NIPI defines Yashodas as volunteer support workers who are paid a performance-linked incentive, working in shifts, placed at the DHs and some CHCs. The objective of the program is to enhance a joint ownership for care coordination at the facility with Yashoda as part of the larger system, where the pregnant women feels welcome as she enters the facility and leaves with her newborn baby with a feeling of being cared for and looked after. The value addition that the Yashoda program brings is the demand generation of services for care of the newborn and improved accountability at the facility level. The profile of Yashodas at the two study districts matched NIPI guidelines. The study found that in Alwar the median age of the Yashodas was 35 years with 52 percent of them in the age group of 35 to 40 yrs. Initially NIPI had specified a minimum age of 25 years for Yashodas; however the acceptability of women in this younger age group proved to be a hindrance in influencing mothers and their families. Considering this, the minimum age limit was increased to 35 years. Forty three percent Yashodas in Alwar were either separated, divorced or widowed. Fifty percent of them took up the position because of necessity which is further supported by the fact that their earnings contribute to 71 percent of her average family income. Thus, this engagement has provided the Yashoda s financial stability especially for those who did not have spouses to depend upon. Also, close to 60 percent of them expressed the wish to continue their service as a Yashoda in the future. The median age of Yashodas was 33 in Anugul DH. Although in Anugul 75 percent of the Yashodas were currently married yet necessity (58 percent) was cited again as the prime reason for working. Here the Yashoda s income contributed to 33 percent of her average family income. The study reported that at the CHC level in Alwar, 25 percent of the Yashodas were from scheduled castes/tribes compared to eight percent at the DH. Most Yashodas lived close to the health facility. All Yashodas in Anugul and 86 percent Yashodas in Alwar stayed less than five km from DH/CHC. As per the recruitment guidelines the minimum qualification required was 8 th grade for Yashodas. This was maintained uniformly across the states. In both states at the DH level 17 percent of the Yashodas had a bachelor s degree compared to five percent at the CHC level in Alwar. Although the Yashoda recruitment guidelines clearly mention that the Yashodas will be engaged as volunteer workers and are not entitled to claim a regular position in the system, more than 40 percent of the Yashodas in DHs (46 percent in Alwar DH and 42 percent in Anugul DH) had aspirations for full-time government posts. This aspiration was reported majorly by the Yashodas who were graduates, 75 percent of the graduate Yashodas in Alwar DH looked forward to permanent government positions. However, 85 percent Yashodas at CHC level were happy to continue in their present positions for the next five years. 34

35 Indicators Table 5.1: Profile of Yashoda Alwar and Anugul District Alwar (Rajasthan) Anugul (Orissa) DH (n=24) CHC (n= 20) DH (n=12) Total number of Yashodas currently appointed Median age-years Marital status (percent) Education level (percent) Caste (percent) Currently married Widowed Separated/divorced th -12 th pass Graduate ST/SC Others Place of residence Live less than 5 km from the health center (percent) Reasons for being a Yashoda (percent) Aspirations of Yashoda (percent) Desire to serve people Necessity other reasons Continue as a Yashoda Get promotion Get permanent government posting Other reasons Remuneration In Rajasthan, payment to Yashodas depend on the number of deliveries in the hospital (an incentive of ` 100 is paid per delivery conducted in the hospital; the total amount of remuneration given to the Yashoda is calculated on the basis of total deliveries that happened within one month and divided equally among the Yashodas.). In Orissa a fixed amount of ` 3000 /month was given to Yashodas. During April-May 2010 (when the survey was being conducted), Yashodas in Alwar reported that they received an average income of about ` 2000 per month. In the rainy season, when the number of deliveries peaked, their income may increase up to ` however, this was infrequent. Yashodas in Alwar did not appreciate the linking of payments with the number of deliveries. On one side, you all say that we must advocate family planning, but our incentive is associated with number of deliveries. How can we counsel mothers to control population? (IDI, Yashoda, Alwar). Yashodas in Orissa and Rajasthan would have liked to have some incentives attached to performance and not necessarily to number of deliveries over which they do not have any direct control. The other concern raised was regarding the delay in receipt of incentives more than 90 percent of the Yashodas in the Alwar DH and Anugul DH reported that their salary arrived between the 2 nd and 4 th week of the month. 35

