1 Materna, Newborn and Chid Heath and Nutrition Practices in Seect Districts of Uttar Pradesh Endine Brief October 2012 Introduction The Government of Uttar Pradesh aims to improve the materna, newborn chid heath and nutrition (MNCHN) status in the state through impementation of the Nationa Rura Heath Mission (NRHM) and other programmes. As per these priorities, the Government of Uttar Pradesh (GOUP) requested the USAID-funded Vistaar Project ( ) ed by IntraHeath Internationa to provide technica assistance (TA) in eight districts in the state - Azamgarh, Banda, Buandshahr, Chitrakoot, Gonda, Kaushambi, Saharanpur and Varanasi 1 districts, encompassing a tota rura popuation of 18.4 miion. The goa of the Project was taking knowedge to practice to improve materna, newborn and chid heath and nutrition status and the Project worked with the Government of India (GOI), Government of Jharkhand (GOJH) and Government of Uttar Pradesh. Starting in 2007, the Project team faciitated a series of evidence reviews and incorporated the findings into district technica assistance pans. Based on the evidence and GOUP priorities, these pans focused on improving frontine worker performance and strengthening Viage Heath and Nutrition Days (VHNDs). The Project support focused on Accredited Socia Heath Activists (ASHAs) within the Department of Heath and Famiy Wefare (DHFW) and Anganwadi Workers (AWWs) within the Department of Women and Chid Deveopment (DWCD) and on improving coaboration between the departments. This brief presents data showing improvements in most components of antenata, deivery and newborn care practices (such as weight monitoring, receipt of iron and foic acid [IFA], and improved breastfeeding practices). It aso reveas areas where there has been ess progress, such as food consumption by pregnant and actating women, as we as by infants over six months of age. The brief aso describes how key processes incuding increased interactions with frontine workers, improved counseing and service use at VHNDs contributed to these outcomes. Technica Intervention Areas The Project, DHFW and DWCD worked together in these key areas, as per agreed upon district TA pans: Improving home s and counseing skis: The Project team worked with district officias to improve ASHAs and AWWs interpersona communication (IPC) skis, through deveopment of an in-service education programme argey buit on existing government structures, such as reguar monthy meetings of frontine workers. For AWWs, this training aso consisted of a two-day standaone training conducted by Mukhya Sevikas. In addition, the Project provided technica assistance to the DHFW and DWCD to deveop and promote use of job aids incuding a fipbook, a counseing guidebook with key messages and a set of frequenty asked questions to assist ASHAs and AWWs in IPC. Strengthening monitoring and supportive supervision: The Project worked with the DHFW and DWCD to buid the capacity of supervisory cadres, incuding encouraging them to shift from a punitive supervisory approach to mentoring and providing support and probem-soving assistance to frontine workers to improve their performance. The Project heped to deveop and introduce supervisory checkists, which aso provided monitoring data. The Project aso faciitated the formation of Technica Resource Groups (TRGs) to sustain ASHA support mechanisms. Optimising monthy meetings: The Project supported DHFW and DWCD officias at district and bock eves to better use their reguar monthy meetings as opportunities for using data to assess progress and sove probems and for short capacity-buiding sessions. Strengthening Viage Heath and Nutrition Days: The Project supported DHFW and DWCD to expand the quaity and coverage of VHNDs. The Project faciitated orientation and increased awareness of the VHND guideines, improved joint panning, and introduced a VHND checkist for USAID FROM THE AMERICAN PEOPLE
2 monitoring and data coection. In addition, the Project faciitated convergence between DHFW and DWCD and promoted the use of data and joint reviews of VHND achievements during reguar meetings. Integrating a focus on equity and gender: The Project team ed gender and equity reviews to inform the intervention efforts, and ensure that information and services reached disadvantaged groups. A systems strengthening efforts incorporated a focus on addressing equity and gender issues. The scae of the technica assistance is refected in the Project outputs presented in Box 1. Box 1: Outputs from Project Management Information System (Juy 2009-March 2012) Ÿ 461 Bock Faciitators trained for faciitating ASHA monthy meetings Ÿ 196 Bock Faciitators trained for faciitating ANM monthy meetings Ÿ 8,071 ASHAs (80% coverage) trained