Available online at CASRP Publisher HSE 1(1) (2015) 3-12

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1 Available online at CASRP Publisher HSE 1(1) (2015) 3-12 Original Article Open Access Public-private partnership in perinatal care- an experience with Unicef in Aligarh, India Athar Ansari a, *, Saira Mehnaz a, Ali Jafar Abedi a, Zulfia Khan a, Nasreen Noor b a Professors, Assistant Professors, Department of Community Medicine b Assistant Professor, Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India Abstract Making perinatal care accessible to women in marginalized periurban areas poses a public health problem. Many women do not utilize institutional care in spite of physical accessibility. Home based care by traditional dais is hazardous. Most barriers to perinatal care can be overcome by social mobilization and capacity building at community level. Social Mobilization Network (SM Net) for Polio Eradication (UNICEF) is able to reach every newborn within one month of birth for OPV coverage. 1.To determine the existing perinatal practices and attitudes. 2. To identify areas of social mobilization by NGO networks needing no added costs. Cross sectional descriptive study. Setting and Participants, The high risk periurban areas of Nabi Nagar, Aligarh has a population of 40,000 living in 5480 households. Mothers having newborn babies in a month, were identified from CMC (Community Mobilization Coordinators) records. 92 mothers were interviewed by home visit. Group discussions were carried out with SM Net workers in the field. Data was tabulated and analyzed using SPSS 17. Analysis revealed that 80.4% mothers had received antenatal care. However, this did not translate into safe delivery practices, as more that 67% women had home deliveries conducted by traditional untrained or trained dai. 56.5% of these deliveries were conducted in squatting position and in 45.% cord was cut by edge of broken cup Prelacteal feeds were given to 45.7% babies and feeding was delayed beyond 24 hours in 8% cases. Although breast feeding was universal, several mothers had breastfeeding problems. Reasons for preferring home deliveries were mostly *Corresponding author: Professors, Assistant Professors, Department of Community Medicine, India. Received 11 April 2015 Accepted 15 May 2015 Available online 20 May 2015

2 4 Athar Ansari et al. / HSE 1(1) (2015) 3-12 tradition (42%) or economic (30%). CMC and BMC felt that social mobilization for safe delivery and appropriate feeding would enhance their own respect by families, leading to better conversion rate of resistant families to OPV drops. Mutually beneficial Public-private partnership is possible Published by CASRP Ltd. Selection and/or peer-review under responsibility of Center of Advanced Scientific Research and Publications Ltd Keywords : Hazardous perinatal practices, social mobilization, NGO network; 1. Introduction Perinatal care has tremendous impact on health of mother and child (Aggarwal et al., 2007; Karkee et al., 2013; Misra et al., 2010; Sinha et al., 2006; Carroli et al., 2007; McDonough et al., 1996). However, good quality of perinatal care is not uniformly distributed in society. Advancements in technology have made sophisticated tertiary care available to those who can pay. At the same time the gap between the rich communities and poor, marginalized, and underserved communities is increasing even within the same country (Islam, 2007; Say and Raine, 2007). Even after RCH-2, it has not been possible to reach a large segment of this marginalized population through the organized health sector. Rapid urban development is outstripping the meager resources at local municipality level. Even where facilities exist, socio economic and cultural barriers prevent their optimum utilization by the women who need them most, consequently resulting in hazardous health practices (Khandekar et al., 1993). The need to restore the community base for health system has long been recommended. For the community to play an active role in its own health, it needs to be provided with information on health risks and guided towards healthy lifestyle (Fikree et al., 2005; Bloom et al., 1990; Baqui et al., 2007). Simple and targeted Information, Education and Communication (IEC) campaigns and Social Mobilization by NGOs in partnership with State Health Services has been able to reach every household having newborn child and has had a significant impact on attitude and practices of underserved, marginalized communities (Ansari et al., 2007). Objectives, In areas where NGO networks for social mobilization exist, partnerships for perinatal care are possible with little added costs. The present cross sectional study was undertaken with following objectives, 1) To determine the existing perinatal practices and attitudes in an under-served urban locality and 2) To identify areas of social mobilization for perinatal care by existing NGO network, needing little additional costs. 2. Methodology Study area, The present cross sectional study was undertaken in the periurban area of Nabi Nagar having a total population of 40,000 living in 5480 households. This highly congested area is situated on the outskirts of Aligarh, having unplanned houses, few roads, open drains and no piped water. Nearly one third of the families have moved in within the last ten years. Most earning members are laborers and small vendors or shopkeepers. Few houses belong to retired government employees. One Urban Health Post is situated within 1 km and the Medical College Hospital within 2 Km of the area. There is one Private Maternity Home and 4 Private Clinics in the area.

