Maternal & neonatal mortality rates in India have declined yet fell short of 2015 millennium development goals (MDG). Several maternal and neonatal health indicators show improvement yet inequities in population-wide coverage in certain geographies and gaps in quality and continuity of care remain unresolved.

Reaching scale to ensure coverage of migrant, high-risk women and children in the care-continuum is a visible gap. Ensuring coverage during their antenatal and postnatal periods in a seamless manner with high-quality emergency obstetric & neonatal care requires newer innovative approaches. Meaningful engagement of grass-root structures such as Gram Panchayats (GP) /Village Health Sanitation and Nutrition Committees (VHSNC) needs to reach scale. Integration of technology interfaces to ensure continuity and real-time data-based planning is required.

Our Approach

Our approach focuses on improving availability, accessibility, quality, utilization, and coverage of critical MNCH interventions among the rural poor through Facility, Community, Health Systems, and Technology. It includes strengthening of health care providers’ knowledge and skills to threshold levels to deliver quality MNCH services in district-level public health care facilities. Our focus is on prioritizing the integration of respectful maternity care principles and practices
We also have a community-level focus on vulnerable populations, which includes community participation and accountability through frontline workers, Village Health, Sanitation and Nutrition Committees (VHSNCs), and Arogya Raksha Samitis. We look to building capacities and scaling up the reach of quality community-based services. This will improve functionality, and generate ownership and accountability of Gram Panchayats and VHSNCs.

We also implement health system strengthening activities to improve the availability of drugs and supplies, accessibility for maternal and neonatal complications, a robust referral system that ensures stabilization of complications and effective infection control practices to reduce maternal and neonatal sepsis.

We aim to integrate and expand the use of technology across the continuum of MNCH care from community to facility levels to expand identification and service delivery for vulnerable populations and strengthen the quality of clinical care at facilities.

Our Achievements

• Our tools and processes such as the ASHA diary, nurse mentor case sheets, frontline health workers’ convergence and VHSNC strengthening to improve MNCH were adopted by the Karnataka government and scaled to the state of Uttar Pradesh by the Bill & Melinda Gates Foundation.
• Our Kangaroo Mother Care Model piloted in Koppal district was adopted and scaled to the entire state by the Government of Karnataka in 2018.
• KHPT received the IMPACT award for ‘Deeply impacting communities through innovation in programs’ for MNCH related initiatives in 2017.
• Our women centered empowerment model to improve nutrition levels within disadvantaged households became a national learning initiative in 2016.
• Our work in MNCH resulted in a ten-point reduction in rates of Neonatal Mortality (41 to 30) and Infant Mortality (54 to 44) between 2010 and 2015.
• KHPT conducted a large-scale Mapping at facility and community levels in 25 high priority districts of UP in 2013.
• Our project learnings from Karnataka have been transitioned and scaled to the state of UP, and were being implemented by the University of Manitoba with other partner organizations in 2013

Context

In India, while maternal and newborn deaths have been declining over the past two decades, the pace has been slow. In particular, progress among the poorest and most marginalised populations in the country continues to lag, with continued disparities in health outcomes. Combination of complex multi-level factors increase vulnerability of this segment to poor health outcomes.

Closer home in Karnataka, the state average for infant mortality rate (IMR) is 35 and maternal mortality rate (MMR) is 144. Many of the less developed northern districts in Karnataka with weaker health infrastructure lag in improvements in Maternal Neonatal Child Health (MNCH) outcomes. Nearly half of the maternal deaths and many more neonatal deaths occur at the time of delivery and first week postpartum. In north Karnataka, IMR and MMR are the above state average. In Raichur district, the IMR is 67 and the MMR is 244 and in Koppal, the IMR is 58 and the MMR is 236.

Implementation

The Sukshema programme was implemented from 2009 – 2015 in eight priority districts in north Karnataka – Bagalkot, Bellary, Bijapur, Gulbarga, Koppal, Raichur and Yadgir. The project supported the National Rural Health Mission to improve the functioning of programmes and resources directed primarily at the interactions between health workers and families/ communities at the home, community and first level health facilities (i.e. up to First Referral Units) to provide a focused set of critical interventions during pregnancy, around birth and during the neonatal period.

The Bill & Melinda Gates Foundation funded the programme. KHPT partnered with University of Manitoba, Canada, St. John’s Academy of Health Sciences, Karnataka, Karuna Trust, and Intra Health to implement the programme.

Several innovative approaches to tackling the problem evolved from the project.

