1. Baseline Findings (21st November 2004 to 30th July 2005)

2. The System A monitoring system has been developed to cover all 36 control and intervention clusters for the duration of the project. The intention is to create a monitoring system that can be easily replicated, at low cost, elsewhere. The system comprises of two stages.

3. Stage One 1). The Identification Stage The system aims to identify: 1. All births to women who permanently reside in the study area AND 2. All deaths to women of reproductive age (15-49) in the study area

4. Key Informants Key informants are either traditional birth attendants (TBAs), relatives of TBAs or active village members. 1 key informant is responsible for covering a logical geographic area of approximately 250 households Their role is to identify all eligible births and deaths within this area irrespective of whether they attended the birth. They are paid an incentive of 30 rupees for every accurate identification. The key informants meet with interviewers once a month. The interviewers visit the identified households to verify the births and deaths before paying incentives

5. Stage Two One interviewer is recruited for each cluster as a full-time salaried member of staff. Their role is to verify the information provided to them by key informants, and where a birth has occurred, to interview the mother once, at around 6 weeks after delivery. Detailed information is collected on the antenatal, delivery and the postnatal periods for all births in the study area, as well as background information on the mother and household characteristics.

6. Verbal Autopsies In the event of a stillbirth or neonatal death the interviewer conducts a verbal autopsy with the mother. In the event of a maternal death, pregnancy related death or late maternal death the interviewer conducts a verbal autopsy with family members who were present at the time of death Verbal autopsies are also completed with the care provider, if one was present at the time of death. This includes informal health care providers such as TBAs, village doctors and traditional healers as well as formal health care providers.

7. Additional Checks All deaths to WRA are identified and maternal, pregnancy late maternal deaths are identified through a process of elimination All women identified are ‘snowballed’ to see if they can identify any other women of reproductive age in the study area who have given birth recently or died. 14% of interviews cross-checked by supervisors.

8. The Monitoring System

9. The Findings

10. Births Number of births4672 Number of singletons4584 Number of twins44 Number of live births4495 Number of infants alive at one month4236 Crude Birth Rate30

11. Neonatal Outcomes Stillbirth rate per 1000 births (n)38 (177) Neonatal mortality rate per 1000 live births (n)58 (259) Early neonatal mortality rate per 1000 live births (n)39 (175) Late neonatal mortality rate per 1000 live births (n)19 (85) Perinatal mortality rate per 1000 births (n)75 (352)

12. Cause of Death

13. Background Characteristics

14. Age

15. Religion

16. Tribe / Caste

17. Education

18. Number of Pregnancies

19. Antenatal

20. Number of Antenatal Visits

21. Timing of 1 st Visit

22. Services Received

23. Received Iron and TT

24. Delivery

25. Place of Delivery

26. Delivery Attendant

27. Use of Items During Delivery

28. Newborn and Postnatal Care

29. Instrument to Cut Cord

30. Wiping and Wrapping

31. Bathing

32. First Breastfed

33. Breastfeeding Practices

34. Newborn Check-up

35. Maternal Postnatal Check-up

36. Population characteristics … Predominantly tribal (HO, Santhal, Bhuiyan, Munda) Non-tribal are predominantly OBC Sarna and Hindu Low education High number of pregnancies Conclusion

37. Very high newborn mortality Low uptake of ANC ANC not offering full range of services – especially advice Uptake of iron and TT better Most delivered at home with assistance of friend / relative or TBA Conclusion

38. Many cut cord with new blade, but very few boiled Very few used SDK, gloves, plastic sheet Most wiped and wrapped in first hour, but few immediately – especially wrapping Most infants bathed in first 6 hours – very few wait 24 hours Very few mothers / infants had postnatal check-up. Those who did - mainly for problem Most infants were breastfed, need to increase exclusive breastfeeding, and resist attempts to increase use of formula milk Conclusion