3 5 Athar Ansari et al. / HSE 1(1) (2015) 3-12 The Social Mobilization Network (SM Net) of the under served Strategy for Polio Eradication (UNICEF) has a network of community based social coordinators (CMC) working in the area. Department of Community Medicine at J.N. Medical Collage, AMU, as a part of polio partnership with UNICEF in Aligarh, is running a health clinic providing pediatric services, and routine immunization services in the area. Before starting the study, approval from institutional ethical committee was obtained. All live births are being routinely recorded by CMC of the area. A list of 98 families having live births was obtained from the CMC of the area (giving a birthrate of 30 per 1000 population). Of these, one mother refused to participate and was excluded from the study. 5 mothers were not available at home on two visits. In all, 92 mothers were included in the study. They were visited by female researcher and interviewed in a non-formal and non-judgmental manner, after obtaining informed consent. Appropriate counseling, treatment and referral were given wherever needed to all mothers. Informal discussions were also held with groups of Community Mobilization Coordinators (CMC) of UNICEF, working in the area. The data was recorded on a preformed proforma and coded and analyzed using SPSS 17. Chi square test was used to test the difference between home and institutional deliveries. A value of < 0.05 was considered as significant. 3. Results Socio-cultural profile of study population, All mothers belonged to the poor socio economic status and lived in a congested, unsanitary environment. As can be seen, from Table I, the joint family system was breaking up in this urban area and majority of the women were living in unitary families (60.9%). Most mothers were young, 84% being less than 30 years of age. Only 2.2% were more than 35 years of age. A majority of 56.5% mothers were illiterate but 20.7% were educated up to high school or more. Table I. socio-economic variables of the study population S. No. Education of the Mother No. % 1. Illiterate Literate Middle High School Graduate Age of the Mother(Yrs) Type of Family 1. Unitary Joint

4 6 Athar Ansari et al. / HSE 1(1) (2015) 3-12 Total Home Delivery, In spite of having a government hospital and a private nursing home within easy reach, a majority of women (67%) preferred to have the delivery at home. Fifty percent of these deliveries were attended by Trained Dais and 40% by untrained Dais. 10% were attended by a private nurse. (Fig.1) Fig. 1. Place of delivery was significantly associated with education of mother ( = 15.8, p <0.003) The decision for place of delivery was significantly influenced by the educational status of women. (Chi=15.8,p=<0.003). Decision was taken mostly by husband (29%), mother in law (27.4%) or jointly by the family (32.3%). (Table II) The most common reason for home delivery was stated as being family tradition (42%) or economic (30%) (Fig. 2). Institutional Delivery, 33%women delivered in an institution, either a Government Hospital or a Private Nursing Home. The main reasons stated for choosing Government Hospital were its proximity to home, and having history of complications in earlier pregnancies. The main reasons for choosing Private Nursing Home were proximity to home, and the perception that proper attention will be given to the patient. Antenatal Care, There were significant differences in health practices among women who delivered at home and those who delivered in institution. While overall a majority of women (80.4%) did have at least one Antenatal Check up in Government hospital or Private Clinic/Nursing home, the number was significantly higher in institutional deliveries. (χ² =4.70, p<0.05) (Table III). Hazardous Practices, Natal care was significantly poor in case of home delivery (N=62), Women had delivery conducted by untrained dais (40.3%) in squatting position (56.5%) and cord was cut by traditional objects such as edge of broken cup (40.3%) (Table IV). Feeding practices, All newborns were breast-fed and colostrum was given to 73.9% babies. However the time of giving first feed was delayed beyond 6 hours of birth in 24.9% and prelacteal feed was given in 45.7% babies.11.9% mothers were having some breast feeding problems at the time of survey (Table V). The rate of OPV coverage during Sub National Immunization Programme (SNID) was very high (98%). Indicators of maternal care, Comparison between home delivery and institutional delivery showed that indicators of maternal care such as receiving of antenatal visits, and Tetvac injection, and giving of colostrum to baby, were significantly better in institutional delivery compared to home delivery (Fig. 3).