• The ASHA Diary, a simple enumeration and tracking tool to assist ASHAs in population level planning and tracking of beneficiaries across MNCH care continuum
• Home-based maternal and newborn care tool to provide high quality service during home visits including screening and referral of complications
• Family-focused communication for facilitating behaviour change within the families
• Onsite mentoring, using a new cadre of nurse mentors, to improve the quality of institutional deliveries in the primary health centres
• Simplified case sheet and other tools and aids to help providers adhere to clinical standards, assist in screening, managing and referral complications in timely manner in addition to being a quality monitoring and improving tool by itself
• Skills and drills intervention to improve quality of emergency obstetric and newborn care at the first referral units
• Supportive community monitoring tools and processes to strengthen community accountability at the grass root level

Impact

The project resulted in considerable improvement in quality of maternal and newborn care at the facility level.

• Arogya Mantapas, formed at the community level, promoted collaborative action at the sub centre level among all front line health workers, Anganwadi workers, junior health assistants as well as community representatives from the Village Sanitation Health and Nutrition Committees
• The ANC check-up rates increased substantially in all project districts
• The Proportion of women who stayed for 48 hours after delivery and proportion of women who received all services across continuum gradually improved

Context

The likelihood of girls from scheduled castes and tribe (SC/ST) families in northern Karnataka completing secondary school is sharply diminished by family poverty, gender discrimination, the traditions of early marriage and devadasi dedication, boys’ actions and attitudes towards girls, inadequate measures to meet girls’ needs at schools and by community authorities and education officials to enforce girls’ right to education. The rates of underage marriage are over 30% among girls from SC/ST communities in Bijapur and Bagalkot districts.

Girls who drop out of school are more vulnerable to HIV infection and other health problems, will have a larger, less healthy family, earn less than their better educated peers, and lack voice, agency and are disengaged from larger community issues.

KHPT’s intervention research project, implemented from 2013 to 2014, chose four First Referral Units (FRUs) facilities, each from two districts, Bagalkot and Koppal, in northern Karnataka, India as intervention and control facilities to evaluate the diagnosis and management of select maternal and newborn complications.

Implementation

The intervention was a composite of the below activities.

• Skills building through refresher training for medical providers
• Emergency drills to strengthen team and system preparedness in handling select obstetric and newborn emergencies
• Supportive supervision provided by obstetric and pediatric specialists along with drills improvement of referral networks.

The intervention focused on strengthening providers’ skills and team work along with documentation.

A formative research collected information related to the facility infrastructure, human resource and supplies. This was followed by visits by experts to ensure adherence to some basic infection control practices at all study facilities. Data collection was completed in October 2014.

The Bill & Melinda Gates Foundation funded the project from 2014 – 2016. KHPT implemented it with support from IECS, Argentina and University of Manitoba, Canada.

Impact

A study, based on a mixed methods approach, evaluated the effectiveness and impact of ‘skills and drills’ intervention on such complications. It showed that the ‘skills and drills’ intervention, a relatively new mode of facility-based intervention was well accepted and appreciated by the providers, especially by the nursing staff of these facilities.

The delivery record, a new documentation format was highly valued, and used for almost all deliveries in both intervention and control facilities.

Context

Building on the learnings of an earlier pilot phase, and recognizing the need to strengthen the capacity of Village Health Sanitation and Nutrition Committees (VSHNCs) and Arogya Raksha Samitis (ARSs) to achieve their active participation in health activities, the NRHM and Karnataka Health System Development Project (KHSDRP) had included a Public Health Competitive Fund (PHCF) in their project design. This fund was granted to NGOs which had been identified based on merit and Joint Appraisal Team (JAT) reports, i.e., Karnataka Health Promotion Trust (KHPT) and Swami Vivekananda Youth Movement (SVYM) to undertake this capacity building project in the districts of Bagalkot and Koppal in Karnataka for two years (April 2010-March 2012)

The objectives of the project were to:

• Clarify the roles and responsibilities of the members of various committees to enable them to achieve their corresponding monitoring and implementation goals
• Strengthen community involvement to better public and individual health by creating awareness on health related issues among the community
• Create sense of ownership of healthcare facilities among the community and thereby make healthcare service staff more accountable, responsible, competent and efficient
• Inform the community about the various healthcare facilities they can avail and also help them voice their challenges in case they are unable to avail them
• Empower the community to coordinate the convergence of various healthcare facilities provided by various organisations and relevant departments

To achieve the stated objectives, the following activities were implemented:

• Capacity building of VHSNC/ARS in all villages and PHCs
• Kala Jathas at PHC and taluk levels
• Jana Samwada at PHC and taluk levels
• Handholding exercises

Impact

Improvement in VHSNC/ARS constitution and functionality

• Successful documentation of VHSNC/ARS meetings and activities
• Effective utilization of untied funds
• Awareness among the community about committees like the VHSNC/ARS.