in IPC skis to improve home s for newborn care Ÿ 1,889 ANMs and LHVs trained in supportive supervision (99% coverage) Ÿ 409 Mukhya Sevikas (92% coverage) trained in IPC skis to train and support AWWs in the fied Ÿ 15,415 AWWs (98% coverage) trained in IPC skis to improve home isits for nutrition and newborn care Ÿ 419 Mukhya Sevikas (95% coverage) trained in supportive supervision Ÿ 41 TRG members trained on design and deveopment of capacity-buiding sessions for ASHAs and on faciitation skis Endine Evauation For evauation, the Project contracted externa agencies to conduct a baseine househod survey in December February 2009 and an endine survey from January to March The seected externa agencies were: GfK MODE Private Limited for baseine and CREATE for endine. The objective of the endine survey was to assess changes in antenata, deivery, postnata, newborn and infant care knowedge and practices. The baseine and endine surveys targeted 500 currenty pregnant women, 500 recenty deivered women with 0-5 month od infants, 500 women with 6-11 month od infants and 20 househod decision-makers from rura and urban areas in every district using a muti-stage custer samping technique. Househod decision-makers incuded mothers-in-aw, fathersin-aw, parents, and husbands. The Project was designed to support government priorities and programmes, particuary NRHM, and most interventions and technica support were aimed at rura areas. Therefore, athough the sampe incuded urban areas, this brief highights the anaysis and findings from rura sampes ony. The rura sampe sizes for the eight districts for the baseine and endine surveys are given in Tabe 1. Tabe 1: Rura sampe sizes for baseine and endine surveys Survey Currenty pregnant women Key Findings Recenty deivered women With infant aged 0-5 months With infant aged 6-11 months The key findings from the endine and baseine survey are presented in sections on: characteristics of the survey respondents; improved MNCHN practices; increased interactions with frontine workers; improved counseing by frontine workers; and service use at VHNDs. Asterisks (*) in the tabes and graphs highight when there is a statisticay significant difference, at five percent eve of significance, between baseine and endine data. Characteristics of Survey Respondents Househod decisionmakers Baseine,69,790,188 6,978 2,044 Endine,072,077,077 6,154 1,920 Background characteristics among pregnant and recenty deivered women were simiar. Over 80 percent were from schedued castes/tribes (2%) or other backward castes (51%).The predominant reigion was Hindu at 85 percent, with the remainder being Musims and other househods. These characteristics did not change from baseine to endine. The proportion of women beonging to higher standard of iving househods was 26 percent at baseine and 41 percent at endine among recenty deivered women, and 0 and 42 percent at baseine and endine respectivey among women who were pregnant at the time of the survey. The proportion of women from ow standard of iving categories was ess in both types of respondents compared to the baseine. Literacy eves and participation in forma education among women were higher among endine respondents. The proportion of women who had received five or more years of schooing increased from 8 to 46 percent among recenty A 2
3 deivered women and 41 to 50 percent among currenty pregnant women. Forty-six percent of pregnant women and 49 percent of recenty deivered women were iiterate or had no forma schooing at endine. Improved MNCHN Practices The endine survey reveaed a number of improvements in MNCHN practices, incuding in antenata care (ANC), deivery care, materna nutrition and newborn care. Antenata care: Pregnant women reported receiving more antenata care services at endine than three years earier suggesting that systems for providing ANC services and ensuring women are accessing ANC have improved. Women who received three or more ANC s increased to 89 percent at endine compared to 48 percent at baseine (Tabe 2). Tabe 2. Antenata care services received by recenty deivered women ANC Services received Baseine Endine Received 1 tetanus injection * Received or more ANC s * Received 100 or more IFA tabets/ bottes of syrup * Consumed 100+IFA tabets/ bottes of syrup * Received deworming medication * (1) Received fu ANC * Tests/check-ups received Abdomina examination * Weight monitoring * Bood pressure measurement * Bood test * Urine test A five tests/check-ups * Advice received Nutrition advice * Advice for institutiona deivery * Advice on deivery date 25..4* A three advices * Number of recenty deivered women with 6,978 6,154 infants 0-11 months (1) Fu ANC: At east three s for antenata care, one TT injection received