5 7 Athar Ansari et al. / HSE 1(1) (2015) % % % 8 13 % 5 8% 0 Tradition Economic Reason Behaviour of HP at Govt. Facility No body to take care at home Any other Fig. 2. Reasons for home delivery Table II. Decision for home delivery Home Delivery (N=62) No. % Who Decides the Place of Delivery Husband Mother-in-Law Self More than One Person Total

6 8 Athar Ansari et al. / HSE 1(1) (2015) 3-12 Table III. practices in home and institutional deliveries S. No. Delivery Conducted by No. % 1. Trained Dai Untrained Dai Nurse Position of Conducting Delivery 1. Squatting Lying Position Cord Cut by Broken Cup 1. No Yes Complications of Delivery 1. No Yes Total Table IV. Hazardous practices in home delivery Description Home delivery Institutional delivery Total S. No. Any Antenatal Care Received NO. % NO. % NO. % No Yes = 4.70, P<0.05, Significant No. of Tetvac Received Nil One Two = 4.70, P<0.05, Significant Who Decides the Place of Delivery Husband Mother-in-Law Self More than one person TOTAL = 7.48, P>0.05, Insignificant

7 9 Athar Ansari et al. / HSE 1(1) (2015) 3-12 Table V. feeding practices S. No. Colostrum Given To Baby Home Delivery Institutional Delivery Total No. % No. % No. % 1. No Yes Total = 5.97, P <0.015, Significant Time Of Giving Of First Feed To The Baby = 3.9, P>0.05 Insignificant Within 6 Hrs of Birth Within 6-12 Hrs of Birth Within Hrs of Birth More Than 24 Hrs Total Prelacteal Feeds Given = 1.4, P>0.05 Insignificant Not Given Total Feeding Problems No = 2.7, P>0.05 Insignificant Yes Total Vaccination Status Nil = 15.15, P<0.05, Significant OPV OPV & BCG Total Areas identified for social mobilization, Group discussions with CMCs identified the areas felt to be useful and practical and easy for social mobilization. Majority of CMCs felt that including these areas in their routine work would enhance their prestige in the families and also improve OPV coverage. Areas for social mobilization and counseling are antenatal care, institutional deliveries, safe home deliveries and appropriate feeding practices. 4. Discussion The present study highlights that in spite of health services being within reach, a majority of women choose to deliver at home, often by untrained Dai. The major limiting factors for institutional delivery were family tradition and economic constrains. Hazardous delivery practices and undesirable feeding practices were common.

8 Percent 10 Athar Ansari et al. / HSE 1(1) (2015) 3-12 At the same time, a positive change in attitude and practice related to OPV drops was achieved by Social Mobilization Network, giving a coverage rate of almost 100%. The present study shows that good quality Maternal and Child Health services are not reaching those who need them most. Although Antenatal Care (ANC) utilization was good, (80 %,) but this did not translate into good delivery practices for many. An earlier study in peri-urban area of east Delhi 14 has also reported ANC utilization rate of 74.3%. This is more than the overall ANC coverage rate in UP which is 25 % (Basic Facts- Uttar Pradesh, ). The rate of delivery at home was 67% in the present study, which is similar to a study conducted in urban slums and periurban area in Delhi where 70% home deliveries reported, of which 81.9% were attended by untrained dais (Aggarwal et al., 1997). The rate of births attended by untrained Dais was comparatively lower in the present study, being 40.3%. For many of these urban families, pregnancy and childbirth is not a priority area of concern. It takes huge efforts to change the tradition of home deliveries. There is an ongoing debate about reinforcing home based birthing strategies with skilled birth attendants in developing countries (Chowdhury et al., 2006). A study from Uttar Pradesh also concludes that among aspects ignored during Antenatal period, patient education is of vast importance (Bloom et al., 1990) ANC Care Inj. Tet Vac Colostrum given Home Institution Fig. 3. Comparing home and institutional deliveries Institutional delivery In the present study the only traditional newborn care practice, which is healthy and encouraging, is breastfeeding. Giving of prelacteal feeds is a deep-rooted custom in India and many studies have reported even up to 100% mothers giving prelacteal feeds (Banapurmath and Selvamuthu, 1995). However in the present study, 45.7% mothers gave prelacteal feeds and the rate was not significantly different in home deliveries compared to institutional deliveries. Delaying of the first feed (22.6%) and discarding of colostrums (26.1%) were other

