Introduction
Department of Public Health and Family Welfare, Govt. of M.P. is implementing Integrated Population and Development (IPD) Project sponsored by UNFPA in five districts of M.P. These districts are Chhatarpur, Panna, Satna, Rewa, and Sidhi. They were selected based on the criteria on Crude Birth Rate, Female literacy, hospital based deliveries, antenatal registration and deliveries by untrained hands.
The objectives of IPD project are:
¨ To enable individuals and couples to achieve their personal reproductive intentions and to ensure the survival and development of their infants and children’s.
¨ To eliminate discrimination against girls and to improve their health, nutrition and educational status.
¨ To achieve gender equity and equality between men and women and to enable women to achieve their full potential.
IPD Project is headed by Director, Public Health and Family Welfare. In state IPD has one State Project Officer and at each district it has one District Project Officer.
Research methodology and sampling criteria:
The study focused on Sub Health Centers, sector PHCs & CHCs. It has been limited to the equipments & infrastructure required for NSV, Laproscopy, RTI, STI & conducting delivery. It studied the issues whether the equipments & infrastructure were in working conditions or were requiring repair & maintenance. It also obtained data on caseload & placement of adequately trained manpower for the job.
This study aimed at:
§ Assess the community need for health interventions. (limited to IPD project goals)
§ Assess the status of health infrastructure & health facilities at health institutions in the project districts at Sub Heath Center. Sector Primary Health Center, Community Health Center / Block Primary Health Center level.
The designed instruments had been sent to all project districts and were distributed to all CHC/BPHC, sector PHC and SHC. The filled instrument would constitute as secondary data. Institute's research team collected the primary data at the sampled institutions.
In each IPD districts 2 CHC/BPHC were selected randomly. In each selected CHC/BPHC 3 sector PHCs were selected. In each selected sector PHC 3 SHCs were selected on random basis. In PHC's having only three or less than three SHCs, all were covered.
Focus group discussions (FGD) were organized in all selected Sub Health Center villages by research team. These focus group discussions were focussed on community need regarding reproductive health and to get the opinion from the community in the village about the functioning of ANM and SHC.
Salient features:
The primary data were collected from 9 CHC/ BPHC, 24 sector PHCs and 80 SHCs. The details regarding need of repair and renovation were collected from 23 SHCs, 8 PHCs and 9 CHCs/ BPHCs as these data were collected from only those institutions which have Govt. owned buildings.
A. Infrastructure available to health centers:
1. Multipurpose worker male and female each must be posted in a SHC but only SHCs of Chhatarpur dist. has all post of multipurpose worker females and Rewa has all post of multipurpose worker males occupied.
2. In Satna district 100 percent SHCs were situated within village locality where as 50 percent of SHCs buildings were outside the village locality in Chhatarpur. 100 percent PHC buildings in Satna and Sidhi district were located at centre of the village. In total 25.00 percent PHCs were located at one end of village and 25.0 percent were located out of the village. Only one of the sampled CHC building in Sidhi district was located at one end of the locality whereas in rest of all CHC buildings were located at centre of the village.
3. Distance of ILR from SHC plays an important role in maintenance of cold chain for effective immunisation. For 17.4 percent SHCs the ILRs were situated more than 50 Km away. and also for 17.4 percent SHCs the ILRs were situated within 5 Km. Whereas for 26.1 percent cases the ILRs were situated between 30 – 50 Km. away from SHCs villages.
4. Although 5 PHCs and 6 CHCs have operation theatre but none of them were performing caesarian deliveries. Only in Sidhi district the sampled CHCs did not have operation theatre.
5. 47.8 percent SHCs had separate labour room but in Satna no SHC had separate labour room. 4 PHCs also had separate labour rooms, but in Sidhi district no PHC had separate labour room. At 4 CHCs separate labour rooms were found available.
6. 41.7 percent PHCs had no facility for admitting patients. Whereas 45.8 percent PHCs had six to ten bed facility, 25.0 percent PHCs at Rewa district had bed capacity more than 15 beds. 6 CHCs had bed capacity less than 30 whereas 3 CHCs had bed capacity between thirty to fifty beds.
7. 91.3 percent SHCs had pucca building, 33.3 percent SHC in Panna and 20.0 percent SHCs in Rewa had katchcha buildings. None of the PHCs had katchcha building. Only one PHC in Rewa district had semi pucca building. In all 7 PHCs had pucca building whereas all sampled CHCs had pucca buildings.
8. 34.8 percent SHCs building had no cracks. 39.1 percent buildings had cracks in inside walls. Only SHCs at Chhatarpur district did not have any cracks in their walls. 5 sampled PHCs buildings had cracks in walls. Sampled CHC buildings at Chhatarpur, Panna and Rewa district had cracks in the walls, but in Satna and Sidhi district only one CHC building in each districts have cracks.
9. Floor of all SHCs building in Panna, Rewa and Satna district were broken and having pits whereas in total 52.1 percent SHC building floors were properly tiled or plastered suitably. Three PHC building floors were found broken whereas in 6 PHC buildings floors were found plastered suitably. At all sampled CHCs at Chhatarpur, Panna and Satna districts and one at Rewa district the floor was found either properly tiled or plastered suitably.
10. 91.3 percent SHC had no proper wastewater disposal facility whereas only half of the sampled PHC in Sidhi district had open pit. One CHC each at Panna and Sidhi district had open pit available for waste disposal, rest of them had no facility for safe disposal of hospital waste.
11. In 56.5 percent SHCs building inside walls and door & windows were found properly painted/ white washed. Outside walls of 60.9 percent SHC buildings were found properly whitewashed whereas only 40 percent of the existing boundary walls were found properly painted / whitewashed. In 5 PHC buildings inside walls were found properly / white washed. In 4 PHC buildings outside walls, doors and windows found properly painted/ white washed. Four CHC buildings were found properly painted / white washed.
12. 69.5 percent of SHCs were using hand pump water as a main drinking water source. In PHCs also the major source of drinking water was hand pump only (5 PHCs). In CHCs as well the major source of drinking water was hand pump. 5 CHCs were using hand pump water, 3 CHCs were using tap water and 1 CHC was using tube well water as drinking water.
13. 65.2 percent SHCs had flush laterines, 13.0 percent had pit laterines where as 21.8 percent SHCs did not have any type of toilet. 5 PHCs had toilet either type flush or pit. All sampled CHCs at Chhatarpur, Rewa, Panna and Satna and one CHC at Sidhi districts had toilet facility.
14. Only 30.4 percent SHC have electric connection but 47.8 percent SHC have proper electric wiring done. Only 4 PHCs have electric connection whereas all sampled CHCs had electric connection but in 3 CHCs proper electric wiring was not done.
15. For ANC check-ups 65.2 percent SHCs were assuring privacy, 30.4 percent SHCs were assuring privacy for RTI / STD diagnosis, 47.8 percent SHCs were ensuring at the time of delivery and 60.9 percent SHCs were ensuring privacy to female patients for IUD services.
16. All sampled PHC did not have any type of vehicle whereas 8 sampled CHCs had Jeeps out of which 7 were in working order, one CHC at Rewa district and both sampled CHCs at Satna district had ambulance facility available in working order.
17. 91.3 percent SHCs needed finance for repair / renovation. 2 PHCs needed financial assistance of less than Rs. 5,000/-, 3 PHCs needed assistance of Rs. 50,000/- to Rs. 1,00,000/- and 2 PHCs needed more than Rs. 1,00,000/-. 4 sampled CHCs needed financial assistance of Rs. 50,000/- to 1,00,000/-, 2 CHCs needed amount more than Rs. 2,00,000/- in same number CHCs needed amount less than Rs. 50,000/-. Whereas one CHC needed amount between Rs. 1,00,000/- to Rs. 2,00,000/-.
B. Workload, stock position and training status:
1. 67 MPW (F) were trained in conducting deliveries and 65 in IUD insertion. 38 MPW (F) were also trained in child survival and safe motherhood. But only 54 MPW (F) were using the skills in conducting deliveries and 51 in IUD insertion at SHCs. At PHCs 10 M.Os were trained in conducting delivery cases while only 5 were found using the skill. In 9 CHCs sampled only 5 M.O.s were found trained in conducting deliveries and all of them were applying these skills also.
2. Availability of trained dai’s in sub health center areas were less than 5 in 46.2 percent of the SHCs, whereas more than 10 trained dai’s were found in only 7.5 percent of SHCs. Availability of 25-50 trained dai’s in the PHCs were in 45.8 percent whereas 4.2 percent PHCs had trained dais in between 50-75 persons. 16.7 percent PHCs had more than 75 trained dais. In CHC areas less than 100 trained dai’s were found in 2 CHCs whereas 4 CHCs had trained dais in between 100-200 and 3 CHCs had more than 200 trained dais.
3. 30 percent SHCs had less than 5 AWCs, whereas 68.8 percent SHCs had 5-10 AWCs and 1.2 percent SHCs did not have AWC in their field. 61.2 percent SHCs had less than 5 Jan Swasthya Rakshaks in the area and 8.8 SHCs had more than 20 JSRs in area.
