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ORIGINAL ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 1  |  Page : 19-25  

Influence of integrated community- and facility-based interventions on select maternal and neonatal outcomes in Northern Karnataka, India: Lessons for implementation and measurement


1 Deputy Director, Karnataka Health Promotion Trust, Bengaluru, India
2 Senior Advisor, Programs, Community and Communications, University of Manitoba, Winnipeg, Canada; Managing Trustee, Karnataka Health Promotion Trust, Bengaluru, India
3 Deputy Director, Monitoring and Evaluation, Karnataka Health Promotion Trust, Bengaluru, India
4 Deputy Director, Communication and Community Interventions, Karnataka Health Promotion Trust; Deputy Director, Communication and Community Interventions, Health Action Trust, Bengaluru, India
5 Assistant Professor, Department of Community Health Sciences; Research Associate, Centre for Global Public Health, University of Manitoba, Winnipeg, Cananda
6 Assistant Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Director, Karnataka Health Promotion Trust, Bengaluru, India

Date of Web Publication16-Feb-2017

Correspondence Address:
Rajaram Subramanian Potty
Karnataka Health Promotion Trust, IT Park, Rajajinagar Industrial Area, Behind KSSIDC Admin, Office, Rajajinagar, Bengaluru - 560 044, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.200256

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   Abstract 

Background: Sukshema project provided technical assistance to National Health Mission of government of Karnataka to improve maternal, newborn and child health (MNCH) outcomes in eight districts of Karnataka between 2009 and 2015. The project designed tools, processes and provided mentoring to frontline workers, community structures, and facilities to improve demand generation and quality of MNCH services. Objectives: To assess over time changes in selected MNCH care indicators among women who had delivered in the past 2 months in Bagalkot and Koppal districts. Methods: An innovative strategy was designed to collect routine monitoring data, namely community behavior tracking survey using mobile technology. The catchment area of an Accredited Social Health Activist (ASHA) was the primary sampling unit, and in each district 200, ASHA areas were selected. Women from these selected ASHA areas were interviewed and information collected on various MNCH care outcomes. Multivariate logistic regression was used to assess changes in selected MNCH care indicators. Results: Gradual increase was noticed in institutional delivery, hospital stay for 48 or more hours, initiation of breastfeeding within 1 hour and continuum of MNCH care. Forty-eight hours stay and initiation of breastfeeding improved marginally possibly due to health systems and cultural norms. Conclusions: Results indicated that the interventions were successful in changing the critical MNCH care indicators and hence have potential for replication in similar high priority district settings.

Keywords: 48 hours stay in facility, breastfeeding initiation, community-based, continuum, maternal, monitoring, neonatal


How to cite this article:
Potty RS, Lakkappa MH, Kar A, Bidappa M, Manjappa RB, Jayanna K. Influence of integrated community- and facility-based interventions on select maternal and neonatal outcomes in Northern Karnataka, India: Lessons for implementation and measurement. Indian J Public Health 2017;61:19-25

How to cite this URL:
Potty RS, Lakkappa MH, Kar A, Bidappa M, Manjappa RB, Jayanna K. Influence of integrated community- and facility-based interventions on select maternal and neonatal outcomes in Northern Karnataka, India: Lessons for implementation and measurement. Indian J Public Health [serial online] 2017 [cited 2017 Feb 21];61:19-25. Available from: http://www.ijph.in/text.asp?2017/61/1/19/200256


   Introduction Top


Evidence suggested shortfall in reducing maternal mortality and under-5 deaths as targeted by the Millennium Development Goals in low- and middle-income countries.[1],[2] In India, the progress of targets for reducing under-5 mortality was moderately on track and improvement in maternal health was slow and offtrack.[3] As such, there is growing interest in interventions aimed at community and health facility levels to improve the health of women and children to accelerate the reduction in maternal and child mortality rates. Community participation has long been advocated to support the provision of local health services and in delivering interventions at the community level.[4],[5] Few community-based intervention trials conducted in Asian countries has provided evidence of improving the neonatal survival.[6],[7],[8] It was documented that universal coverage of 16 proven newborn health interventions could avert up to 72% of all newborn deaths.[9] Home-based package of maternal and newborn health interventions delivered by community health workers reduced neonatal mortality by 62%.[10] Seventy-four percent of maternal deaths could be averted if all women had access to interventions that address complications of pregnancy and childbirth, especially emergency obstetric care.[11] Systematic review of the effectiveness of training in emergency obstetric care concluded that training programs may improve quality of care, but strong evidence is lacking.[12]

In India, the National Rural Health Mission was launched by the honorable prime minister on April 12, 2005, to provide accessible, affordable, and accountable quality health services even to the poorest households in the remotest rural areas.[13] The major objective was to reduce the number of mothers and infants who die during and immediately after birth, and the number of children under five who die from common illnesses. Karnataka state is better placed as far as the maternal, newborn and child health (MNCH) indicators are concerned in comparison to the national level.[14] However, within the state, the MNCH indicators vary considerably across various districts.[15]