and 100 IFA tabets or adequate amount of syrup consumed (same definition 2 used in DLHS- ) The data aso indicate that pregnant women were getting more compete ANC services with significanty more women reporting receiving weight monitoring, abdomina examinations, bood pressure measurement and bood tests compared to baseine. Simiary, counseing has improved and significanty, more pregnant women are receiving nutrition advice (81% at endine compared to 49% at baseine) and advice to have an institutiona deivery (80% at endine compared to 4% at baseine). Notaby 8 percent of recenty deivered women reported that they had received 100 IFA tabets during pregnancy compared to 18 percent at baseine athough the reported increase in consumption of IFA was ess (Tabe 2). Pace of Deivery: More women were deivering at heath faciities. This is ikey a resut of the Janani Suraksha Yojana (JSY). However, the improved IPC skis of frontine workers are a contributing factor for motivation to have an institutiona deivery and awareness of the JSY scheme. Institutiona deiveries at government and private faciities increased from 49 to 7 percent overa. At government faciities, it increased from 2 to 58 percent. Institutiona births in government faciities increased across a eight Project-supported districts, but were most pronounced in Kaushambi district, which increased from 24 percent of women deivering in a government faciity at baseine to 72 percent at endine (Figure 1). Figure 1: Deiveries at government heath faciities Azamgarh Banda Buandshahr Chitrakoot Gonda Kaushambi Saharanpur Varanasi A eight districts * 55* Baseine Endine Neary 90 percent of those who deivered in a government faciity aso received JSY benefits. The argest reported increase in proportion of deiveries at government faciities was among the ow standard of iving category (100% increase). The reative proportion of Musim women going for an institutiona deivery (24% at baseine, 41% at endine) continues to be ower than their Hindu counterparts (% at baseine, 61% at endine). 4 42* 9* 59 59* 58* 75* 72* 72*
4 Materna nutrition: The endine shows that nutrition and anaemia reated knowedge among pregnant and recenty deivered women has improved. Awareness of anaemia among recenty deivered women was high at baseine (78%) and further increased at endine (91%). More women aso knew the causes of anaemia and how to prevent it (such as by increasing consumption of green eafy vegetabes) than at baseine. This suggests that nutritiona counseing is reaching beneficiaries. As noted earier, receipt and consumption eves of IFA aso increased (Tabe 2). However, consumption of foods that can prevent anaemia did not show any significant gains. GOI heath sector guideines recommend that a women eat an additiona mea during pregnancy and actation. Whie more women reported receiving nutrition advice during pregnancy (from 49% at baseine to 81% at endine), ony 16 percent of currenty pregnant women reported consuming an extra mea each day at endine, up from six percent at baseine. More modest upward trends were reported by recenty deivered women during pregnancy. On the other hand, there was a sma reduction in the proportion of women who had one extra mea during actation (Tabe ). This is a concerning trend and may revea the difficuty of changing dietary practices which have deep socia and cutura infuence and significance. Tabe : Consumption of an extra mea during pregnancy and actation period Consumption of extra mea Consumption of mea during pregnancy period by CPW Baseine Endine % CPW Less than before * Same as before * Had extra mea * Number of currenty pregnant women,69,072 Consumption of mea during pregnancy period by RDW Less than before Same as before * Had extra mea * Number of recenty deivered women with infants 0-11 months Consumption of mea during actation period by RDW 6,978 6,154 Less than before * Same as before * Had extra mea * Number of recenty deivered women with infants 0-11 months 6,978 6,154 The endine aso showed that three out of four househod decision-makers beieved that women shoud eat after men or edery members of the househod, which may mean ess food is avaiabe for women to consume. This negative trend coud aso possiby be reated to the increasing cost of food during this intervention period, or due to increasing workoad and outside work for women, resuting in time restrictions for food preparation and consumption. Newborn care: There have been improvements in severa newborn care practices. Women with infants 0 to 5 months were more ikey to initiate eary breastfeeding within one hour of birth at endine (from 14% to 28%) and coostrum feeding increased from 58 to 78 percent. Eary breastfeeding initiation rates were highest among women who deivered in a government heath faciity (7%). The practice of not giving preactea feeds improved from 1 to 48 percent. The proportion of newborns who were weighed or were not bathed for at east three days aso increased from the baseine (Tabe 4). Tabe 4: Newborn care practices reported by recenty deivered women Newborn care practices Initiated breastfeeding within one hour of birth Baseine Endine * Newborns given coostrum * No pre-actea feed given to the newborn * Newborns weighed at birth * Newborns' bathing deayed by at east three days Nothing appied after cutting the cord and before it fe off Number of recenty deivered women with infants 0-5 months * NA 5.1,790,077 4