36 Capacity building The NIPI guideline has a holistic approach towards capacity building which is not only limited to training but encompasses the following: Training Support systems and supervision Simple formats and reports Assessment and feedback processes Clarity on the reporting and monitoring processes Learning, sharing and career growth opportunities Recognition and rewards The training components includes induction training upon recruitment, continuous hands on training and refresher training. Training activities varied across states as of April 2010, 63 percent of the Yashodas in Alwar district reported that they had attended two training sessions and 90 percent in Anugul district had attended three training sessions. The trainings usually lasted two to three days. A review of the training material and flip charts used by Yashodas in Rajasthan was done. Booklet on role of Yashoda This booklet is a simple and comprehensive manual to guide the Yashoda on her role and functions in the facility. In the beginning, it explains to the Yashoda the rationale behind her nomenclature and her expected role as a sympathetic friend, assistant and counselor to women coming to the facility for delivery. Her functions include ensuring a conducive/comfortable environment before delivery, assisting in the labor room and counseling in the PNC ward. It also contains tips on efficient utilization of work hours and effective teamwork with other staff members and fellow Yashodas. While the format of the manual is simple, the language is technical in many places and may not be easily understandable. Flip charts for Yashoda to aid counseling of mothers and family members on postnatal & newborn care The flip chart is to be used while counseling mothers on postnatal and newborn care. This is well illustrated, with effective guidance to enable Yashodas to use them as effective instruments in educating the women. However, some illustrations contain English sub-heads, which need to be translated to Hindi. Important observations from the review are as follows: Content: On the whole the manuals and flip chart for Yashodas are comprehensive and cover all essential elements of birth preparation, postnatal care, newborn care including breastfeeding, care of postnatal mothers, identification and care of high-risk newborns, and other relevant issues like immunization and hygiene. Format: Pictorial depictions have been extensively used in all material and are helpful in easy comprehension. Explaining situations through simple stories is also helpful. However, at places the language is complicated and not necessarily conversational. This may be difficult to comprehend for women who are generally not educated above the eighth grade, that too in rural settings. Some captions are in English and therefore not useful for Yashodas. 36

37 Branding / Identity: An attempt has been made to depict the Yashoda s distinct identity in the illustrations in all manuals and flip charts. Yashodas are shown with pink aprons and a tiny caption Yashoda printed somewhere on the figure, which is often in English. The mode of identification needs to be made starker and also the distinct roles of nurses and Yashodas need to be more clearly illustrated, for the understanding of community members as well. Role of Yashoda as sympathetic friend : Several aspects of the Yashoda s role in comforting the mother are illustrated in the manual, such as making her comfortable, assisting her with toilet/drinking water, occasionally massaging her back, holding her hand and comforting her during delivery. However, at the same time, she is expected to closely watch the nurses and learn from them the various clinical tasks related to delivery care. This would naturally create an expectation among nurses and also a realization among Yashodas that they need to assist nurses in their tasks. Eventually this could erode her role and identity as a mother s companion and assistant, and not a nurses aide. It is important to suitably highlight her role as mother s aide, possibly illustrating the importance of emotional support in ensuring a satisfactory delivery experience and her crucial role in ensuring the same. At the same time, less emphasis must be paid to the need for Yashoda to learn all clinical deliveryrelated tasks from nurses and other hospital staff. This would help her and the staff to understand and appreciate her role and create her unique identity in the facility. The Yashodas found the training sessions helpful in defining their role clarity and dispensing their duties. After attending the trainings, we know what our exact work is. Why we are appointed as Yashoda. We learned a lot about mother and child care. Through this training we got knowledge about family planning, immunization, breast feeding, diet of the mother, how to receive a mother and child after delivery, how to maintain hygiene within the hospital, what are the problems that a mother faces after delivery etc. (IDI, Yashoda, Alwar and Anugul). However some Yashodas stated that many of them did not perceive themselves to be well-informed enough to handle questions from the mother/family during counseling especially regarding complications. We want more information about mother and child s complication. How do we know immediately that the mother is having a complication? (IDI, Yashoda, Anugul). Majority of the Yashodas recommended refresher training to upgrade their skills. If we have training every six months, it will be good (IDI, Yashoda, Alwar). In training we get to learn new things and clear our doubts. This training should happen more often (IDI, Yashoda, Anugul). Some of the Yashodas, especially the more educated also suggested the need for more paramedical training (nurse s aide rather than mother s aide). 37