4. In 15.0 percent SHCs oral pills were not distributed during October 2002. Whereas 100 packets of pills were distributed in 65.0 percent SHCs. In 7.5 percent SHCs distribution of oral pills were made to more than one thousand eligible women. 45.8 percent PHCs did not distribute oral pills, whereas at 20.8 percent PHCs the distribution made was between 1-250, in 16.7 percent PHCs distribution of oral pills was made between 250-500 and in 4.2 percent PHCs distribution made was more than 1,000. Less than 500 oral pills were distributed in 2 CHC/BPHCs area. Between 500-1,000 pills were distributed in 4 CHCs and more than 1,000 pills were distributed by 3 CHCs.
5. 17.5 percent SHCs did not distribute condoms during the month of October 2002. 38.8 percent of SHCs distributed condoms in between one hundred to five hundred and 5.0 percent SHCs distributed more than one thousand condoms. In 45.8 percent PHCs condoms were not distributed during the month of October 2002 whereas above one thousand condoms distribution were made by 20.8 percent PHCs. 5 CHCs distributed condoms less than 5,000 during the month of October 2002. One CHC each at Rewa and Satna districts were distributed more than 10,000 condoms.
6. 46.3 percent SHCs distributed IFA tablets to one to twenty five pregnant women, 5.6 percent SHCs at Chhatarpur and 6.7 percent SHCs at Sidhi district did not distribute IFA tablets to any pregnant women. 20.0 percent SHCs distributed more than hundred tablets also to pregnant women. In 50.0 percent PHCs no distribution of IFA tablets was made, where as 8.3 percent PHCs distributed IFA tablets to 250-500 pregnant women. 5 CHCs distributed IFA tablets to less than one thousand pregnant women, whereas 1 CHC distributed IFA tablets more than 5,000 pregnant women. 3 CHCs distributed IFA tablets to one thousand to five thousand pregnant women.
7. Total deliveries conducted in all the SHC areas were 1694 and 4 cases were referred to PHC/ CHC. Total deliveries conducted in the PHC areas were 1759 out of which 28 were admitted and 19 were referred to BPHC/ CHC. No. of institutional deliveries were 194 out of which only 2 deliveries were conducted in Satna district. 2 caesarian deliveries were also conducted at Sidhi district. Total deliveries conducted in the area were 6023 out of them 1981 were home deliveries that were attended by ANMs. 635 home deliveries were attended by untrained dais also. Number of institutional deliveries were 227. Highest number of institutional deliveries were 98 conducted at CHCs of Satna district whereas lowest number of Institutional deliveries were 12 which were conducted at Sidhi district. No caesarian delivery was conducted at any CHC/ BPHC.
8. 61.3 percent SHCs had adequate stock of IFA tablets. Disposable delivery kits were found adequate in 61.5 percent SHCs at Panna district. Medicines for RTI/ STD were found adequate in only 23.1 percent SHCs at Panna district. At Satna district PHCs did not have adequate stock of all the essential medicines, vaccines, contraceptives etc. In all districts medicines for RTI/ STD were not available in adequate quantity. The stock of T.T. doses were not kept at PHCs because of unavailability of deep freezer/ ILR. The vaccines were taken from CHC/ BPHC on daily requirement basis. Out of 9 sampled CHC/ BPHCs 7 had adequate stock of disposable delivery kits. Only 2 CHCs had adequate stock of copper T, disposable needles, reusable needles and medicines for RTI/ STD. One sampled CHC at Chhatarpur district did not have adequate quantity of reuasble syringes, needles and medicines for RTI/ STD.
C. Equipment status in health institutions:
a. At SHC:
Only 27 haemoglobinometer were found available at 26 SHCs. Out of them 16 were found in working condition. Only 49 infant weighing scales were found available in 34 SHCs. Out of them only 25 were reported in working condition. 83 adult weighing scales were found available at 54 SHCs. 68 were in working conditions, 5 needed repairing. At 20 SHCs adult weighing scales were needed. Only 8 examination tables and footsteps were found in 7 and 4 SHCs respectively. 1 of them was unserviceable. 26 SHCs had reported about inadequacy of examination tables whereas 21 reported inadequacy for footsteps. 85 vaccine carriers were found in stock at 66 SHCs. Out of them 78 were in working condition. 25 SHCs had reported about the inadequacy of vaccine carriers. 37 steam sterilisers were found available at 34 SHCs. Out of them 6 were unserviceable and 2 needed repair. Cheatle forceps were found available only in 44 SHCs (1 each). Out of them 4 were unserviceable. 18 knife handles were found in working condition. Only 2 SHCs reported about adequacy of knife handles, 86 artery clamps were available at 33 sHCs and only one was unserviceable. 14 SHCs had reported their inadequacy.
b. At PHC:
Only 11 infant weighing scales were found available. Out of them 9 were in working condition. Demand was made for 23 infant weighing scales. 22 adult weighing scales were available. Out of them only 12 were in working condition and 6 needed repairing. 6 weighing scales were needed in various PHCs. Only 4 uterine sound were available in working condition and 8 PHCs needed 12 uterine sound. 3 vulsellum forceps at 2 PHCs, 11 Sim's vaginal double ended speculum at 6 PHCs, 6 Sim's vaginal depresser/ retractor at 3 PHCs, 4 Cusco's bivalve vaginal speculum at 2 PHCs and 10 IUD removal forceps at 7 PHCs were found available. Only 5 ILR at 5 PHCs and 7 deep freezers at 6 PHCs were found available, 2 deep freezers needed repairing.
c. At CHC:
20 ILR were found available at 6 CHCs. Out of them only 6 were in working condition and 3 needed repairing, whereas 12 deep freezers were found in stock at 3 CHCs. Out of them 9 were in working condition and 3 needed repairing. Not a single CHC had catheter either nasal or endotracheal. But required quantities were expressed by 3 CHCs for 102 and 81 respectively. Catheter suction rubber type was found in 5 number at 1 CHC but all were unserviceable. 21 catheters were found in further demand by 2 CHCs. Only 6 complete tubectomy kit were found available in 2 CHCs and all of them were in working condition. One CHC expressed the need for one complete tubectomy kit.
D. COMMUNITY NEEDS ASSESSMENT:
For assessing the need of community regarding reproductive health FGDs were conducted at each sampled SHC village. The persons involved in the discussions were mainly among the following:
§ Local people of the same and adjoining villages.
§ Teachers posted and residing in the village.
§ Elected representatives of PRI, Member of Parliament, Member of Legislative Assembly or local leader.
§ Anganwadi worker of the village.
§ Traditional birth attendant.
§ Members of self help groups and mahila mandals.
§ Shopkeepers.
§ Govt. employee posted or residing in the village.
§ Influential persons of the village.
The major needs of the community are listed below:
1. Health needs before marriage/ Adolescents:
They did not know the reason behind fixing of minimum age at marriage so they marry their children at early age. At some places of Chhatarpur and Panna districts female group members suggested that proper awareness generation programmes should be organized for creating awareness about causes of maternal mortality.
2. Health needs after marriage:
Most of the people did not know the importance of small family and also the measures to be taken in this direction. The reasons for low CPR were told as:
1. Place for getting contraceptives was not known.
2. Contraceptives were not made available at health centers at times.
3. Unaware regarding importance of use of contraceptives.
4. The incentive money was not distributed regularly and money should also be given to motivators.
5. Females did not like taste of oral pills.
6. Oral pills can cause ill effects on their health.
7. At some places in Panna and Chhatarpur district women complained that a few MPW (M) and ANMs asks for fee for LTT operations.
3. Antenatal care need:
Community did not prefer ANC check-ups because ANMs perform these check-ups in the presence of other patients also. A mobile health care unit providing privacy for such check-ups will increase ANC registration. At some places in case of any complication ANMs did not intimate family members regarding steps to be taken at that stage. Because of unawareness of complication family members did not make any arrangements to take pregnant women to higher health institutions and at the last moment due to lack of time and lack of transport facility maternal mortality takes place. Community members were well aware about the advantages of immunization during pregnancy.
4. Need during delivery (Natal care):
A few of them talked of disposable delivery kit but very less in numbers. The VHC should be trained for ensuring cleanliness during home delivery in the village.
At Jawa PHC community wanted training of dais should be done. In case of emergency women feel insecured with untrained dais. In Panna and Chhatarpur districts many villages were inaccessable. People of that region told that in some of the delivery cases they had taken pregnant women to the hospitals on cot. In one of the case women died on the way to the hospital.
5. Need after delivery (Post natal care):
At some places community had misconception regarding side effects of immunisation, i.e., fever etc. They also think that no one can prevent their children from God’s curse. There is a need for proper campaigning of importance of immunisation at such places.
6. Child care:
Almost all the places few women were not aware about the importance of weighing children after birth. Women were also not aware regarding early initiation of breast-feeding in the areas of Chhatrpur, Panna and Sidhi. At all the districts men as well as women were found unaware regarding importance of oral rehydration solution. Community members were also not well aware about early diagnosis of morbidity.
7. Other needs:
Due to lack of medical stores and poverty medicines written by health institutions could not be bought by community. There is a need to increase number of Jan Swasthya Rakshak. Even at few places they suggested the JSR should be a women equipped with more knowledge in ANC and PNC. The TBAs may also be encouraged for JSRs course. At some time in case of emergency health centers were found closed because of lack of staff.