5 The improvement in newborn care practices were generay simiar by caste and socioeconomic status indicating that messages and services are aso reaching the poor and most vunerabe. Acceptance eves of these newborn care practices tended to be higher among Hindu women compared to Musim women, but each segment showed gains. Care-seeking behaviour among recenty deivered women with newborns experiencing heath probems within the first month has improved with newborn referras higher at endine (87%) compared to baseine (77%). Infant feeding: Infant feeding guideines ca for immediate and excusive breastfeeding for the first six months, foowed by the introduction of age-appropriate compementary foods and continued breastfeeding for up to 24 months. Whie breastfeeding practices improved in the immediate period after birth, adherence to excusive breastfeeding for the first six months was ony nine percent at endine (Tabe 5). Tabe 5: Infant feeding practices reported by recenty deivered women Infant feeding practices Baseine Endine Infants aged 6-11 months excusivey breastfed for at east up to six months Infants aged 6-11 months currenty breastfed and received soid or semi-soid food in the 24 hours preceding the survey Infants aged 6-11 months currenty breastfed and received food from or more major food groups in the 24 hours preceding the survey Infants aged 6-11 months currenty breastfed and received semi-soid and/or soid foods in the 24 hours preceding the survey and had two servings per day Number of r ecenty deivered women with infants 6-11 months NA * *,188,077 Despite increased counseing on the topic, compementary feeding practices have either remained unchanged or decreased over the period (Tabe 5). Ony 25 percent of chidren who had received compementary food the previous day had two servings, we beow the 48 percent rate at baseine. Likewise ony 24 percent received food from three or more major food groups, aso a decine from 2 percent at baseine. The data suggest many infants are not getting diverse compementary foods (from three or more food groups) and are not getting at east two servings a day. As with materna food consumption, this may be due to the difficuty of changing dietary practices, the increasing cost of food during this time period or increasing workoads and time restrictions on women (since compementary feeding of an infant is very timeconsuming). Increased Interactions with Frontine Workers The improvements in materna and newborn heath practices have come about in part because of increased interactions with frontine workers who provide pregnant women and mothers with advice and counseing during home s and VHNDs. The baseine and endine surveys show that interactions with frontine workers have increased throughout the antenata, postnata and newborn care periods. Furthermore, ASHAs and AWWs have been effective in reaching women from disadvantaged groups. Antenata care s: As noted in Tabe 2, 89 percent of women received three or more ANC s ups from 48 percent at baseine. More women are now receiving ANC services through home s. At endine, 82 percent of women received ANC services through a provider at home compared to just 9 percent at baseine. The argest reative gain among women who had three or more ANC contacts was among the ow standard of iving category from 6 percent at baseine to 84 percent at endine. Eighty-four percent of recenty deivered women had met with an ASHA during their pregnancy at endine and 68 percent had met with an AWW. Whie at baseine, pregnant women had on an average two contacts with either an ASHA or AWW or both, at the endine they had on average 4.4 contacts with ASHAs and.1 contacts with AWWs. Postnata care s: As part of counseing, ASHAs and AWWs recommend postnata care (PNC) s. At endine, more women reported receiving a PNC foowing deivery (87%) and were significanty more ikey to receive second and third PNC s. At baseine, ony 16 percent of recenty deivered women had a second PNC compared to 55 percent at endine. Over 6 percent of recenty deivered women had a third PNC compared to ony six percent at baseine (Figure 2). Women who deivered at a faciity were most ikey to receive at east three PNC check-ups/s. # Figure 2: Postnata care s reported by recenty deivered women First PNC Second PNC Third PNC * 54.7* * Baseine Endine # by any provider (e.g. Medica Officer, Lady Heath Visitor, ANM, ASHA or AWW) 5
