1 Role of Dais in Promoting Safe Motherhood and New Born Care In Resource Poor Settings: The SEWA Rural Experience

2 Family Centred Safe Motherhood and New Born Care Project (2003 onwards) Coverage Whole of Jhagadia Block Whole of Jhagadia Block 168 Villages and 171,000 pop. 168 Villages and 171,000 pop. Rural, Poor and Tribal Pop. Rural, Poor and Tribal Pop. Working Closely with 6 Govt. PHCs Working Closely with 6 Govt. PHCs About 80 % Home Delivery at the Beginning of the Project in 2003 About 80 % Home Delivery at the Beginning of the Project in 2003 Less than 1.5 % Delivery in Public Health Institutions Less than 1.5 % Delivery in Public Health Institutions Every Year Every Year Monitoring Every (about 4000) Pregnancy OutcomesMonitoring Every (about 4000) Pregnancy Outcomes Monitoring Every (about 3600) NeonatesMonitoring Every (about 3600) Neonates 2

3 Family Centred Safe Motherhood and New born Care Project (2003 Onwards) (168 Villages, 171,000 pop., About 4000 Pregnancy Outcomes Every Year ) Rural, Tribal and Poor Community with 80 % Home Delivery

4 Base Line Status of Jhagadia Block Complete ANC Care: <10 % Institutional Delivery: 22 % –In Govt. Institutions: 1.5 % Immediate New Born Care: 49 % –Initiation of Breast Feeding Within First Hour: 20 % –No Bathing on First Day: Immediate Post Natal Visit: Negligible

5 Base Line Status of Jhagadia Block Institutional Delivery: 22 % (in 2001 – 03) In Govt. Institutions: 1.5 % Maternal Deaths: 35 (in ) MMR: % During Prenatal Period, 30 % Post Natal Period, 10 % Unsafe Abortion Practises Neonatal Deaths: 151 (in 2003 – 04) NMR: % on First Day

6 Results & Realities (Population : 1,71,000) Live Births 3129 (98%) 3236 (91%) 3676 (89.2%) 3479 (89%) 3536 (90%) 3525 Still Births 18 (0.5%) 71 (2%) 103 (2.8%) 84 (2%) 89 (2.2%) 82 Abortions 33 (1.0%) 165 (5%) 194 (3.5%) 210 (5.4%) 191 (4.8%) 189 MTPs 15 (0.5%) 76 (2%) 142 (3.5%) 140 (3.6%) 110 (3%) 109 Total Preg. Outcome Maternal Deaths Neonatal Deaths

7 Maternal Mortality Ratio (MMR) Jhagadia Block 171,000 Pop. (about 3500 Deliveries a Year)

8 8 Neonatal Mortality Rate (NMR) Jhagadia Block 171,000 Pop. (about 3500 Deliveries a Year)

9 How Did This Happen? How Did This Happen?

10 Family Centred Safe Motherhood and New born Care Project (168 Villages, 171,000 pop., About 4000 Pregnancy Outcomes Every Year ) Village Level Front Line Volunteers: TBAs and Arogya Sakhis (200 Each) Middle Level Supervisory Cadre: Link Workers (Setu Karyakers) (21) Field Supervisors (8) Support From Govt. PHC Staff (6) Head Quarter Referral Support: SEWA Rural Base Hospital (FRU) at Jhagadia Providing Comprehensive Emergency Obstretic & Neonatal Care (CEmONC) Farthest Village about 50 km. away (takes less than two hours to reach Base Hospital)

11 Core Roles of a Dai at SEWA Rural Promoting Institutional Delivery and Role of a Birth Companion If She Has to Attend Home Delivery, then…. (With the Support of Arogya Sakhi) Conduct Safe and Clean Normal Delivery Provide Immediate New Born Care Timely Identification of Delivery Complications and Ensuring Prompt Referral to an Active FRU