All the villagers of Tingudi PHC expressed about the need of lady doctor at sector PHC. Due to lack of staff 5 mothers and 6 children died there.
At a PHC group members reported that the doctors were posted but attend duty only once a month. At Sinhawal BPHC all the three sampled PHCs doctors were posted but due to not having residential accommodation doctors were not residing in the PHC village. At the places where ANMs were locally posted, due to Parda Pratha and social customs they fail to visit the field and their husbands carry out routine work on their behalf. In Sinhawal block at few places ANM and MPW (M) were carry out private practices and they charge fee for their routine works.
8. Observation by research team of IIDM:
At one place at Panna district research team saw early marriage where bride as well as bridegroom both were of below 10 years. One place in Sinhawal block husband of ANM was conducting immunisation of children. At some places where ANM or MPW (M) were of upper caste they hesitated to check-up lower caste patients and vice versa. Many posts of ANM and MPW (M) were found vacant at the time of data collection which affected proper implementation of health services. There is a need to construct SHC buildings with ANM residence having all basic amenities like toilet facility and electric connection.
At Raipur PHC in Teonthar block community informed that doctors did not want to reside at PHC level and the health services suffered. Wine shop and restaurants were located nearby Chandrapur SHC at Teonthar block. So women were hesitating to come to SHC.
Garhi SHC at Jawa PHC is located other side of river and did not have bridge over river. Area was “Daquiat” affected also, so doctor and other servants did not want to posted there even patients were also not want to go for treatment at this PHC.
A Blog where we all believe that world needs happy solutions rather than just solutions so we are here to give our contribution to make word a better place to be in for every one
Wednesday, September 17, 2008
End Line Evaluation of Sub District RCH II Interventions in Mizoram
Introduction
The Endline Evaluation survey was sponsored as part of Sub District Reproductive and Child Health Project by Government of India and Government of Mizoram with the financial assistance from World Bank. In Mizoram, Indian Institute of Development Management Bhopal carried out this endline evaluation survey during April to June, 2004 at districts of Aizawl, Champhai, Kolasib and Saiha as sample districts in the endline survey. The main focus of the endline survey was on the following aspects:
1. Coverage of ANC and Immunization services.
2. Proportion of safe deliveries.
3. Contraceptives prevalence rate.
4. Unmet need for family planning.
5. Awareness about RTI, STI and HIV (AIDS).
6. Utilization of Health Services and User’s satisfaction.
7. Management of Project.
8. Efficacy of strategies adopted in the Sub District Project.
The survey was carried out in 1595 households from rural areas. The total population covered in the survey was 9488 out of which 4680 were males and 4808 were females. The sex ratio of the population covered was1027 females per 1000 males. The state was mostly inhabited by Christians with 99.4 percent population. Similarly population of Scheduled Tribes (99.1 percent) was also highest in the state in the sampled population.
Out of total 1595 households 480 eligible women were selected randomly of whom 478 women were interviewed. These eligible women were usual resident, currently married in the age group of 15 to 45 years. Age at consummation of marriage below 18 years was 9.8 percent where as for 18 years and above it was 90.2 percent. The mean age at marriage for boys and girls who married since 1 January, 2001 was 23.5 and 21.3 respectively. The mean number of children ever born to women age 15 to 45 years was 2.8.
Among the 478 interviewed women only 3.2 percent were illiterate whereas 69.0 percent attended schools for 9 years and 27.8 percent attended school for 10 years or more. The mean children ever born and surviving to women age 15-45 years was 2.8 and 2.6 respectively.
The ANC coverage of women in Mizoram was 76.4 per cent. Of those who received ANC, 92.9 per cent had it from Government health facility and only 6.3 per cent had it from Private Health Facility. 20.2 per cent of women had minimum three ANC visits and 14.7 percent had first ANC visit in the first trimester. 69.9 percent and 51.3 percent of women had daily doses of one or two IFA tablets and 45.6 per cent had 2 TT injections. 50.6 per cent and 52.3 per cent had check up of blood pressure and weight respectively during pregnancy and 49.3 per cent had 3 or more abdominal check up. A full ANC package of at least one TT, daily consumption of IFA tablets and 3 ANC visits was received by 47.5 per cent of the pregnant women.
Institutional deliveries were of the order of 40.1 per cent of the total deliveries and 96 per cent of the institutional deliveries were in Government health facilities. Nurse/ANM and Trained Dais conducted 22.8 per cent and 21.5 percent of the home deliveries. On the whole in this state, 86.5 per cent were safe deliveries. Delivery related complications were experienced by 14.0 per cent of the women. Out of the total women who had delivery complications 38.5 per cent had obstructed labors and 21.5 percent had Prolonged Labors (12 + hours) during delivery and 36.4 per cent had post delivery complications.
The Vaccination coverage of Children in this state was 75.3, 64.9, 58.9 and 61.3 per cent respectively for BCG, three doses of DPT, three doses of polio and measles. 39.1 per cent of the children were fully protected against six vaccine preventable diseases.
64.7 per cent of children were breast fed within two hours of birth and 16.7 percent were given colostrums. 92.9 percent of women exclusively breastfed their children for at least 4 months. 91.0 per cent of the women were aware of diarrhea management and 25.9 per cent of danger signs of pneumonia.
Knowledge of family planning was widely spread in Mizoram state with 95.2 per cent women knowing at least one modern method. Contraceptive prevalence rate in this state was 72.8 per cent with 67.6 per cent CPR due to modern methods and 5.2 per cent due to traditional method. Among the methods adopted Condom/Nirodh (33.1%) and IUD/Loop (26.5%) predominated. A total of 10.7 per cent of women had unmet need for family planning out of which 2.5% was for Limiting and 8.2 % for Spacing.
42.7 per cent of eligible women reported that the ANM visited their houses during three months prior to the survey. The counseling by ANM to unmarried adolescent girls was done only in 6.5 per cent of households. IFA tablets were distributed to adolescent girls in 15.4 percent families. During the last three months only 16.1 per cent of the women visited Government health facility and 15.3 per cent of them expressed center good enough for recommending to others.
The awareness of RTI among females was 15.5 per cent. The corresponding figures for STI was 28.2 percent and for HIV (AIDS) 87.9 per cent. 4.2 percent of women reported at least one symptom of RTI. Newspapers (66.1 percent) and Electronic media (45.8 percent) contributed mostly in spreading the awareness of HIV (AIDS). Only 2.1 per cent of females were ignorant of the mode of transmission of HIV (AIDS) while 84.7 percent and 72.4 percent told that it spreads by Sexual intercourse and Needles/Blades/Skin Puncture. 14.4 percent of women believed that (AIDS) could be cured. Nearly 73 per cent of female respondents were aware of preventing HIV (AIDS) by practicing safe sex.
In about 97 percent Sub Centers male Health Workers and in 85 percent Sub Centers female Health Workers were found posted. The longest distance to be covered by Health Workers for reaching 7 villages was 16 Kms. and above. 87 percent of Sub Centers were located in Government buildings. The status of 47 percent buildings of sub centers was reported poor and in 25 percent it was reported in good condition. Water supply and Electricity supply in 33 percent and 31 percent sub centers was reported continuous. Sufficient stock of vaccines, ORS, and Cotrimaxazole was reported sufficient in only 31 percent, 36 percent and 26 percent sub centers respectively. Records and Registers in 90 percent SHCs were found complete and in 87 percent SHCs accurately maintained.
Posts of Medical Officer was found vacant in only 3 Primary Health Centers out of 10 Centers studied and Lady Doctor/Gynecologist was available in only 3 PHCs. All the PHCs were located in Government buildings but condition of only 3 buildings was reported good. Condition of water supply and electricity supply was found continuous in 2 and 5 buildings only. Sufficient stock of Vaccines, Cotrimaxazole, and General Medicines was reported sufficient in 4, 4 and 1 PHC only. Records and Registers of 8 PHCs were found complete and accurate.
Presence of Village Health Workers/Village Health Guide was reported by 75 percent of Village Heads in Mizoram state and 67 percent of them reported that VHGs of their villages have visited the house of village heads. Among the 40 villages studied 23 Village Heads reported that they do not have Village Health Committees in their villages. 32 out of 40 village heads intimated that in their villages N.G.O.s have also contributed for village health interventions. Almost all the village heads were aware about the RCH Project and its contribution in village health programme.
Team approach, positive attitude of service providers towards the community and the senior officer’s supportive leadership were the strengths of the project. But at the same time planning, monitoring and controlling mechanism were in want of improvement. The political environment, the community and NGOs had been quite supportive to the project interventions; but the resource availability was sometimes irregular which hampered the project progress.
The facility survey was needed for planning and allocating the budget properly but this survey could not be under taken. The budgets along with action plans were prepared. In this project OTs & Laboratories at PHCs were constructed and about 246 sub centers were upgraded. The diagnostic equipments for RTI/STI and facilities for MTP were procured but facilities for emergency obstetric care were not established or strengthened. Under this project the medicines were not procured at state level. They were supplied directly by GOI to PHCs. Therefore state Government was facing difficulty in sending correct status in time to GOI.