6 Newborn care s: Frontine workers aso promote newborn care s. Nine in ten newborns had at east one newborn care compared to 72 percent at baseine. Further, 61 percent received a second compared to just 19 percent at baseine. The incidence of third s aso improved, highighting that frontine workers are paying increasing attention to supporting the heath of newborns (Figure ). Women who deivered in a heath faciity were much more ikey to receive newborn care s from any provider compared to those who deivered at home. Figure : Newborn care s # reported by recenty deivered women First NBC Second NBC Third NBC * * 90.0* Baseine Endine # by any provider (e.g. Medica Officer, Lady Heath Visitor,ANM, ASHA or AWW) Improved Counseing by Frontine Workers Improved counseing: Increased interactions with ASHAs and AWWs appear to be increasing women s knowedge about recommended pregnancy and newborn care practices as evidenced by their reca of counseing messages. During endine, recenty deivered women recaed receiving mutipe messages reated to ANC and birth preparedness. Reca rates were high for most core messages, especiay around taking two doses of tetanus toxoid (TT) (74%) and consumption of nutritious foods during pregnancy (58%), the importance of identifying a pace of deivery (64%), and information on JSY (68%) as part of birth panning. The reca of newborn care messages from ASHAs about initiating breastfeeding rose to 1 percent from 8 percent at baseine. Neary 0 percent of women recaed receiving counseing from ASHAs about excusive breastfeeding and 10 percent received this advice from AWWs (Tabe 6). Tabe 6. Reca of counseing messages on newborn care received during pregnancy Newborn care messages counseed by ASHA counseed by AWW Baseine Endine Baseine Endine Initiation of breastfeeding within one hour of birth * * Benefits of coostrum feeding NA 27.0 NA 9.6 Excusive breastfeeding up to 6 months Drying and wrapping of newborn immediatey after birth * * * * Getting the newborn weighed * * Getting newborn immunised (OPV-0 dose and BCG) * * Cord care * * Not bathing newborn for 7 days Number of recenty deivered women with infants 0-11 months NA 1.2 NA 4.0 6,978 6,154 6,978 6,154 In interactions with any frontine worker in the one month period after giving birth, haf or more of mothers remembered messages on the importance of immunisations, excusive breastfeeding, keeping the newborn warm and materna nutrition, much higher than at baseine. Over one-third were 6
7 counseed about referra faciities in the event of compications compared to just six percent at baseine. Twenty-eight percent were counseed about the proper timing for initiating compementary feeding (Tabe 7). Tabe 7: Reca of counseing messages on newborn care after deivery Newborn care messages Baseine Endine Immunisation * Excusive breastfeeding * Keeping the baby warm * Materna nutrition * Weighing newborn * Referra faciity (mother/newborn) * Initiating compementary feeding around seven months NA 27.6 Cord care * High risk symptoms/danger signs in newborn * Number of recenty deivered women with infants 0-11 months 6,978 6,154 The impact of counseing by ASHAs is noteworthy as further anaysis of data shows that women who received an ASHA during pregnancy and/or postnata period were more ikey to adopt recommended newborn care practices compared to those who did not receive home s. Service Use at Viage Heath and Nutrition Days The improvements in ANC and newborn care may aso be due, at east in part, to increased use and quaity of VHND services. NRHM promotes VHNDs as an essentia patform for primary heath care intervention and issued guideines for VHNDs in At baseine, VHNDs were not happening reguary, as evidenced by very ow eves of awareness and participation in VHNDs among providers. At baseine, the number of AWWs reporting that three or more VHNDs had occurred in their viage in the previous three months was 46 percent, which increased to 89 percent at endine. Sixty-four percent of ASHAs were unaware of any VHND in their viage happening in the previous three months at baseine. The endine survey reveaed high eves of participation in VHNDs by recenty deivered women, with an average of over 75 percent of women attending a VHND during pregnancy. In addition, women from a socio-economic segments were equay ikey to attend VHNDs. Musim women were somewhat ess