With a little bit of help...

Shobha Shukla - CNS
A hot and dusty 2 hours ride on bumpy roads brought me from Kanpur to the nondescript Rasoolabad block of Kanpur Dehat, where a Home Based Post Natal Care Project (HBPNC) has brought about measurable improvements in maternal and child health. This project, funded by the World Bank and executed by a Kanpur based NGO Shramik Bharti in Rasoolabad over a period of April 2012--September 2013, has proved to be an effective and innovative approach to avert maternal and neonatal deaths in the rural community by focussing on home based management of Postpartum Haemorrhage (PPH), as a large number of maternal deaths occur in the postpartum period of 42 days after delivery, mainly due to haemorrhage.

Under the HBPNC, 225 ASHAs (Accredited Social Health Activist—one female community health activist per 1000 rural population is appointed under the National Rural Health Mission—NHRM- scheme to work as an interface between the community and the public health system) were taught simple life saving skills for crisis management during pregnancy, at time of birth and in postpartum period (to prevent PPH). The 3 days in-house training (followed by refresher training sessions) equipped the ASHAs to play a crucial role in protecting maternal and child health.

The project coordinator Shivani told me that: “The inspiration for these nontechnical PPH management techniques comes from the American College of Nursing and Midwifery, from where these simple and field tested steps have been taken. The practice sessions of ASHAs’ training focused upon simple methods like womb massage and the two hands hold method to stop the bleeding and help in contraction of uterus. Making the new mother urinate frequently in the squat position also helped a lot of women. Also, if the mother is unable to breastfeed, patting/stimulating the nipples tricks the uterus into believing that breastfeeding has begun and it contracts.”

Under this project, ASHAs maintained a track record of 2000 pregnant women in their 3rd trimester during the entire 6 months period of July 2012 to January 2013. The information collected was quite revealing and pointed to the grim scenario of maternal and neonatal health in Rasoolabad (which is representative of rural India): Out of the 2000 deliveries there were 11 maternal deaths (5 during pregnancy and 6 in postpartum period) and 99 neonatal deaths (including 52 still births) during this period. Thus maternal mortality rate for this block was 563 (as compared to India’s 212) per 100,000 live births and neonatal mortality rate was 51 (compared to India’s 32) per 1000 live births.

All the 11 women who died were below 35 years of age. Almost 55% of the maternal deaths were during the first pregnancy and in the age group 18-21 years which shows how vulnerable the reproductive health of young women is in rural India.

Unsafe abortions accounted for 40% of the deaths during pregnancy; and excessive bleeding killed 50% women in postpartum period. Also 38% of neonatal deaths were during the first pregnancy which highlights the vulnerability of first time mothers. Out of the total 74maternal complications reported, a whopping 59% were due to postpartum haemorrhage.

During my informal chat with over a dozen ASHAs, they echoed that the programme had not only increased their knowledge on safe motherhood but also helped them to save many lives. They were happy that by applying techniques learnt in the training they could save 74 mothers’ lives and 34 neonates’ lives.

“Even we have been woken from our slumber through this training. It has boosted our confidence and capacity and we have gained a lot of support and respect from the community, especially the poor—something which was absent earlier.”

“We talk to the women about family planning also. But it is not easy to change mind sets overnight. Most women have more than 3 children. Condoms are very popular, but women prefer Copper-T as it gives them more control over reproductive rights. But in some cases it has resulted in internal infections. Pills are not that popular as many users face a lot of side effects, perhaps due to their anaemic condition.”

“There are very few toilets in the village and mostly people defecate in the open. But nobody cares as it is more of a woman’s problem. Men do not mind going to the fields to defecate. Women have raised these issues in gram panchayats, but nobody has paid any heed.”

It was with pride in their voices that they shared with me their personal stories of saving lives due to the knowhow imparted to them under the project. Here are some of their inputs (names have NOT been changed to give them due credit for their selfless service):

Pushpa Yadav -- On 31 December, 2012 Shabnam, a woman of my village Chandanpurva gave birth to a child at 5 am. At 10 pm she started sweating and bleeding profusely, and said that she could not see anything. The doctor referred her to the government hospital in Kanpur. But her family was too poor to afford the journey. It was a no win situation but I did not lose my cool. I massaged her stomach slowly till the uterus muscles tightened and she felt better. When I made her squat on the ground to urinate clots of blood came out. As she was not able to breastfeed her baby I rubbed her nipples. Meanwhile I kept on massaging her abdomen. The doctor was annoyed that the patient was still there despite being referred to another hospital. But later when she saw that her condition had improved she appreciated my efforts.

Rekha Sharma—It was August 2012. It was the 5th pregnancy and 1st institutional delivery for Geeta, a woman of my village Bilha. Repeated child bearing had already made her very anaemic. I had been guiding her during this pregnancy—got her immunised, given her iron tablets, convinced her for an institutional delivery. Geeta delivered a boy around 5pm. At night I asked her if she had breastfed her child. She said that she was not able to see anything. When I removed her sheet I found her bleeding profusely. It was an emergency situation and no doctor or nurse was available. I put the infant to her breast and later helped her urinate in the squat position. Three blood clots came out. I massaged her abdomen, but even I was scared. She had come to the hospital at my insistence and was now in a bad shape. It was 3 am. I managed to get a glass of tea and some biscuits for her. I made her urinate again and again till the urine was clear of clots. Gradually she became better and was discharged the next morning. It was only the life saving techniques learnt in my training at Shramik Bharti that could save Geeta’s life.

(When I later met Geeta with her one year old sickly son in her lap she said that, “I am indebted to Rekha who helped me even when the doctors had given up and referred me to Kanpur—a journey I could not afford. But Rekha’s techniques worked and I recovered. But my child is very weak. We are very poor. My husband works on the fields of others. We defecate in the open. I would like to have a toilet but will never be able to afford it. I would rather use the money to educate, feed and clothe our children. I have 5 sons. I kept on getting pregnant in the hope of having a daughter.”)

Sri Devi—A woman delivered a girl child on 20th October, 2012 at the hospital. She had already lost 3 children who had died within 3 months of birth. She was discharged the next day. For 2 days she remained okay but on the 3rd day started bleeding. Her family sent for me. I massaged her lower abdomen, made her breastfeed her child and gave her some jaggery and milk to eat as she was very weak. She had also not urinated since morning. So with her sister-in-law’s help I made her sit on the ground and urinate, after which her condition improved.

Rama Devi-- I took one woman of my village Anta case to the Bilhaur community health centre for her 1st delivery. There I saw another woman, who had delivered her 6th child, in a bad shape and bleeding profusely. I used all the techniques I knew—rubbed her nipples; made her squat on the ground and urinate when a big clot came out; rubbed her stomach slowly for a long time and made her drink tea. Her condition improved gradually. Seeing all this, the 30 odd ASHAs present there were very impressed and on their request I then gave them a live demonstration of the techniques I had learnt.

The simple interventions have resulted in drastic improvements in a short period as is evident from baseline and end line survey data—

Postpartum maternal deaths decreased by 37%-- from 92% to 55%

Percentage of institutional deliveries increased from 72% to 75%.

Percentage of ASHAs providing birth preparedness information to the women increased from 11% to 89%.

Percentage of ASHAs making the requisite six visits during the postpartum period of 42 days for maternal and neonatal safety jumped from 28% to 77%.

This project seems to be a workable model and it would be worthwhile to incorporate it in the NRHM and other public health programmes with a view to decrease maternal and child mortality and improve health.

Shobha Shukla, Citizen News Service - CNS
October 2013
(The author is the Managing Editor of Citizen News Service - CNS. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, violence against women and girls, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org) 

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