The training needs were assessed and training courses were designed for health personals of different cadres. The project management has developed its own IEC material in Mizo language. Though the written communication was adequate, but department could not think of producing video films for IEC purpose. Department has organized healthy baby shows at village and PHC level. The department could not organize orientation programs for village councils and neither the department could organize any inter-village exchange program as envisaged earlier.
The micro level planning has not been attempted in the state. The project management has developed its own MIS by incorporating the main issues of MIS formats supplied by GOI for RCH. The project management has designed project specific MIS; but MIS was not effective as the feed back to the senders was rarely made during later part of the interventions.
The Endline Evaluation survey was sponsored as part of Sub District Reproductive and Child Health Project by Government of India and Government of Mizoram with the financial assistance from World Bank. In Mizoram, Indian Institute of Development Management Bhopal carried out this endline evaluation survey during April to June, 2004 at districts of Aizawl, Champhai, Kolasib and Saiha as sample districts in the endline survey. The main focus of the endline survey was on the following aspects:
1. Coverage of ANC and Immunization services.
2. Proportion of safe deliveries.
3. Contraceptives prevalence rate.
4. Unmet need for family planning.
5. Awareness about RTI, STI and HIV (AIDS).
6. Utilization of Health Services and User’s satisfaction.
7. Management of Project.
8. Efficacy of strategies adopted in the Sub District Project.
The survey was carried out in 1595 households from rural areas. The total population covered in the survey was 9488 out of which 4680 were males and 4808 were females. The sex ratio of the population covered was1027 females per 1000 males. The state was mostly inhabited by Christians with 99.4 percent population. Similarly population of Scheduled Tribes (99.1 percent) was also highest in the state in the sampled population.
Out of total 1595 households 480 eligible women were selected randomly of whom 478 women were interviewed. These eligible women were usual resident, currently married in the age group of 15 to 45 years. Age at consummation of marriage below 18 years was 9.8 percent where as for 18 years and above it was 90.2 percent. The mean age at marriage for boys and girls who married since 1 January, 2001 was 23.5 and 21.3 respectively. The mean number of children ever born to women age 15 to 45 years was 2.8.
Among the 478 interviewed women only 3.2 percent were illiterate whereas 69.0 percent attended schools for 9 years and 27.8 percent attended school for 10 years or more. The mean children ever born and surviving to women age 15-45 years was 2.8 and 2.6 respectively.
The ANC coverage of women in Mizoram was 76.4 per cent. Of those who received ANC, 92.9 per cent had it from Government health facility and only 6.3 per cent had it from Private Health Facility. 20.2 per cent of women had minimum three ANC visits and 14.7 percent had first ANC visit in the first trimester. 69.9 percent and 51.3 percent of women had daily doses of one or two IFA tablets and 45.6 per cent had 2 TT injections. 50.6 per cent and 52.3 per cent had check up of blood pressure and weight respectively during pregnancy and 49.3 per cent had 3 or more abdominal check up. A full ANC package of at least one TT, daily consumption of IFA tablets and 3 ANC visits was received by 47.5 per cent of the pregnant women.
Institutional deliveries were of the order of 40.1 per cent of the total deliveries and 96 per cent of the institutional deliveries were in Government health facilities. Nurse/ANM and Trained Dais conducted 22.8 per cent and 21.5 percent of the home deliveries. On the whole in this state, 86.5 per cent were safe deliveries. Delivery related complications were experienced by 14.0 per cent of the women. Out of the total women who had delivery complications 38.5 per cent had obstructed labors and 21.5 percent had Prolonged Labors (12 + hours) during delivery and 36.4 per cent had post delivery complications.
The Vaccination coverage of Children in this state was 75.3, 64.9, 58.9 and 61.3 per cent respectively for BCG, three doses of DPT, three doses of polio and measles. 39.1 per cent of the children were fully protected against six vaccine preventable diseases.
64.7 per cent of children were breast fed within two hours of birth and 16.7 percent were given colostrums. 92.9 percent of women exclusively breastfed their children for at least 4 months. 91.0 per cent of the women were aware of diarrhea management and 25.9 per cent of danger signs of pneumonia.
Knowledge of family planning was widely spread in Mizoram state with 95.2 per cent women knowing at least one modern method. Contraceptive prevalence rate in this state was 72.8 per cent with 67.6 per cent CPR due to modern methods and 5.2 per cent due to traditional method. Among the methods adopted Condom/Nirodh (33.1%) and IUD/Loop (26.5%) predominated. A total of 10.7 per cent of women had unmet need for family planning out of which 2.5% was for Limiting and 8.2 % for Spacing.
42.7 per cent of eligible women reported that the ANM visited their houses during three months prior to the survey. The counseling by ANM to unmarried adolescent girls was done only in 6.5 per cent of households. IFA tablets were distributed to adolescent girls in 15.4 percent families. During the last three months only 16.1 per cent of the women visited Government health facility and 15.3 per cent of them expressed center good enough for recommending to others.
The awareness of RTI among females was 15.5 per cent. The corresponding figures for STI was 28.2 percent and for HIV (AIDS) 87.9 per cent. 4.2 percent of women reported at least one symptom of RTI. Newspapers (66.1 percent) and Electronic media (45.8 percent) contributed mostly in spreading the awareness of HIV (AIDS). Only 2.1 per cent of females were ignorant of the mode of transmission of HIV (AIDS) while 84.7 percent and 72.4 percent told that it spreads by Sexual intercourse and Needles/Blades/Skin Puncture. 14.4 percent of women believed that (AIDS) could be cured. Nearly 73 per cent of female respondents were aware of preventing HIV (AIDS) by practicing safe sex.
In about 97 percent Sub Centers male Health Workers and in 85 percent Sub Centers female Health Workers were found posted. The longest distance to be covered by Health Workers for reaching 7 villages was 16 Kms. and above. 87 percent of Sub Centers were located in Government buildings. The status of 47 percent buildings of sub centers was reported poor and in 25 percent it was reported in good condition. Water supply and Electricity supply in 33 percent and 31 percent sub centers was reported continuous. Sufficient stock of vaccines, ORS, and Cotrimaxazole was reported sufficient in only 31 percent, 36 percent and 26 percent sub centers respectively. Records and Registers in 90 percent SHCs were found complete and in 87 percent SHCs accurately maintained.
Posts of Medical Officer was found vacant in only 3 Primary Health Centers out of 10 Centers studied and Lady Doctor/Gynecologist was available in only 3 PHCs. All the PHCs were located in Government buildings but condition of only 3 buildings was reported good. Condition of water supply and electricity supply was found continuous in 2 and 5 buildings only. Sufficient stock of Vaccines, Cotrimaxazole, and General Medicines was reported sufficient in 4, 4 and 1 PHC only. Records and Registers of 8 PHCs were found complete and accurate.
Presence of Village Health Workers/Village Health Guide was reported by 75 percent of Village Heads in Mizoram state and 67 percent of them reported that VHGs of their villages have visited the house of village heads. Among the 40 villages studied 23 Village Heads reported that they do not have Village Health Committees in their villages. 32 out of 40 village heads intimated that in their villages N.G.O.s have also contributed for village health interventions. Almost all the village heads were aware about the RCH Project and its contribution in village health programme.
Team approach, positive attitude of service providers towards the community and the senior officer’s supportive leadership were the strengths of the project. But at the same time planning, monitoring and controlling mechanism were in want of improvement. The political environment, the community and NGOs had been quite supportive to the project interventions; but the resource availability was sometimes irregular which hampered the project progress.
The facility survey was needed for planning and allocating the budget properly but this survey could not be under taken. The budgets along with action plans were prepared. In this project OTs & Laboratories at PHCs were constructed and about 246 sub centers were upgraded. The diagnostic equipments for RTI/STI and facilities for MTP were procured but facilities for emergency obstetric care were not established or strengthened. Under this project the medicines were not procured at state level. They were supplied directly by GOI to PHCs. Therefore state Government was facing difficulty in sending correct status in time to GOI.
The training needs were assessed and training courses were designed for health personals of different cadres. The project management has developed its own IEC material in Mizo language. Though the written communication was adequate, but department could not think of producing video films for IEC purpose. Department has organized healthy baby shows at village and PHC level. The department could not organize orientation programs for village councils and neither the department could organize any inter-village exchange program as envisaged earlier.
The micro level planning has not been attempted in the state. The project management has developed its own MIS by incorporating the main issues of MIS formats supplied by GOI for RCH. The project management has designed project specific MIS; but MIS was not effective as the feed back to the senders was rarely made during later part of the interventions.
OR Interventions for Reducing Maternal Mortality in MP-DANIDA Project
Introduction:
The principal goal of a reproductive health programme is to reduce unwanted fertility safely & to provide high quality health services. There by satisfying the needs of the individuals, as well as, stabilizing the population. Under Reproductive Child Health (RCH) project various interventions were carried out to enable clients to make informed choice, to receive counseling & education which is responsible for healthy sexual behaviour, to access user-friendly services for preventing unwanted pregnancy & safe abortion, maternity care & child survival and management of reproductive tract infections (RTI) and sexually transmitted diseases (STD). Even after these interventions the desired changes in maternal mortality could not be achieved at country level in general and MP state in particular.