38 Supervision and mentoring As per NIPI guidelines overall supervision is provided by the ADMO /medical superintendent identified by the CDMO/CMHO/PMO in the DHs as the case may be in each state. In the case of CHCs, the RCHO could provide the overall leadership in managing the intervention. In the NIPI focus districts, the District Child Health Managers/Maternal and Child Health Coordinators will assist the ADMO/Medical Superintendent in discharging/coordinating all Yashoda related functions and day to day operations. Yashodas are supervised and supported by the Child Health Supervisor (CHS) and two Deputy Child Health Supervisors (DCHS) so that for each shift one supervisor is available. It has been suggested that the DCHS should be from the nursing stream --- preferably a retired nurse/anm/lhv because of their understanding of the health system --- and can begin to support the Yashodas. The CHS on the other hand requires more managerial skills and could be from a social sciences background. It has been observed that the above cadres have been fulfilling their supervisory duties. The supervisors also provide a strong support system for Yashodas within the hospital setup and ensure that Yashodas are used for appropriate tasks. Some examples: The Yashoda Supervisor, after coming to Hospital, on duty, takes a round and marks attendance of the Yashodas. She visits the labor room every half an hour and keeps a watch on the Yashoda (Observation, Alwar DH) The supportive supervision role is also demonstrated effectively by the supervisors: Supervisor didi tells us how we can counsel the mother better and shows us by talking to the mothers (IDI, Yashoda, Anugul) The supervisor didi supervises our work personally. She interacts with mothers and asks them what information they have received from the Yashoda. She suggests us in which way we can do our work better. (IDI, Yashoda, Alwar) In Rajasthan, the supervisors were appointed after the Yashodas and hence their role in handholding Yashodas seems to be limited. In Orissa, the supervisory cadre was appointed before the Yashodas and hence played an important role in fitting Yashodas into the hospital environment. During the study period there was no supervisory cadre present at CHCs in Rajasthan. This had some implications on the discharge of duties by the Yashoda. 38

39 Table 5.2: Operational guidelines for Yashoda and their implementation in Rajasthan and Orissa (Data in this table has been synthesized from NIPI process documents of both states and survey of Yashodas.) Parameters NIPI guidelines Alwar (Rajasthan) Anugul (Orissa) Place of work and number of Yashodas Working hours Recruitment process Orientation training Supervision mentoring and and Payment system Places where delivery load is high. Adequate number of Yashodas should be recruited including reserves to cover absence due to leave and sickness. 8 hourly shifts and their leave is a local arrangement As it locally suits, involve some stakeholders from the health system and some district authorities At least 2 days training, one day for familiarizing Yashodas with the hospital environment and second day focusing on counseling Supervisory cadres to be appointed, who will handhold Yashodas in the hospitals, mentor them and ensure availability of Yashodas at all times, etc. Yashoda performance incentives. received based DH and some CHCs which have high delivery load. However some CHCs with comparatively low delivery load also have Yashodas. 8 hourly shifts -- leave sanctioned by supervisor. Yashodas get a day off after completing two shifts consecutively. Under the direction of the DHS, recruitment occurs under a committee comprising of the CMHO, DPM, representative of the DM, and Principal Medical Officer (PMO). Initial two days training given to all Yashodas, about 70 percent of the Yashodas reported to have attended refresher training. In Rajasthan, the child health coordinator and the deputy child health coordinator fulfill this role. On the job mentoring seems to be poor and supervision is a monitoring rather than a mentoring process. In Rajasthan, an incentive of Rs. 100 in paid to be paid to Yashodas per delivery conducted in the hospital. There is no fixed salary, total amount of remuneration given to the Yashoda is calculated on the basis of total deliveries that happened within one month and divided equally among the Yashodas. Restricted to only DH and not extended to the CHC level. 8 hourly shifts -- leave sanctioned by supervisor. Recruitment is a districtbased process, similar to Rajasthan. However, here the supervisory cadre for Yashodas was recruited first. Initial three days of training given to all Yashodas. About 90 percent Yashodas reported to have attended two refreshers. In Orissa, there is a child health supervisor. These were recruited along with Yashodas and the mechanism seems to have worked better A fixed salary of ` 3000 is given per month 39