9 11 Athar Ansari et al. / HSE 1(1) (2015) 3-12 customs, which have been reported, in similar earlier studies (Sethi et al., 2003; Gupta and Gupta, 2015; Srivastava, 1994). Areas identified for social mobilization which can be taken up by CMC during their routine visits to families include, counseling for Antenatal care, aseptic delivery practices by trained dais or at institutions and optimal feeding practices for newborns. During informal discussions, the CMCs agreed that spending time with families and solving these problems for them would enhance their prestige and acceptance by the community and also make it easier to motivate for immunization. Limitations of study, Being a pilot study, the area covered is relatively small but typical of most periurban slum areas. Utilization of government services (at the medical college hospital) may be more than usual for such underserved areas because of its proximity and because of the referrals from the Health Clinic. 5. Conclusion Social and cultural accessibility is as important as, physical accessibility to services. Any upgradation of services must go hand in hand with community based research at local level, and address the barriers to community acceptability. At the same time care must be taken to meet the demand generated by social mobilization. It is practical and feasible to work out a partnership of NGO with Government Health Services. References Aggarwal, O.P., Kumar, R., gupta, A., Utilization of antenatal care services in peri-urban areas of East Delhi. Indian Journal of Community Medicine 22(1), Aggarwal, A., Pandey, A., Bhattacharya, B.N., Risk factors of maternal mortality in Delhi slums, a community based case control study. Indian Journal of Medical Sciences 61(9), Ansari, M.A., Khan, Z., Khan, I.M., Reducing resistance against polio drops. Journal of Royal Society for Promotion of Health 127(6), Banapurmath, C.R., Selvamuthukumarasamy. Breast feeding and the first breastfeeds, correlation of initiation pattern to mode of delivery in 1279 hospital delivered babies. Indian Paediatrics 32, Baqui, A.H., Williams, E.K., Darmstadt, G.L., Kumar, V., Kiran, T.U., Panwar, D., Sharma, R.K., Ahmed, S., Sreevasta, V., Ahuja, R., Santosham, M., Black, R.E., Newborn care in rural Uttar Pradesh. Indian Journal of Paediatrics 74, Basic Facts-Uttar Pradesh., Concurrent assment of Healthand Family Welfare Programme and Technical Assistance to Districts of Uttar Pradesh. Editor, J V Singh, Department of Community Medicine, K G Medical University, Lucknow, India. Bloom, S.S., Lippeveld, T., Wypij, D., 199. Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning 14(1), Carroli, G., Rooney, C., Vilar, J., How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of evidence; Special Programme of Research and Development Training in Human Reproduction, WHO 2007, Paediatric Perinatal Epidemiology 15(1),1-42. Chowdhury, M.E., Ronsmans, C., Killewo, J., Anwar, I., Gausia, K., Das-Gupta, S., Blum, L.S., Dieltiens, G., Marshall, T., Saha, S., Borghi, J., Equity in use of home-based or facility-based skilled obstetric care in rural Bangladesh, an observational study. Lancet 367 (9507), Fikree, F.F., Ali, T.S., Durocher, J.M., Rahbar, M.H., Newborn care practices in low socio-economic settlements of Karachi, Pakistan. Social Science Medicine 60(5), Gupta, A., Gupta, Y.P., Status of infant and young child feeding in 49 districts of India- A National Report of the Quantitative study. BPNI (Available at of iycf.pdf accessed on ). Islam, M., The safe motherhood initiative and beyond. Bulletin of World Health Organization 85(10), Karkee, R., Binns, C.W., Lee, A.H., Determinants of facility delivery after implementation of safer mother programme in Nepal, a prospective cohort study. BMC Pregnancy and Childbirth 13, 193. Khandekar, J., Dwivedi, S., Bhattacharya, M., Singh, G., Joshi, P.L., Raj, B., Childbirth practices among women in slum area. The Journal of Family Welfare 39(3),13-7. McDonough, M., Is antenatal care effective in reducing maternal morbidity and Mortality. Health Policy and Planning 11,1-15. Misra, P.K., Thakur, S., Kumar, A., Tandon, S., Perinatal mortality in rural area with special reference to high risk pregnancies. Journal of Tropical Paediatric 39(1), Say, L., Raine, R., A systematic review of inequalities in the use of maternal health care in developing countries, examining the scale of the problem and the importance of context. Bull World Health Organization 85(10),

10 12 Athar Ansari et al. / HSE 1(1) (2015) 3-12 Sethi, V., Kashyap, S., Seth, V., Infant feeding practices in a relocation slum- A pilot study. Indian Paediatrics 40, Sinha, S., Outcome of antenatal care in an urban slum of Delhi. Indian Journal of Community Medicine 31(3), Srivastava, S.P., Breastfeeding Pattern in neonates. Indian Paediatrics 31, How to cite this article: Ansari, M.A., Mehnaz, S., Abedi, A.J., Khan, Z., Noor, N., Public-private partnership in perinatal care- an experience with Unicef in Aligarh, India, HSE 1(1), p