In Rajgarh district where the problem is greatest, most maternal deaths go unregistered; either entirely so or their cause is not specified. There has been the tendency to underestimate the gravity of the situation. It is estimated that as many as ¼ to 1/3 of these deaths may be a consequence of complications of unsafe abortion procedures. This is also a major cause for high level of MMR in the district. In addition to this the major causes of maternal deaths are Anaemia, Hemorrhage, Eclampsia, Obstructed Labour and Infection. About 72% of all maternal deaths are preventable. Therefore it has become very necessary to identify the local causes of maternal deaths in Rajgarh & recommend appropriate interventions for preventing the causes. Therefore an operation research study was carried out in Rajgarh.
About project district:
The Rajgarh district is the most backward district in the state with lowest literacy & poor health indicators. The maternal deaths due to Abortion, Anaemia, Hemorrhage, Eclampsia, Obstructed labour & Infection are at higher side due to ignorance in the community. Being culturally associated with neighbouring Rajsthan the desire for male child is very strong among the general population. For want of male child women risk themselves for pregnancies leading to higher maternal mortality.
Health infrastructure in the district is adequate but poorly manned. There are 1 District Hospital, 2 Civil Hospitals, 6 CHCs/BPHCs, 34 PHCs and 159 Sub Health centers in the district. This study was carried out in two blocks namely Bioara and Khilchipur. Firstly Narsinghgarh block was selected instead of Khilchipur but as per suggestion of CMHO and DWCDO of Rajgarh district during workshop for finalization of research tools Narsinghgarh block was replaced by Khilchipur block.
There are 30 Sub Health Centres in Bioara block and 24 Sub Health Centres are in Khilchipur block.
Facilities available in villages:
The information regarding facilities were collected from each village and the inquiry was made either from ANM or AWW or JSR or Sarpanch or Teacher or any other influential person who has every information regarding their village.
In India almost 60-70 percent population resides in villages. For assessment of cause for maternal mortality it is necessary to study about facilities available in villages. In this study we gathered information from all villages of both the blocks.
In case of emergency every person calls his neighbour first. If village habitation is dense then the aid will be available early but in case of sparse habitation the neighbour takes time to attend the call while the condition may become critical and deteriorate further.
In both the blocks more than 85 percent villages were densely populated and 12.5 percent villages were sparsely populated. In both the block highest percent (Bioara 63.8 percent and Khilchipur 75.3 percent) of houses were of Other Backward Classes. Lowest percent (4.4 percent) of houses were of Scheduled Tribes. As highest percentage of other backward class houses, the percentage of population was also highest (68.4 percent) of other backward class and lowest percent (4.5) of population was of Scheduled Tribe caste. Almost 60 percent (59.7 percent) families had agriculture as their occupation. Only 2.3 percent families rely on business. In Bioara block only 5.6 percent families were non-farm labours where as in Khilchipur block 32.0 percent families were in this group. Unfortunately 71.1 percent villages were located more than 2 Km away from road. Only 7.6 percent villages were situated on road and about 6.2 percent villages do not have any road linked with the village. In both the blocks almost 70.0 percent (69.0 percent in Bioara block and 72.7 percent in Khilchipur block) villages do not have any access to road.
Only 20.4 percent villages had accessed through Govt. or private bus. 85.2 percent villages had facility of other mode (vehicle) i.e., bullock cart, tractor or motorcycle.
In 84.9 percent villages some or other transport facility was available during night. In Bioara block 92.9 percent villages had transport facility available.
Although government as well as private health institutions have facility of ambulance and in case of emergency any one can call it to get early treatment, but these facilities are available only in urban areas and not a single respondent gave response in favour of availability of ambulance to any village. In 79.5 percent villages tractors were available in emergency where as in 5.8 percent villages government or private buses were also available during night. 82.0 percent villages had facility of bullock carts and 27.5 percent villages had other transport facility i.e., motorcycle or manual carriage (cot) as mode of transport. 341 villages have access to private tractor.
In both the blocks more than 95 percent villages had electricity connectivity.
In India almost 80.0 percent deliveries are conducted at home. For safe delivery and to safe life of women it is necessary that every village had atleast one trained dai. 82.0 percent villages had atleast one trained dai. Where as 59.7 percent villages had untrained dai also. 18.9 percent villages had unregistered private practitioners. In Khilchipur block only 2.9 percent villages where as in Bioara block 36.3 percent villages had unregistered private practitioners.
51.6 percent villages relied on neighbours, relatives, other known persons and influential persons to get money on credit. In Bioara block 59.7 percent villages got help from self help groups in case of emergency. 26,5 percent villages rely on local money lenders for getting money on interest.
Facility of fast communication also helps in reduced casualty in case of emergency. But only 20.8 percent villages had facility of STD/PCO. Only 3.0 percent villages had medical shops available.
Research objectives:
This study mainly aimed at to ascertain the causes of maternal morbidity and mortality in Rajgarh. To carry out interventions for reducing maternal morbidity and mortality.
Therefore it tried to determine causes of maternal mortality and morbidity, determine awareness and knowledge in the community regarding maternal morbidity and mortality i.e. in terms of awareness and recognition of danger signals of pregnancy related complications, when and where to seek care and reasons for failure to seek care. Study infrastructure facilities available for maternal care, particularly Emergency Obstetric Care, its accessibility and utilization by the community, Study service providers’ (government, NGO, private) perception of maternal morbidity and mortality, Creating awareness among community, government employees and local opinion leaders for initiating steps for reduction of maternal morbidity and mortality and Empower women members of PRIs for reduction of maternal mortality.
Research Methodology:
The study was designed in two phases. The first phase was designed to assess the causes of mortality and the 2nd phase was designed to conduct certain interventions by community themselves to reduce maternal mortality. The first phase was further divided into two parts. In the part I we conducted retrospective data collection and 2nd part we collected data on prospective cases of mortality.
Retrospective study:
During this study the data about the deceased mothers were collected by verbal autopsy with their relatives.
The data were collected for the mortality cases of past 2 years which the relatives could easily recall. The data were also collected from attending health institutions. For this purpose we studied 48 cases in Bioara block and 66 cases in Khilchipur block.
The profile of cases studied in terms of their caste, religion, monthly income of the family, educational status and occupation of deceased women are given in table below
48.2 percent mortality cases were from OBC category. Almost 96.5 percent females were hindus where as only 3.5 percent cases were from Muslim community. None of the deceased women were Sikh or Christian. Almost half (48.2 percent) of the pregnant women were from low income group (upto Rs. 750/- P.M.). It was very difficult to assess the correct income of their family. In both the blocks majority of deceased women were illiterate. Only 2.6 percent were educated up to the primary level. Low level of awareness about health, early marriage and maternal care are due to low level of literacy among the community. Thus we can say that the low literacy rate & poverty were also responsible for maternal mortality. More than half (52.6 percent) of the deceased women were housewives and 40.4 percent were agricultural labour. In Khilchipur block all women were either house wife or agriculture/non farm labour. On the analysis of data on age at marriage it was observed that the death took place in 95.6 percent mothers who were married below 20 years. The younger age at marriage appears one of the causes of mortality. The interventions were required on these issues. In all about 63.2 percent women were registered either with ANM or AWW of their respective area.
As per the information given by relatives 42.1 percent deceased women consumed IFA tablets and 38.6 percent women had not consumed it. In this study almost half (49.1% women) died in first delivery (Primy Para). Above 60 percent women died were less than twenty-five years. 14.3 percent relatives of deceased women affirmed the cause of death was abortion. In almost 62.3 percent cases the women died either at home or on the way to hospital before getting any treatment.
Major disorders during pregnancy were (75.4 percent) fever, body ache, nausea, and other disorders. 26.3 percent women died due to hemorrhage. Whereas in Khilchipur block 24.2 percent women died due to anaemia. 14.0 percent respondents revealed that one of major causes of death for woman was delay in arranging money. A major group (39.6 percent) could not specify whether any delay was responsible for the death of a woman.
Prospective study:
We understand that in case of retrospective study the responses may not be very reliable because of longer time gap after the event has taken place, as the respondent had to recollect the event and then respond. To overcome this shortcoming we designed prospective study for collecting the required data from the conception stage. During this study 2026 pregnant women from Bioara block and 1480 women from Khilchipur block were studied. Highest proportion (59.6 percent) of the respondents were OBC.
The occupation of 48.6 percent families of pregnant women was agriculture and 33.5 percent women were from the farm labour family. Highest 34.6 percent women were from the families having income in between Rs. 750/- to 1,000/- and only 8.5 percent families had income more than Rs. 5,000/- per month.
More than half (51.5 percent) of the respondents were housewives. 78.1 percent respondents were illiterate where as 11.0 percent respondents had formal education. Only 1.5 percent of the respondents had more than middle level education. Age at the time of marriage and gauna plays an important role in reproductive life of a woman. Government promulgated Sharda Act to restrain marrying a girl before the age of 18 years. But in Khilchipur block 33.4 percent respondents got married before 16 years of their age. Whereas in Bioara block 37.0 percent respondents got married in same age bracket.