40 According to NIPI guidelines, monthly load of deliveries serve the basis for calculation of Yashoda requirements. DHs and select CHCs with high delivery load were considered for implementation of the Yashoda program. Yashodas are expected to attend to five to six mother-child dyads during any eight hour shift. In Rajasthan, Yashodas have been placed at the DH (DH) and at some Community Health Centers (CHC) with high delivery load. In Orissa, Yashodas are placed only at the DH. The study observations however indicated that Yashodas placed at CHCs in Rajasthan were not being efficiently utilized. This was especially true for facilities that reported less than four deliveries a day and had a full time nurse available at the facility. In addition, the lack of supportive supervision for Yashodas at CHCs contributed to the lack of clarity in their roles. Only four out of 11 CHCs in Alwar reported more than five deliveries a day and one of them (Rajgarh) had two full time nurses and two Yashodas on duty. See Annexure 4. Low delivery load and lack of supervision raise concerns regarding the performance of Yashodas at the CHC level. 5.2 The Yashoda program Health provider & community perspectives Health provider s perspective and interaction The role of Yashodas as a mother s aide seems to be generally well understood, however, there is a thrust for the Yashodas to become a nurse s aides rather than her envisaged role as a mother s aide. The Yashoda Operational Guide 2010 mentions While the Yashoda fills a critical gap for counseling the mother on newborn care and to coordinate services within the maternity ward, Yashoda is NOT a substitute for nurses. From the point of view of the hospital staff, the most important role played by Yashodas is in reducing the work burden of nurses (in caring for mothers):..after the coming of Yashodas at the hospital, we have got much help from them, because, now we do not to worry about mothers as Yashodas take care of the mothers (IDI, Staff nurse, Alwar DH). Observations recorded instances where Yashodas were being used for clinical support: The Yashoda told us that she is well acquainted with giving injections and drips. On asking her, Do you help nurse in all this? She replied hesitatingly, I help the nurse, and while helping, I gradually learnt all this, with the help of the nurse. In general, the importance of the counseling and psychological support roles of Yashodas is not completely acknowledged by other health staff, they see Yashoda or would like to see them as nurse s aides rather than a mother s aide. Some Yashodas are not well-trained, they cannot give injection nor do dressing. Other than counseling they should know some more things. Previously what the sisters were doing it is no longer sufficient now since the number of deliveries have increased. So someone should help them (IDI, Doctor, Anugul). Further, the Yashoda said that nurse asked her to learn all this (Observation, Alwar). Doctors also felt that in an environment where clinical staff was not adequate, it would be very useful if the Yashodas were trained to assist in simple para-clinical tasks. Many Yashodas also expressed a wish to learn simple clinical skills. About the Yashodas, it has been said: skill upgrading is required 40

41 training for dressing, change of saline, danger signals of pregnancy and PNC other than counseling, they should know about some more things (IDI, Doctor, Anugul). The contact between doctors and Yashodas is limited and in general, their relationship is cordial. The most interesting relationship is the one between Yashodas and nurses. Before the arrival of Yashodas, nurses were the main caretakers of hospital wards. Thus, while nurses recognized the advantages of Yashodas, there was also an underlying tension between the two cadres in some places. The tension seemed to have eased with time. In the beginning, when Yashodas joined the hospital, hospital staff troubled them a lot, but, at present there is better co-operation, (FGD, Yashodas, Alwar). We do not have much interaction with the doctors and the nurses, because, they understand that we are not permanent government staff and hence give us less importance. The behavior of the nurses has improved, however the behavior of class IV employees is so-so neither so good nor so bad. (IDI, Yashoda, Alwar) Overall the relation with nurses is good they are cooperative, but at times they under estimate us. Staff nurses feel they are more educated. (IDI, Yashoda, Anugul) The color of apron provided to Yashodas contributed to some of the tension initially the aprons given to Yashodas were white in color, which caused the community to mistake them for nurses. Later the color of the apron for Yashodas had been changed to pink subsequently, which distinguishes them from other health care providers in the facility. The appropriate branding and identity of Yashodas are important; therefore a distinct uniform with specific office space and appropriate positioning within health system is important. The staff in the health facility generally regarded the non-clinical training of Yashodas as a limitation. There is also concern that Yashodas affectionate behavior towards mothers is only beginner s enthusiasm and would not last over time. Community perspective Community survey Demographic, socio-economic profile & pregnancy history Demographic and socio-economic characteristics of the respondents provide useful insight into the factors which influence population health, reproductive behaviors and some aspects of utilization of health facilities. This section describes the household and respondent characteristics of the sample, including background information on the current birth of the respondents (Table 5.3). As mentioned earlier, the survey covered a total of 1652 women, 810 in intervention and 842 in control districts respectively. Total respondents numbered 940 in Rajasthan and 712 in Orissa. Demographic & social characteristics Age structure: The age of the respondents ranged from 18 years to 40 years, with the median age being 23 years in Intervention group and 24 in Control group. 41