ikey to attend VHNDs than Hindu women (64% Musim compared to 77% recenty deivered Hindu women). In Gonda and Azamgarh, participation eves were somewhat ess (Figure 4). Figure 4: VHND participation among recenty deivered women at endine Azamgarh Banda Buandshahr Chitrakoot Gonda Kaushambi Saharanpur Varanasi A eight districts The endine data showed that recenty deivered women reported receiving many services from VHNDs incuding TT immunisation (98%), IFA tabets (79%) and weight monitoring (51%). As VHNDs are aso an outet for providing heath information and counseing, it is encouraging to note that neary 47 percent of recenty deivered women participated in group discussions on heath care issues (Tabe 8). Tabe 8: Utiisation of VHND services during pregnancy by recenty deivered women Services avaied Endine Received TT injections 98.2 Received IFA tabets 78.7 Weighed 51.2 Bood pressure measured 20.5 Abdomina check-up done 26. Participated in group meetings/discussion on heath issues Number of recenty deivered women with infants 0-11 months who participated in VHNDs during pregnancy ,717 7
8 Together, buiding heathier communities Vision IntraHeath Internationa beieves in a word where a peope have the best possibe opportunity for heath and we-being. We aspire to achieve this vision by being a goba champion for heath workers. Mission IntraHeath empowers heath workers to better serve communities in need around the word. We foster oca soutions to heath care chaenges by improving heath worker performance, strengthening heath systems, harnessing technoogy, and everaging partnerships. One of the key services provided during Strengthening supervision and monitoring VHNDs is the provision of suppementary systems nutrition. Neary 5 percent of currenty Strengthening VHNDs, especiay through pregnant women received take-home ration improved panning, monitoring and compared to just 18 percent at baseine. supportive supervision Among recenty deivered women, 42 percent reported receiving suppementary nutrition at Optimising monthy meetings for inter- endine in the two months preceding the departmenta convergence, frontine survey. A districts have improved access to worker support and use of data for suppementary nutrition over the evauation period. Concusions The Project coaborated cosey with the DHFW and DWCD in Uttar Pradesh to improve access to MNCHN services and knowedge and practices among the community, buiding on GOUP priorities and existing programmes. The endine survey shows increases in many areas, incuding ANC services, receipt and reca of counseing messages, increases in institutiona deivery, and improvements in newborn care practices, incuding eary breastfeeding. The interventions of the GOUP and the Project have ikey contributed to these improvements. These interventions incuded: Buiding counseing and communication skis for frontine workers (ASHAs and AWWs), incuding introducing and increasing use of job aids improved programming It is notabe that the improvements occurred at scae (the Project worked in eight districts with a tota popuation of 18.4 miion) and the resuts were consistent across socioeconomic eves, indicating success in reaching disadvantaged groups. The resuts of this coaborative effort show the importance of working cosey with government officias, supporting government priorities, and buiding on existing patforms and systems to achieve improvements at the popuation eve. The data show that there are sti significant chaenges, such as improving food consumption for mothers and infants. However, the findings aso show that there are a number of simpe systems-eve changes and capacity-buiding efforts which can improve materna and newborn services and practices, which shoud be scaed up in more districts of Uttar Pradesh and beyond. For more information, The Purpose of the Vistaar Project To assist the Government of India and the State Governments of Uttar Pradesh and Jharkhand in taking knowedge to practice for improved materna, newborn, and chid heath and nutritiona status IntraHeath Internationa, Inc. is the ead agency for the Vistaar Project. For more information on the Vistaar Project, see: Technica assistance partners: A S S O C I AT E S ge gsa vkids kfk kfk MAMTA 1 Provisiona Popuation Tabes, Census of India Internationa Institute for Popuation Sciences (IIPS), District Leve Househod and Faciity Survey (DLHS-), : India This data was not coected during baseine. Discaimer: This brief is made possibe by the generous support of the American peope through the United States Agency for Internationa Deveopment (USAID). The contents are the responsibiity of IntraHeath Internationa and do not necessariy refect the views of USAID or the United States Government.