To see the pattern of morbidity it is necessary to observe full gestation period carefully. ANM of the area were instructed to visit every pregnant women atleast thrice the whole gestation period. The ANMs and AWWs of the project blocks were trained by us and their role in the research was also clarified.
In this study 34.2 percent cases had their first pregnancy where as 21.9 percent cases had fourth or higher parity. Even after the involvement of service providers only 21.3 percent women got either three or more ANC check ups.
51.8 percent of the respondents got two vaccines or booster vaccines against tetanus. High blood pressure leads to eclampsia and eclampsia claims 17 percent of the maternal deaths. But 15.7 percent women did not have their blood pressure measured. Edema during pregnancy is risky. 5.9 percent respondents had suffered from edema. Pregnancy burdens the functioning of heart. It leads risk to women's life. 4.7 percent of the respondents complained that they had some trouble in their heart. During this study haemoglobin estimation of 52.4 percent respondents was not performed.
In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.
In 97.8 percent cases pregnancy terminated as live birth. In 0.4 percent cases (9 in number) mothers died during delivery. In 2.1 percent cases of neonate deaths and in 2.6 percent cases of the maternal deaths the delivery was assisted by untrained dai. Similar trend was observed in case of deliveries attended by relatives with respect to still births (3.3 percent) and maternal deaths. Our study shows that 88.8 percent deliveries were conducted at home. Only 10.7 percent of the deliveries were conducted either at government or private hospital (Institutional deliveries).
In case of 8.8 percent respondents the delivery was conducted by untrained dai. In
For safe deliveries it is essential to use five cleans or disposable delivery kit or use of new blade to protect mother and baby from tetanus. But during this study we found that only in 61.8 percent cases disposable delivery kits were used. Only in 1.2 percent cases old blade was used to separate placenta. 73.1 percent respondents did not face any complication during delivery. 21.4 percent respondents faced excessive labour pain. 3.0 percent respondents faced excessive bleeding. Only 0.1 percent respondent complained about fighting eclampsia.
One of the main object of this study was to find morbidity pattern among pregnant women. We found that 2.4 percent respondents had high blood pressure. 5.9 percent respondents had suffered edema. 4.7 percent of the respondents complained that they had some trouble in their heart. In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.
Facilities available at health institutions:
Availability of generator/inverter is very essential for O.T. in case of emergency but in Bioara block only 1 and in Khilchipur block only 3 health institutions had generator/inverter available with them.
Availability of atleast one separate labour room was essential to ensure privacy at the time of delivery. Therefore the data were collected on this aspect also.
4 health institutions in Bioara block and 3 institutions in Khilchipur block had 3 or more rooms. 2 institutions in Khilchipur block and one institution in Bioara block did not have labour room. Half of the health institutions had sanctioned bed strength of six to ten beds. Whereas 4 institutions had beds capacity in between ten to thirty.
6 health institutions did not have proper waste disposal facility. It is hygienic to have incinerator facility for disposal of medical waste but only one health institution (Sultania Hospital Bhopal) had facility of incinerator. One health institution in Bioara block which had facility of open pit did not functional at the time of survey.
Information regarding availability of vehicle in functional state was also collected from the health institutions. 8 health institutions did not have any type of vehicle. Rest of 6 health institutions had 12 jeeps 8 ambulance and 1 mobile van. All of the vehicles were found functional.
In Bioara block only 1 Medical Officer was available for Caesarian and anesthesia. Whereas in Khilchipur block no Medical Officer was found available for Caesarian and anesthesia. Sufficient number of Health Workers were available for conducting deliveries and in handling of emergency. The status of training in the field of maternal health, such as conducting deliveries, safe motherhood, MTP, Caesarian section etc. and information regarding application in the same fields was also collected from Medical Officers as well as health workers. It was found inadequate.
32 Medical Officers were found trained in conducting deliveries and 23 in performing MTP. In Khilchipur block no Medical Officer was trained in performing MTP or Caesarian section or anesthesia. Sufficient number of health workers were available in conducting deliveries and checking blood pressure.
In the rural areas around 80 percent deliveries are conducted at home. In such cases availability of trained dai in villages would have helped in safe delivery and low maternal mortality. The information regarding number of trained dais available in health centers was also collected. The availability of trained dais in the field was inadequate and there was a need for imparting training to more dais. So that the home deliveries may be attended by these dais. In both the blocks 2 health institutions did not have any trained dais in their area. Only 3 health institutions had more than 10 trained dais available in their area.
Stock availability of some medicines required in case of emergency, TT vaccines, IFA tablet, Disposable delivery kit etc., was also obtained from health institutions. 12 health institutions had adequate stock of IFA tablets. District hospital Rajgarh and Sultania hospital at Bhopal had adequate medicines. The information about workload at health institutions was also obtained in the form of number of registered or treated cases at the center. The data was obtained only for the activities related to safe delivery and emergency.
Total 20877 cases were registered for ANC, out of these 2473 high-risk pregnant women were diagnosed. Number of pregnant women treated for anaemia were 8320. In Khilchipur block only 367 pregnant women were treated for anaemia. 5843 home deliveries in the field of Bioara and Khilchipur block were assisted by ANM. Total 9086 institutional deliveries were registered.
The use of bio-medical equipments is very essential for diagnosing the diseases. Even in routine check-up the equipments like sphygmomanometer, weighing machine, torch, thermometer, etc. are extensively used. The specific check-ups like antenatal check-ups or for conducting deliveries, immunization, MTP, etc. need specific equipments. These are very common equipments used in health institutions. Therefore it was felt essential to know the status of these equipments. The data regarding the status of equipments used in above stated activities were collected.
Interventions for reduction of maternal mortality:
The second phase of this study was more important, because in this phase we carried out interventions to reduce maternal mortality. For these interventions 5 panchayats in each block were selected. Major role of this part was to sensitize the stakeholders. So that they should get involved in process consultation and developing action plan.
The criteria for selecting the intervention villages was the maternal morbidity. Before proceeding to these interventions the Study Findings were summarized and then shared with the participants. The PRI members and VHC members for each gramsabha were called for 2 days workshop at each Block Head Quarter. These workshops were carried out using process consultation, confrontation and problem solving approaches. In the month of December and January five members from each panchayats were called for interventions. In all these workshops the VHC members, Anganwadi workers, ANMs, PRI members, opinion leaders, local citizens were involved. The team building interventions were also planned among these groups. The group members chalked out the activity plan for reduction of maternal morbidity and mortality. The follow-up activities were carried out at these intervention villages. For determining awareness and knowledge about maternal morbidity and mortality we conducted focus group discussions in both the blocks. These intervention workshops were conducted in two phases.
In these workshops awareness among stakeholders about causes of maternal mortality were pointed out. After finding awareness among stakeholders the activities for reduction of maternal mortality and morbidity were designed by themselves. Next follow up activities were carried out for these intervention villages. The problems in administering those interventions will be assessed and were solved in next round of workshops. As an outcome of these interventions in some of the villages self help groups were formed to save money for loaning for transportation at the time of delivery. The awareness creation and ANC registration increased to a great extent resulting into lower morbidity of diseases among pregnant women.
The principal goal of a reproductive health programme is to reduce unwanted fertility safely & to provide high quality health services. There by satisfying the needs of the individuals, as well as, stabilizing the population. Under Reproductive Child Health (RCH) project various interventions were carried out to enable clients to make informed choice, to receive counseling & education which is responsible for healthy sexual behaviour, to access user-friendly services for preventing unwanted pregnancy & safe abortion, maternity care & child survival and management of reproductive tract infections (RTI) and sexually transmitted diseases (STD). Even after these interventions the desired changes in maternal mortality could not be achieved at country level in general and MP state in particular.
In Rajgarh district where the problem is greatest, most maternal deaths go unregistered; either entirely so or their cause is not specified. There has been the tendency to underestimate the gravity of the situation. It is estimated that as many as ¼ to 1/3 of these deaths may be a consequence of complications of unsafe abortion procedures. This is also a major cause for high level of MMR in the district. In addition to this the major causes of maternal deaths are Anaemia, Hemorrhage, Eclampsia, Obstructed Labour and Infection. About 72% of all maternal deaths are preventable. Therefore it has become very necessary to identify the local causes of maternal deaths in Rajgarh & recommend appropriate interventions for preventing the causes. Therefore an operation research study was carried out in Rajgarh.
About project district:
The Rajgarh district is the most backward district in the state with lowest literacy & poor health indicators. The maternal deaths due to Abortion, Anaemia, Hemorrhage, Eclampsia, Obstructed labour & Infection are at higher side due to ignorance in the community. Being culturally associated with neighbouring Rajsthan the desire for male child is very strong among the general population. For want of male child women risk themselves for pregnancies leading to higher maternal mortality.
Health infrastructure in the district is adequate but poorly manned. There are 1 District Hospital, 2 Civil Hospitals, 6 CHCs/BPHCs, 34 PHCs and 159 Sub Health centers in the district. This study was carried out in two blocks namely Bioara and Khilchipur. Firstly Narsinghgarh block was selected instead of Khilchipur but as per suggestion of CMHO and DWCDO of Rajgarh district during workshop for finalization of research tools Narsinghgarh block was replaced by Khilchipur block.