42 Education levels: Respondents on the whole had low levels of education. Thirty percent respondents had no formal education while 42 percent had only basic education between first to eighth grades. Women in Rajasthan had much lower levels of education, with 42 percent not having any formal education and only 14 percent educated above basic level (ninth grade and above). Women in Orissa had comparatively higher level of education, with about 40 percent women educated above basic level. Women on the whole were slightly better educated in intervention areas as compared to control areas. Religion and Caste status: Hinduism was the dominant religion among the respondents, which is reflective of the religious composition of the overall population. In terms of caste status, the vulnerable social categories of Other Backward Classes (45 percent), Scheduled Castes and Scheduled Tribes (41 percent) together constituted about 85 percent of the surveyed women. Proportions were similar in the intervention and control areas in both the states. Marital status and age at marriage: Almost all women covered in the survey were currently married. Women in Rajasthan had been married for 6 years on average while women in Orissa had been married for 5 years. The prevailing system of marriage at very young age was evident from the age at marriage data, with 53 percent respondents having been married below the age of 18 years. Household size: The household size of the respondents varied from two to 17 members, with majority (43 percent) ranging between five to seven members. The average size of a household was seven members. Below Poverty Line (BPL) status: Possession of a Below Poverty Line card in poor households enables them to access various social benefits and welfare entitlements. Among the respondents, one third had a BPL card (although almost 41 percent were from SC/ST categories). 42

43 Table 5.3: Key indicators of socio-economic characteristics of respondents Rajasthan Orissa Intervention Control Intervention Control Number of respondents Median Age Level of Education: ( percent women) No formal education 1-8 grade 9-12 grade More than 12 grade Mean years of marriage SLI Groups: ( percent women) Low Medium High Median monthly household income (`) Median income across Income Quartile groups: (`) First Second Third Fourth Type of House ( percent women) Pucca Semi-pucca Kuccha ,000 3,000 4,500 7,450 16, ,500 2,500 4,150 7,000 16, ,500 2,500 4,100 7,000 14, ,000 2,700 4,500 7,000 13, Economic Profile Income and expenditure: Households in the sample had a median of two earning members per household in both the states. The monthly household income of the sample households ranged from ` 3,200 (25 percent quartile) to ` 10,000 per month (75 percent quartile). The median total household income was ` 5,200 per month. Median household income was higher in Rajasthan (` 7000 per month) than in Orissa (` 4000 per month). This is partly due to the higher proportion of urban sample in Rajasthan, (especially in Alwar) than in Orissa. Median incomes were similar across intervention and control districts in both states (Table 4.3). Occupation: The occupation profile of surveyed households was similar across intervention and control districts in both states. The only significant difference was a higher proportion of agricultural sector workers in control districts. (Figure 5.1) 43

44 Figure 5.1: Occupational structure of sample population Household characteristics House type and cooking space: More than half of the respondents lived in pucca houses, 19 percent in semi-pucca and 23 percent in kaccha houses. There is marked difference in terms of types of houses between the two study states. In Rajasthan the majority (71 percent) lived in pucca houses, while in Orissa an equal proportion (about 40 percent) lived in pucca and kaccha houses. A significantly higher proportion of respondents (80 percent) lived in pucca houses in the intervention district in Rajasthan as compared to the control district (63 percent). The trend was similar between the intervention and control district in Orissa, though the difference was lesser (46 and 34 percent respectively). Drinking water and electricity: About 43 percent of the total households were dependent on private sources of water, either tap, hand pump or tube well. Forty one percent depended on public water supply, either through piped connection or hand pump. About 87 percent of the houses had electricity connections, the proportions being similar across intervention and control areas in both states. Reproductive history of respondents Some information on the parity of the respondents and details about their current birth was collected to understand their pregnancy history and maternal care seeking behavior. This helps explain many aspects of their overall reproductive behavior, perceptions on care and their choice of place of delivery. Parity: Information on parity included the current birth of the respondents. The median parity level of the respondents was two, while about 34 percent had a parity of one. A higher proportion of women in Rajasthan had higher parity levels as compared to women in Orissa (Table 5.4). 44