12 Capacity Building of Dais Dai’s Tool Kit Dai in Action Pairing with Sakhis Use of Mucus Aspirator

13 Initiation of Breast Feeding Within First Hour (Among All Live Births)

14 Baby Bath After First Day

15 All Important Back up Support by a Fully Functional First Referral Unit By SEWA Rural’s Base Hospital Providing Round the Clock Comprehensive Emergency Obstretic and Neonatal Care which includes…. –24 by 7 Ambulance Response –Presence of Gynecogist, Anaesthetist, Paediatrician and Supporting Staff –Life Saving Medicines and Equipments in Place –Facility of Operation Theator, Blood Bank and Laboratory –Cesarian Section Rate: About 15 % –Clean Wards Ensuring Water, Light and Food

16 All Important Back up Support by a Fully Functional First Referral Unit By SEWA Rural’s Base Hospital Providing Round the Clock Comprehensive Emergency Obstretic and Neonatal Care which includes…. –Hospital Staff Sensitive and Receptive to Referral from Field –Allowing Field Staff to be with the Mother in the Labor Room –Close Linkage and To and Fro Feedback Mechanism With the Field Staff –Detailed Documentation of All Maternity Admissions (Which Includes About 1500 Deliveries a Year) –Susidised Charges with Safety Net for Poor –Approved Under Chirinivi / Janani Schemes

17 All Important Back up Support by a Fully Functional First Referral Unit By SEWA Rural’s Base Hospital Ambulance (Round the Clock) Health Education in OPD Front line Workers Welcomed in Labor Room Operation Theater Blood Transfusion Neonatal Intensive Care Unit

18 Hospital Delivery (%) Jhagadia Block 1.71 Lac Pop. (Out of about 3500 Deliveries a Year)

19 Referral of Maternal Cases by Front Line Workers to Base Hospital

20 Total Maternal Admissions at Base Hospital

21 Complicated Maternal Admissions at Base Hospital

22 Possible Solutions for Improving Safe Motherhood and New Born Care in Resource Poor Settings Not a Uniform Jacket For All, but the Region Specific Strategy is the Answer Maternal, Foetal and Neonatal Care Should Go Together in a Combined Package Evidences Have Shown That In Resource Poor Settings and Where Community Continues to Delivering at Home… –Not the Expensive Gadgets and Infrastructure, but Locally Adaptable Simple and Cheaper Interventions Can Make A Big Difference –The Front Line Workers including TBAs (Dais) HAVE the Potential to Play a Critical Role

23 Possible Solutions for Improving Safe Motherhood and New Born Care in Resource Poor Settings What is Important is Skilled Attendance at Birth and not Necessarily Institutional Delivery What These Front Line Workers Need is…. –Respect, Trust and Sustained Efforts Towards Capacity Building in True Sense –Sound Telecommunication & Transportation Network for Timely Referral of a Case with Complications –All Important Back up Support of a Fully Functional FRU

Practising Dais & 163 Arogya Sakhis Experience

Practising Dais & 163 Arogya Sakhis Age Age

Practising Dais & 163 Arogya Sakhis Education

27 A Dai on an average conducting about 10 deliveries a year Considered as “Dharam nu Kam”, Not much Monetary Gain About 25 % of villages have now less than 15 % home Delivery (only 2 – 3 Delivery a year) No Dai in about 20 % of villages at present About 25 Arogya Sakhis in remote villages have started conducting deliveries and were given formal training Direct Role in Prenatal Care, Post natal Care both for mother and New Born baby and expanded role continues, birth companion during delivery Looking Ahead…….

28 Looking Ahead……. Birth companion during delivery ? Worth Debating…… Why not Normal Delivery be Conducted Safely and Cleanly in the Conducive Environment at Home by A Skilled Person like A DAI ? IF…… She can timely identify delivery complications … Transport Network in place for prompt referral of a complicated case …..and Back up Support of a Functopnal FRU providing CEmONC is in Place..

29 Let The March Continues.. Towards Let The March Continues.. Towards

30 Healthy Motherhood Promising Childhood & Better Society