Improving maternal and newborn health among tribal communities in Eastern India THE EKJUT TRIAL 2

1. Improvingmaternalandnewbornhealthamongtribalcommunitiesin Eastern IndiaTHEEKJUTTRIAL2 A collaboration between: Centre for International Health and Development With assistance from: PRADAN

2. Women’s group intervention The ekjut trial

3. Historical perspective on community mobilisation Successful pilot community mobilisation programmes: • Jamkhed Project – Maharashtra, India • Kakamega Project - Western Kenya??? • Communities were assisted to identify their own problems, collect data, and implement solutions. • These demonstration projects brought substantial improvements in health for communities.

4. Previous studies There has been little research on community mobilisation: • SCF Warmi Project, Bolivia - 50% reduction in PMR (small sample size, not RCT) • MIRA Makwanpur trial in Nepal (RCT) - 30% reduction in NMR - fewer maternal deaths in intervention areas Both projects used a participatory women’s group action cycle.

5. Why women’s groups? • Existing women’s groups are an untapped resource and might have inbuilt sustainability. • Conventional behaviour change methods are not always successful. • Can peer groups unlock the behaviour change and personal empowerment crucial to improving health outcomes and benefit poor families? • Can the impact seen in the Makwanpur trial be replicated in a different setting? • Are interventions that empower groups cost-effective and benefits equitable?

6. Our intervention • 1 local woman facilitator per cluster (18 facilitators in 18 intervention clusters) • Each facilitator was responsible for an average of 13 groups. Total - 244 groups • Each group met once a month • Facilitators used manuals to guide their meetings WOMEN’S GROUPS - a participatory approach to improve maternal and newborn health Facilitator’s Manual

7. The facilitator • Not a teacher • Local woman selected using criteria agreed with the community • Two thirds of the facilitators belonged to the tribal community • 5 + 2 days residential training

8. Profile of Groups (n = 244)

9. Characteristics of group members * Group members who delivered

10. Deliveries in our intervention areas

11. Profile of group members

12. 4 Phases of intervention Phase 1 Identifying and prioritising problems together Phase 4 Evaluating together Phase 2 Planning solutions together Phase 3 Implementing solutions together

13. Women’s group action cycle

14. To Chaibasa 3 2 Chaibasa road To Kharswan Sanjay river From CKP PILOT VILLAGES 1-Narangabeda 2-Ichapi 3-Uliguttu 1 Pansua

15. MEETING CYCLES (first 2 phases) 1st to 5th Meetings : Identifying & prioritizing problems with the help of picture cards 6th to 9th Meetings : Planning strategies to solve the problems through story telling and bridge game

16. MEETING CYCLES (last 2 phases) 10th to 18th Meetings : Implementing identified strategies 19th & 20th Meetings : Evaluating together

17. Phase One Identifying and prioritizing problems Meetings -1 to 5

18. Piggy back game

19. Understanding cultural practices • Cord is cut only after delivery of placenta • Fair number of men conducted deliveries • First service provider is the shamen / ojha / faith healer • Colostrum is considered to be bad for the baby • Bamboo strip, maize leaf, knife, arrow used for cord cutting • Women in postpartum period are given one meal a day

20. Picturecards

21. Prioritizing problems Prioritizing maternal and newborn problems by the community using 6 stones: Most important 2nd Most important 3rd Most important

22. Phase Two Planning strategies Meetings - 6 to 9

23. Understanding cause and effect Stagnant water Not using bed nets Did not seekcare Unable to see ANM for 5 days Performing puja Malaria (fever with Chills, vomiting, Headache) Stillborn baby Mosquito breeding Bitten by mosquito Less fetal movement

24. Understanding cause and effect Cause & effect relationship through pictorial stories, followed by ‘but why’ game

25. Prioritizing strategies ‘Bridge Game’ • 1st BRICK – Where are we now? (This refers to Meeting 2) • 2nd BRICK – Where do we want to be? • THE RIVER – The barriers we face (This refers to Meeting 6) • 2 LONG STICKS – The strengths we have as a group (This refers to Meeting 1) • SHORTER PLANKS – The strategies we come up with (We decide these now!)

26. Arriving at Strategies To arrive at the causes & solutions, the facilitator needs to ask: • “But why did this happen?”after the story telling session • “But how can we prevent the problems from happening?” • To arrive at the strategies, thefacilitator needs to ask: • How they would like to deal with these solutions? • What can be done to prevent the problem? • How feasible is the strategy?

27. Process for sharing Deciding on… • Reasons for holding the community meeting • Who to invite and how to invite • Method of dissemination to the community • How to arrange for the meeting

28. Preparation and Practice Deciding on… • Roles and responsibilities • Venue, time and place • Invitation list • Logistics arrangements • Rehearsal and practice

29. Community Meeting - 1

30. Phase Three Putting strategies into practice Meetings -10 to 18

31. Meeting 10- Taking responsibilities • Members decide who takes what responsibility • What resources are required and how to obtain them • How non-members can help • Jointly overcoming obstacles

32. Meeting 11 - Measuring progress • Group members decide on simple • indicators • Are the strategies being implemented ? • What are the problems faced?

33. Green cards – for prevention • Brown cards – for home care • Red cards – for emergency/facility care

34. Picture card games (Understanding solutions) Meeting 12 Preventing maternal problems Meeting 13 Preventing newborn problems Meeting 14 Understanding home care cards Meeting 15 Understanding Facility based- Emergency cards

35. Meeting 16 -Emergency preparedness • To identify emergency problems • To discuss possible delays in responding to emergencies -‘Emergency drill’ • To discuss how these delays could be reduced

36. Meeting 17-Non-emergency Care • To identify non- emergency problems • To discuss how to respond to non-emergency problems and appropriate referral – ‘voting with feet’ game Picture or video

37. Meeting 18-Learning from others Learning and sharing of experiences and strategies that other groups have used

38. Preparation and Planning for Cluster level Community Meeting - 2

39. Cluster level Community Meeting

40. Meeting 19 Phase-wise evaluation by group members: of their achievements and the help provided by them

41. Meeting 20 Evaluation of impact of the intervention on the larger community - Do they think they have influenced the behaviour of others in their community? If so, how? What facilitated & what prevented - How have men been involved in the cycle? How do the group members feel about their level of involvement?

42. Thank You