45 Outcome of current birth: The outcome of current birth was a live birth for almost 99 percent of the respondents. Only one percent pregnancies resulted in still birth or abortions. Place of delivery: Fifty-five percent respondents delivered in DH or SDH in their current birth (by design of survey), while 20 percent delivered in CHC/First Referral Units (FRU). About 12 percent delivered in private facilities and eight percent delivered at home. Orissa showed more delivery in private facilities as compared to Rajasthan. PHC and Sub Center (SC) deliveries together accounted for only five percent of total deliveries. Compared to previous to last pregnancy, utilization of DH/SDH increased from 38 to 55 percent; CHC/FRU decreased from 27 to 20 percent; and home deliveries showed an almost 40 percent decline (from 13 to eight percent). Assistance during delivery: More than three fourths (78 percent) of the deliveries were conducted by nurses. This was the pattern in both intervention and control areas in Rajasthan as well as Orissa. About 42 percent births were assisted by doctors and nurses. Only seven percent deliveries were assisted by dais, five percent by ASHAs and three percent by family members. Decision on place of delivery: The majority of respondents reported self/husband/family members as the major influencers of decisions regarding place of delivery (79 percent), followed by ASHAs (58 percent). Both the family members and ASHAs together influenced about 40 percent of the deliveries. ANMs and other health providers did not play a significant role in influencing decisions on place of delivery. The actual decision was also taken largely by self/husband/family members, as reported by 91 percent respondents. Cost played an important role in influencing decisions regarding place of delivery as reported by 41 percent respondents. But the biggest reason for choosing place of delivery was the perception of good facility, reported by 66 percent respondents. Distance (25 percent), family/peer counseling (22 percent) and incentives (15 percent) were other important reasons. Utilization of antenatal care: More than 95 percent women received some antenatal care in their current birth; however, only 53 percent reported having more than three ANC visits. About a fifth of the respondents had three ANC visits, while a little less than a fifth (20 percent) had only two visits. Seventy-four percent women had their first ANC visit in the first trimester, while 23 percent women had their first ANC visit in the second trimester. The last ANC visit was in the eighth month for 40 percent and in the ninth for 39 percent of respondents. These trends are similar across intervention and control districts in both states. A quarter of the respondents had their ANC checkups in DH/SDH, while a little more than one fourth (27 percent) visited the SC or AWC for antenatal checkup. Twenty six percent women had their ANC checkup in private facilities. Eighty percent of the women reported being visited by an ASHA during their antenatal period. 45

46 Table 5.4: Key Indicators on pregnancy history of respondents Rajasthan Orissa Percent women with: Intervention Control Intervention Control Birth order: and above Live birth as outcome of current birth: Assistance during delivery: (highest 4) Doctors Nurses ASHAs Dais Decision on place of delivery taken by: (highest 3) Self/husband/family members ASHAs ANM Three or more ANC visits: First ANC in first trimester Last ANC in ninth month Place of ANC: (highest 5) DH/SDH SC/AWC Private facility CHC Home JSY and health care expenditure The cost analysis showed that the majority of households reported expenditures towards maternal care at facilities. Break up of costs by medical and non-medical categories were provided by very few households. Among the various cost categories, the spending on ANC was reported by 75 percent to 95 percent of the household and the median expenditure related to ANC was highest among all categories of care: costs varied from ` 1950 in Sawai Madhopur to ` 3000 in Alwar; in Orissa, ` 2160 in Anugul as compared to ` 2480 in Bargarh. All households reported expenditure on delivery and reported median cost was ` 1200 in Sawai Madhopur; ` 1350 in Alwar; ` 1600 in Anugul and Bargarh in Orissa (Table 5.5). Informal payments were reported by 25 to 46 percent of households in Rajasthan and 70 to 73 percent of households in Orissa, and ranged from ` 300 to ` 400 in Rajasthan and Orissa. Expenditures related to postnatal care at home were reported by six to 21 percent of households. Illness or need for medical care was reported by almost 50 percent of the households, with 92 percent of them reporting a visit to a 46

