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 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.
We work to improve maternal, neonatal health outcomes and address their nutritional status deficits to achieve India’s ‘Good Health and Wellbeing’ target of Sustainable Development Goal 3 in the areas of project implementation. We focus on creating innovative quality Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCHA) care models including strengthening grassroots level community structures and building integrated technology RMNCHA solutions in high priority states in India.
Improve rural women’s health and nutrition before, during and after pregnancy
Improve new-borns’ health through management of complications and post-birth care
Increasing the practice of KMC for a prolonged duration to improve newborn health
Strengthening the capacity of frontline workers in Bihar
Tackling vitamin and micronutrient deficiencies through food fortification
Studying the efficacy of micronutrient fortified rice on school children and mothers
About 27% of all babies are born low birth weight (LBW) in India (MoHFW 2014). Kangaroo Mother Care (KMC) comprised of skin-to-skin contact along with exclusive breastfeeding is proposed as a ‘game-changer’ for improved newborn health among low birth weight newborns. It has also proven to improve bonding between mother and infant, reduce newborn infections, lower stress levels, and many other benefits.
Currently, KMC coverage is minimal in India and across the globe despite its cost-effectiveness being known for decades due to various barriers at the community, health care workers, and facility level.
Government of India guidelines also recommend KMC practice of prolonged duration to reduce mortality due to low birth weight. The World Health Organization awarded funds to St. John’s Research Institute and KHPT for an implementation research initiative for scaling up KMC in Koppal district, Karnataka. Koppal was selected since it’s a high priority district as per the National Health Mission and also because of prior experience of the study teams with MNCH work in Koppal.
The project had a formative research period of 4 months to understand barriers/facilitators to KMC utilization from the perspective of program managers, care providers, and families within the local Karnataka context before scaling up the intervention covering a population of 1.6 million through the existing health system of public-private mix in rural and urban areas.
The project aimed to develop, implement and evaluate an innovative implementation model designed to attain Kangaroo Mother Care (KMC) coverage of 80% among all eligible babies with birth weight <2000gms in one under-served district of Karnataka state (Koppal district). The project had interventions at two levels. This included the facility level wherein all stable babies weighing under 2000g received KMC as early as possible and families were enabled to continue to provide KMC through a cadre of nurse mentors. At the post-facility level, families were enabled to continue KMC at home (learn how to support the continuation of KMC during the neonatal period or until the baby no longer accepts it) where ASHAs were trained along with the ASHA facilitators.
KHPT continues to implement and evolve the KMC initiative in Koppal
Maternal, neonatal and child health is an important public health goal. Despite progress, communities are still failing women in developing countries. In order to improve maternal and child health, barriers that limit accessibility, availability of quality maternal health services should be identified and addressed at the health system, and community level. It is to be noted that a large number of maternal mortality is a result of low level of maternal healthcare-seeking behavior. There are multiple factors which act as a barrier to women to receive adequate care during pregnancy like: lack of information, cultural beliefs, distance to facilities, poverty and non-availability of quality health services. Both access to and utilization of maternal healthcare are prerequisites for better health outcomes among women and child.
It is widely agreed that communities should take an active part in improving their own health outcomes and that front line health workers (FLW) can play a vital role. Better health requires that women and children have the ability to access quality services from conception and pregnancy to delivery, the postnatal period, and childhood. The ASHA, ANM and AWW work across the primary health care spectrum to provide health education and promotion, distribute commodities, diagnose and manage illness, and provide referrals. Substantial evidence suggests that community-based interventions are an important platform for improving health care delivery and outcomes.
With the support of the Bill & Melinda Gates Foundation, the Bihar Technical Support Program (BTSP) spearheaded by CARE focused on supporting the government of Bihar in improving the efficiency, effectiveness and equity of public sector delivery of interventions critical for the survival of the new-born and the mother. One of the focus areas was to improve the performance of front line workers, specifically to increase the quantity and quality of interactions between the FLWs and the community to drive critical RMNCH behaviours.
KHPT is working with CARE to build the capacity of field level implementation team through Block Coordinators and AHSA facilitators to effectively engage pregnant women, mothers, newborns, their family decision makers and community structures. The model will be focused towards developing audio-visual online based modular training to develop a team of trainers within key staff of CARE with representation from district and block level along with select ASHA Facilitators. In view of the SARS-CoV 2 pandemic, the package will be disseminated through internet based platforms
The intervention will address three focus areas:
The duration of the engagement will be for a period of 9 months from July 2020 – March 2021.
KHPT has entered into an agreement and is collaborating with the Global Alliance for Improved Nutrition (GAIN) to curb and tackle the endemic and widespread deficiency of Vitamin A and D, Folic acid, Vitamin B12 and Iron in general populations across many states in India. The project aims to create a favourable policy environment to promote food fortification, build capacity of industry to adopt fortification of edible oil and milk and increase awareness on benefits of fortified food among general population in intervention states. The project also intends to work closely with industry stakeholders, to promote and strengthen fortification of edible oil, milk and wheat flour as per notified standards.
The initiatives include
Through these initiatives, KHPT aims:
KHPT is conducting a study entitled “The Long term (2 years) efficacy of indigenously developed micronutrient fortified rice (fortified with iron, vitamin B12 and folic acid) in improving iron stores in school children and their mothers” in the Koppal district of Karnataka and Gangawati, one of the blocks in Koppal, which is the highest rice producing block in the state, and is also known as the “rice bowl of Karnataka”. Koppal also forms part of the Hyderabad-Karnataka region which is the most backward region in the state in terms of development indicators.
I knew KMC means ‘keeping the low birth weight baby covered and keeping the baby next to the mother’. In 2016, I received exclusive training on KMC and there I learnt that KMC is much beyond this and how it benefits both mother and baby and also the practical sessions on KMC. Now I confidently speak about KMC and promote KMC in the community.
I delivered 3 female babies in Koppal district hospital and they were very small when they were born. After hearing that I had delivered three girls, my husband left me alone in the hospital and went away. I was heartbroken, but the doctor and hospital staff counselled me about the importance of female children and told me about the importance of doing Kangaroo Mother Care. If they hadn’t counselled me, my babies wouldn’t have survived today! Don’t discriminate against girl children. They are a gift.
The ASHA told me that even fathers can give KMC (Kangaroo Mother Care) to low birth weight babies. I then decided to support my wife and started giving KMC to my baby. It brought me and my baby together!
Improving facility and community level care of new mothers, infants and children
Strengthening providers’ skills to manage maternal and newborn complications
Strengthening community involvement to better public and individual health
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.
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 project resulted in considerable improvement in quality of maternal and newborn care at the facility level.
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.
The intervention was a composite of the below activities.
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.
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.
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:
To achieve the stated objectives, the following activities were implemented:
Improvement in VHSNC/ARS constitution and functionality