There are 30 Sub Health Centres in Bioara block and 24 Sub Health Centres are in Khilchipur block.
Facilities available in villages:
The information regarding facilities were collected from each village and the inquiry was made either from ANM or AWW or JSR or Sarpanch or Teacher or any other influential person who has every information regarding their village.
In India almost 60-70 percent population resides in villages. For assessment of cause for maternal mortality it is necessary to study about facilities available in villages. In this study we gathered information from all villages of both the blocks.
In case of emergency every person calls his neighbour first. If village habitation is dense then the aid will be available early but in case of sparse habitation the neighbour takes time to attend the call while the condition may become critical and deteriorate further.
In both the blocks more than 85 percent villages were densely populated and 12.5 percent villages were sparsely populated. In both the block highest percent (Bioara 63.8 percent and Khilchipur 75.3 percent) of houses were of Other Backward Classes. Lowest percent (4.4 percent) of houses were of Scheduled Tribes. As highest percentage of other backward class houses, the percentage of population was also highest (68.4 percent) of other backward class and lowest percent (4.5) of population was of Scheduled Tribe caste. Almost 60 percent (59.7 percent) families had agriculture as their occupation. Only 2.3 percent families rely on business. In Bioara block only 5.6 percent families were non-farm labours where as in Khilchipur block 32.0 percent families were in this group. Unfortunately 71.1 percent villages were located more than 2 Km away from road. Only 7.6 percent villages were situated on road and about 6.2 percent villages do not have any road linked with the village. In both the blocks almost 70.0 percent (69.0 percent in Bioara block and 72.7 percent in Khilchipur block) villages do not have any access to road.
Only 20.4 percent villages had accessed through Govt. or private bus. 85.2 percent villages had facility of other mode (vehicle) i.e., bullock cart, tractor or motorcycle.
In 84.9 percent villages some or other transport facility was available during night. In Bioara block 92.9 percent villages had transport facility available.
Although government as well as private health institutions have facility of ambulance and in case of emergency any one can call it to get early treatment, but these facilities are available only in urban areas and not a single respondent gave response in favour of availability of ambulance to any village. In 79.5 percent villages tractors were available in emergency where as in 5.8 percent villages government or private buses were also available during night. 82.0 percent villages had facility of bullock carts and 27.5 percent villages had other transport facility i.e., motorcycle or manual carriage (cot) as mode of transport. 341 villages have access to private tractor.
In both the blocks more than 95 percent villages had electricity connectivity.
In India almost 80.0 percent deliveries are conducted at home. For safe delivery and to safe life of women it is necessary that every village had atleast one trained dai. 82.0 percent villages had atleast one trained dai. Where as 59.7 percent villages had untrained dai also. 18.9 percent villages had unregistered private practitioners. In Khilchipur block only 2.9 percent villages where as in Bioara block 36.3 percent villages had unregistered private practitioners.
51.6 percent villages relied on neighbours, relatives, other known persons and influential persons to get money on credit. In Bioara block 59.7 percent villages got help from self help groups in case of emergency. 26,5 percent villages rely on local money lenders for getting money on interest.
Facility of fast communication also helps in reduced casualty in case of emergency. But only 20.8 percent villages had facility of STD/PCO. Only 3.0 percent villages had medical shops available.
Research objectives:
This study mainly aimed at to ascertain the causes of maternal morbidity and mortality in Rajgarh. To carry out interventions for reducing maternal morbidity and mortality.
Therefore it tried to determine causes of maternal mortality and morbidity, determine awareness and knowledge in the community regarding maternal morbidity and mortality i.e. in terms of awareness and recognition of danger signals of pregnancy related complications, when and where to seek care and reasons for failure to seek care. Study infrastructure facilities available for maternal care, particularly Emergency Obstetric Care, its accessibility and utilization by the community, Study service providers’ (government, NGO, private) perception of maternal morbidity and mortality, Creating awareness among community, government employees and local opinion leaders for initiating steps for reduction of maternal morbidity and mortality and Empower women members of PRIs for reduction of maternal mortality.
Research Methodology:
The study was designed in two phases. The first phase was designed to assess the causes of mortality and the 2nd phase was designed to conduct certain interventions by community themselves to reduce maternal mortality. The first phase was further divided into two parts. In the part I we conducted retrospective data collection and 2nd part we collected data on prospective cases of mortality.
Retrospective study:
During this study the data about the deceased mothers were collected by verbal autopsy with their relatives.
The data were collected for the mortality cases of past 2 years which the relatives could easily recall. The data were also collected from attending health institutions. For this purpose we studied 48 cases in Bioara block and 66 cases in Khilchipur block.
The profile of cases studied in terms of their caste, religion, monthly income of the family, educational status and occupation of deceased women are given in table below
48.2 percent mortality cases were from OBC category. Almost 96.5 percent females were hindus where as only 3.5 percent cases were from Muslim community. None of the deceased women were Sikh or Christian. Almost half (48.2 percent) of the pregnant women were from low income group (upto Rs. 750/- P.M.). It was very difficult to assess the correct income of their family. In both the blocks majority of deceased women were illiterate. Only 2.6 percent were educated up to the primary level. Low level of awareness about health, early marriage and maternal care are due to low level of literacy among the community. Thus we can say that the low literacy rate & poverty were also responsible for maternal mortality. More than half (52.6 percent) of the deceased women were housewives and 40.4 percent were agricultural labour. In Khilchipur block all women were either house wife or agriculture/non farm labour. On the analysis of data on age at marriage it was observed that the death took place in 95.6 percent mothers who were married below 20 years. The younger age at marriage appears one of the causes of mortality. The interventions were required on these issues. In all about 63.2 percent women were registered either with ANM or AWW of their respective area.
As per the information given by relatives 42.1 percent deceased women consumed IFA tablets and 38.6 percent women had not consumed it. In this study almost half (49.1% women) died in first delivery (Primy Para). Above 60 percent women died were less than twenty-five years. 14.3 percent relatives of deceased women affirmed the cause of death was abortion. In almost 62.3 percent cases the women died either at home or on the way to hospital before getting any treatment.
Major disorders during pregnancy were (75.4 percent) fever, body ache, nausea, and other disorders. 26.3 percent women died due to hemorrhage. Whereas in Khilchipur block 24.2 percent women died due to anaemia. 14.0 percent respondents revealed that one of major causes of death for woman was delay in arranging money. A major group (39.6 percent) could not specify whether any delay was responsible for the death of a woman.
Prospective study:
We understand that in case of retrospective study the responses may not be very reliable because of longer time gap after the event has taken place, as the respondent had to recollect the event and then respond. To overcome this shortcoming we designed prospective study for collecting the required data from the conception stage. During this study 2026 pregnant women from Bioara block and 1480 women from Khilchipur block were studied. Highest proportion (59.6 percent) of the respondents were OBC.
The occupation of 48.6 percent families of pregnant women was agriculture and 33.5 percent women were from the farm labour family. Highest 34.6 percent women were from the families having income in between Rs. 750/- to 1,000/- and only 8.5 percent families had income more than Rs. 5,000/- per month.
More than half (51.5 percent) of the respondents were housewives. 78.1 percent respondents were illiterate where as 11.0 percent respondents had formal education. Only 1.5 percent of the respondents had more than middle level education. Age at the time of marriage and gauna plays an important role in reproductive life of a woman. Government promulgated Sharda Act to restrain marrying a girl before the age of 18 years. But in Khilchipur block 33.4 percent respondents got married before 16 years of their age. Whereas in Bioara block 37.0 percent respondents got married in same age bracket.
To see the pattern of morbidity it is necessary to observe full gestation period carefully. ANM of the area were instructed to visit every pregnant women atleast thrice the whole gestation period. The ANMs and AWWs of the project blocks were trained by us and their role in the research was also clarified.
In this study 34.2 percent cases had their first pregnancy where as 21.9 percent cases had fourth or higher parity. Even after the involvement of service providers only 21.3 percent women got either three or more ANC check ups.
51.8 percent of the respondents got two vaccines or booster vaccines against tetanus. High blood pressure leads to eclampsia and eclampsia claims 17 percent of the maternal deaths. But 15.7 percent women did not have their blood pressure measured. Edema during pregnancy is risky. 5.9 percent respondents had suffered from edema. Pregnancy burdens the functioning of heart. It leads risk to women's life. 4.7 percent of the respondents complained that they had some trouble in their heart. During this study haemoglobin estimation of 52.4 percent respondents was not performed.
In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.
In 97.8 percent cases pregnancy terminated as live birth. In 0.4 percent cases (9 in number) mothers died during delivery. In 2.1 percent cases of neonate deaths and in 2.6 percent cases of the maternal deaths the delivery was assisted by untrained dai. Similar trend was observed in case of deliveries attended by relatives with respect to still births (3.3 percent) and maternal deaths. Our study shows that 88.8 percent deliveries were conducted at home. Only 10.7 percent of the deliveries were conducted either at government or private hospital (Institutional deliveries).