47 facility and almost all of them (96 percent) reporting expenditures ranging from ` 400 to ` 500 in Rajasthan and ` 600 to ` 690 in Orissa (Table 5.5). Table 5.5: Median household expenditure towards maternal and neonatal care Expenditure towards maternal and neonatal care (in `) Rajasthan Orissa Categories Intervention Control Intervention Control ANC 3000 (n= 278) 1950 (n=275) 2160 (n=273) 2480 (n=309) Delivery 1350 (n = 341) 1200 (n=367) 1600 (n=286) 1600 (n=325) Informal Payments 300 (n=85) 350 (n=169) 400 (n=209) 400 (n=227) PNC 800 (n= 36) 1000 (n=46) 200 (n=20) 500 (n=75) Referrals 400 (n=209) 500 (n=198) 600 (n=173) 690 (n=141) Receipt of JSY ` 1400 (percent) Under the NRHM, all mothers in Rajasthan and Orissa are eligible for the JSY scheme under which they are paid Rs for institutional deliveries. Almost all respondents of the survey reported receipt of money under the JSY scheme (89 to 99 percent) and 84 percent of them found the cash assistance to be very useful. The usage of JSY funds varied across the two states, with 68 to 80 percent of mothers in Rajasthan reported spending the money on food, whereas 65 to 71 percent in Orissa reported using the money on medicines. However, the cost analysis showed that JSY only covers a small fraction of the total expenses incurred by households towards maternal and newborn care. Gender Gender is a key social factor influencing newborn care in the patriarchal social setup of northern India. Rajasthan in particular is among the states in India with low child sex ratios and practice of female foeticide, indicating discrimination against the girl child. As per the census of India 2011, the sex ratio of Rajasthan was 926 females per 1000 males. The sex ratio of the newborns covered in the community survey was 891 females per 1000 males suggesting discrimination happening before the birth of the child. To see the effect of gender on newborn care, four key indicators length of stay in facility, initiation of breastfeeding, immunization at the facility and referral were analyzed by sex of the newborn. No significant differences were found in these outcomes by gender. 47

48 Pre delivery and Delivery experience The first responsibility listed in the operational guideline for Yashodas states that she is responsible for welcoming the pregnant woman heartily (in the facility) and make sure that she relaxes, and reassure her that she is in a safe place and among people, who care for her. Considering registration as the first point of contact for the pregnant woman and her family members in the health facility, it is important for the Yashoda to interact with them at this point. Figure 5.2: Time allocation of Yashoda However, of the total time spent by Yashodas at health facilities only one percent was spent in registering mothers. Yashodas reported spending 17 percent of their time in ANC wards and an almost equal proportion of time in labor rooms (39 percent) and PNC wards (43 percent). Responses from mothers obtained from facility and community surveys further corroborated that Yashodas spend minimal time at registration. While in facility survey, only three percent mothers in Alwar DH and nine percent mothers in Anugul DH reported having first met the Yashoda during registration; none of the mothers from the community survey reported having met her during registration. The facility survey reports that in Alwar, registration was mostly facilitated by family members (82 percent) while in Orissa ASHAs assume a prime role in registration of mothers. Close to 60 percent of the mothers both in Anugul and Bargarh reported having received help from the ASHA during registration. In the context of continuum of care this has significant implications 61 percent of respondents of the community survey reported that ASHAs accompanied them to the place of delivery. Also, the presence of ASHAs seems to influence sharing of the ANC card at the health facility, although sharing of ANC card was reported universally in Orissa with 95 to 97 percent of mothers in intervention and control districts reporting this; in Rajasthan this practice was higher in the intervention district compared to the control district. Facility survey findings show that most mothers were taken to the labor room immediately after registration (48 to 69 percent). Of those who were taken to the ANC ward prior to delivery, 50 percent in Alwar DH and 89 percent in Anugul DH interacted with the Yashoda in the ward. The community survey reported that, 81 percent of the respondents in Alwar received a physical examination/ investigation/ diagnostics prior to delivery compared to 63 percent in Sawai Madhopur. On analyzing this variable specifically for the DH level a similar trend was observed. However, an opposite trend was observed in Orissa where the intervention district Anugul reported lesser proportion of respondents (46 percent) who received a physical examination prior to delivery compared to women in Bargarh, the control district (51 percent). 48