In case of 8.8 percent respondents the delivery was conducted by untrained dai. In
For safe deliveries it is essential to use five cleans or disposable delivery kit or use of new blade to protect mother and baby from tetanus. But during this study we found that only in 61.8 percent cases disposable delivery kits were used. Only in 1.2 percent cases old blade was used to separate placenta. 73.1 percent respondents did not face any complication during delivery. 21.4 percent respondents faced excessive labour pain. 3.0 percent respondents faced excessive bleeding. Only 0.1 percent respondent complained about fighting eclampsia.
One of the main object of this study was to find morbidity pattern among pregnant women. We found that 2.4 percent respondents had high blood pressure. 5.9 percent respondents had suffered edema. 4.7 percent of the respondents complained that they had some trouble in their heart. In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.
Facilities available at health institutions:
Availability of generator/inverter is very essential for O.T. in case of emergency but in Bioara block only 1 and in Khilchipur block only 3 health institutions had generator/inverter available with them.
Availability of atleast one separate labour room was essential to ensure privacy at the time of delivery. Therefore the data were collected on this aspect also.
4 health institutions in Bioara block and 3 institutions in Khilchipur block had 3 or more rooms. 2 institutions in Khilchipur block and one institution in Bioara block did not have labour room. Half of the health institutions had sanctioned bed strength of six to ten beds. Whereas 4 institutions had beds capacity in between ten to thirty.
6 health institutions did not have proper waste disposal facility. It is hygienic to have incinerator facility for disposal of medical waste but only one health institution (Sultania Hospital Bhopal) had facility of incinerator. One health institution in Bioara block which had facility of open pit did not functional at the time of survey.
Information regarding availability of vehicle in functional state was also collected from the health institutions. 8 health institutions did not have any type of vehicle. Rest of 6 health institutions had 12 jeeps 8 ambulance and 1 mobile van. All of the vehicles were found functional.
In Bioara block only 1 Medical Officer was available for Caesarian and anesthesia. Whereas in Khilchipur block no Medical Officer was found available for Caesarian and anesthesia. Sufficient number of Health Workers were available for conducting deliveries and in handling of emergency. The status of training in the field of maternal health, such as conducting deliveries, safe motherhood, MTP, Caesarian section etc. and information regarding application in the same fields was also collected from Medical Officers as well as health workers. It was found inadequate.
32 Medical Officers were found trained in conducting deliveries and 23 in performing MTP. In Khilchipur block no Medical Officer was trained in performing MTP or Caesarian section or anesthesia. Sufficient number of health workers were available in conducting deliveries and checking blood pressure.
In the rural areas around 80 percent deliveries are conducted at home. In such cases availability of trained dai in villages would have helped in safe delivery and low maternal mortality. The information regarding number of trained dais available in health centers was also collected. The availability of trained dais in the field was inadequate and there was a need for imparting training to more dais. So that the home deliveries may be attended by these dais. In both the blocks 2 health institutions did not have any trained dais in their area. Only 3 health institutions had more than 10 trained dais available in their area.
Stock availability of some medicines required in case of emergency, TT vaccines, IFA tablet, Disposable delivery kit etc., was also obtained from health institutions. 12 health institutions had adequate stock of IFA tablets. District hospital Rajgarh and Sultania hospital at Bhopal had adequate medicines. The information about workload at health institutions was also obtained in the form of number of registered or treated cases at the center. The data was obtained only for the activities related to safe delivery and emergency.
Total 20877 cases were registered for ANC, out of these 2473 high-risk pregnant women were diagnosed. Number of pregnant women treated for anaemia were 8320. In Khilchipur block only 367 pregnant women were treated for anaemia. 5843 home deliveries in the field of Bioara and Khilchipur block were assisted by ANM. Total 9086 institutional deliveries were registered.
The use of bio-medical equipments is very essential for diagnosing the diseases. Even in routine check-up the equipments like sphygmomanometer, weighing machine, torch, thermometer, etc. are extensively used. The specific check-ups like antenatal check-ups or for conducting deliveries, immunization, MTP, etc. need specific equipments. These are very common equipments used in health institutions. Therefore it was felt essential to know the status of these equipments. The data regarding the status of equipments used in above stated activities were collected.
Interventions for reduction of maternal mortality:
The second phase of this study was more important, because in this phase we carried out interventions to reduce maternal mortality. For these interventions 5 panchayats in each block were selected. Major role of this part was to sensitize the stakeholders. So that they should get involved in process consultation and developing action plan.
The criteria for selecting the intervention villages was the maternal morbidity. Before proceeding to these interventions the Study Findings were summarized and then shared with the participants. The PRI members and VHC members for each gramsabha were called for 2 days workshop at each Block Head Quarter. These workshops were carried out using process consultation, confrontation and problem solving approaches. In the month of December and January five members from each panchayats were called for interventions. In all these workshops the VHC members, Anganwadi workers, ANMs, PRI members, opinion leaders, local citizens were involved. The team building interventions were also planned among these groups. The group members chalked out the activity plan for reduction of maternal morbidity and mortality. The follow-up activities were carried out at these intervention villages. For determining awareness and knowledge about maternal morbidity and mortality we conducted focus group discussions in both the blocks. These intervention workshops were conducted in two phases.
In these workshops awareness among stakeholders about causes of maternal mortality were pointed out. After finding awareness among stakeholders the activities for reduction of maternal mortality and morbidity were designed by themselves. Next follow up activities were carried out for these intervention villages. The problems in administering those interventions will be assessed and were solved in next round of workshops. As an outcome of these interventions in some of the villages self help groups were formed to save money for loaning for transportation at the time of delivery. The awareness creation and ANC registration increased to a great extent resulting into lower morbidity of diseases among pregnant women.
Tuesday, September 16, 2008
Games People Play in Development Sector-04
The public servants in development sector sometimes use the development consults to complete the formalities. In general for any limited tender three proposals are needed. The development agency is already decided for the job. They write to few agencies for submitting the proposals. The agencies in their enthusiasm prepare the proposal by devoting good time on that proposal. They submit the proposal & keep on waiting & no response is given to them until the job is completed by predecided agency. This game is played by even international agencies. The IIDM has been used by a handful of international agencies in such games. This game is played at what cost?
In the next occasion IIDM will not prepare the proposal with that interest to such organizations. Both will be the loosers.
Seeking your comments & similar experiences
Dr S K Trivedi
In the next occasion IIDM will not prepare the proposal with that interest to such organizations. Both will be the loosers.
Seeking your comments & similar experiences
Dr S K Trivedi
Games People Play in Development Sector-03
The public servants in development sector sometimes use the brokers/ journalists as partner in their network. A Project Director of one of the multi billion dollar project in one of the state issued advertisements to hire the professional services of development consultants. The proposals (Technical & Financial) were invited by development consulting organizations. The agencies were short listed. These brokers / journalists were given the details of short listed organizations. They were asked to negotiate the shortlisted agencies a part of their fee for this network. To convince the short listed agencies the original documents are also handed over by these development managers to these network members. If the development consulting agencies do not negotiate then the efforts are made to black list these agencies by hook or crook using fake games. Even some times the proposals are declared that no body could qualify for the assignment. It is to be re-tendered till they get the agency accepting their terms.
Seeking your comments & similar experiences
Dr S K Trivedi
Seeking your comments & similar experiences
Dr S K Trivedi
Research Organization & NGO not synonimous
There is confusion in many of the public servants heading development projects. They want to get the monitoring & evaluation of their project done by external agencies. They approach to NGOs arround. Many of whom have never even understood the intricacies of research but they jump into the fray to carry out monitorig & evaluation. Many of them even unable to differentiate between base line, mid term & endline evaluation. For them all these things are surveys. For them Qualitative data collection tools are same as quantitative data collection tools. These NGOs then start cajoling the polliticians / leaders to pressurise the development managers to assign these jobs to these NGOs. Neither the leader nor the development manager understands the importance of these reseach & evaluation activities. Thus evaluation process meets into casualty.
The M&E and research are specific jobs which require training & experience in consulting organzations or research organization rather getting a NGO registered under Society Act.
Be careful while selecting the agency.
Dr S K Trivedi
The M&E and research are specific jobs which require training & experience in consulting organzations or research organization rather getting a NGO registered under Society Act.
Be careful while selecting the agency.
Dr S K Trivedi
Power of RTI (Right To Information Act)
The more and more persons should use the RTI Instruments to strengthen the transparency in government. The corruption is directly proportion to hiding of the information. It is not only the corruption, it is the arrogance/ power of public servant which is directly proportional to the hiding of information.
The public servant does not respond to the letters of the service providers or the development partners from NGO sector with the notion what will happen if he does not respond. But by RTI one can get recorded / certified information that he has ignored the person for whom he is appointed, he will be put to task. The public servant will then not dare to ignore the partners.
Till now they use to keep their notings hidden only open to their bosses to camaflogue the fact & harass the parties. These can be exposed now if RTI is used properly.
DR S K Trivedi
The public servant does not respond to the letters of the service providers or the development partners from NGO sector with the notion what will happen if he does not respond. But by RTI one can get recorded / certified information that he has ignored the person for whom he is appointed, he will be put to task. The public servant will then not dare to ignore the partners.
Till now they use to keep their notings hidden only open to their bosses to camaflogue the fact & harass the parties. These can be exposed now if RTI is used properly.
DR S K Trivedi
Subscribe to:
Posts (Atom)