To address the inequities and improve the MNCH outcomes in the Karnataka state a technical assistance project focused on eight districts in the northern Karnataka namely, Bagalkot, Koppal, Bellary, Raichur, Bijapur, Yadgir, Gulbarga, and Bidar among the rural population. The project prioritized technical interventions at health facility and community levels based on detailed situational assessment and thorough deliberation with stakeholders. Both the interventions were field tested in two districts separately and subsequently scaled up into other six districts. At the facility level, in 2012, the project introduced on-site mentoring of primary health center (PHC) staff nurse on clinical and delivery issues through dedicated cadre of nurse mentors. This intervention was first tested in Gulbarga and Bellary districts on a pilot basis and then scaled up into other six districts. Community level intervention was first introduced in Bagalkot and Koppal districts in 2012 and then scaled up into other six districts. The community intervention included a package of tools and processes for frontline workers such as enumeration tracking tool for tracking beneficiaries across MNCH care continuum, home-based maternal, and newborn care tool to improve quality of home visits, family focused communication to improve behaviors and practices, supportive community monitoring tool to improve community-level engagement and accountability and subcenter forum (Arogya Mantapa) to coordinate all the activities in the subcenter region. The front-line workers (FLW) such as Accredited Social Health Activists (ASHAs), Anganwadi workers, and Junior Health Assistants were provided with training for using and maintaining these tools and activities. The interventions aimed at increasing the frequency and quality of interactions of FLWs with families, improve the community's knowledge and practice regarding MNCH care, improve the quality of care at birth and immediate postpartum care at health facilities, and improve the community participation in planning and monitoring of MNCH program. These interventions were operational between 2012 and 2014.

In this context, the objective of the present paper is to examine the changes in selected MNCH indicators over time in two districts, namely, Bagalkot and Koppal, where the community interventions were first introduced along side the facility-based interventions. These two districts were selected for the analysis because the community interventions were piloted in these two districts before scaling up to the rest of the region and also the exposure to community level activities were longer in these two districts as compared to other districts.


   Materials and Methods Top


Study design

Serial cross-sectional surveys were adopted as part of monitoring system for the project. New methodology was named community behavior tracking survey (CBTS) as the surveys tracked community behaviors around critical MNCH indicators such as institutional delivery and 48 h stay. Mobile phones were used to collect the information from the eligible mothers. The data collected were transferred to the server immediately after the interview was completed. This provided a real-time feedback data to the project, reducing the lag between data collection, data entry, and analysis of data for monitoring the progress. The information was collected on selected background characteristics of women; knowledge on danger signs during pregnancy, delivery, and postpartum, anemia among pregnant and delivered mothers, birth planning, government schemes for mother and children; and utilization of antenatal care (ANC), delivery care, and postnatal care (PNC) services.

Sampling strategy

In this survey, the catchment area covered by an ASHA was the primary sampling unit. In each district, a sampling frame was prepared consisting of all the ASHA catchment areas, irrespective of whether ASHA positions were filled or vacant. Thus, it was ensured that the sampling frame represented all the rural areas in the district. The sample frame was regularly updated before each round of CBTS. In each district, 200 ASHA areas were selected from the sampling frame using systematic sampling method, stratified at the block (Taluka), and PHC levels. Within each selected ASHA areas, households were enumerated using a house listing form in a clockwise fashion with a random start. The investigators listed all the eligible women, who had delivered in the past 2 months before the survey – either a usual resident or a visitor in the household and interviewed them. The enumeration and interviews were halted when a maximum of 5 completed interviews was achieved or 200 households in the ASHA area were enumerated or if < 200, all the households (HHs) in the ASHA areas were enumerated.

Data collection

In Round-1 of CBTS in Koppal and Bagalkot districts, paper-based questionnaires were used instead of mobile application to collect the data. Furthermore, the data were collected by the resource persons who were involved in the community intervention in these districts. However, after the Round-1 of CBTS in Koppal and Bagalkot districts, 20 field investigators were recruited and trained for conducting the CBTS using the mobile phone application. In each district, the data collection was carried out by ten field investigators and completed within 1 month. Round-1 data were collected during June–July 2012; Round-2 was collected during March–April 2013; Round-3 was collected during July–August 2013; Round-4 was collected during November–December 2013; and Round-5 was collected during April–May 2014.

Statistical analysis

The selected background characteristics of the women were compared between the five CBTS rounds. Further, the changes in selected MNCH care outcome indicators were observed between the five CBTS rounds. A nonparametric test was also applied for trends across five rounds of CBTS for the selected MNCH care indicators. Multivariate logistic regression model was performed to identify changes in selected MNCH care indicators between first and other rounds. In the logistic model, continuum of maternal and neonatal care and breastfed within 1 hours were used as the outcome variables. To identify statistically significant changes in the outcome variables between first round and subsequent rounds, four separate logistic models were applied for each of the outcome variables. Since our main interest was to study the difference in the selected MNCH care indicators across various rounds as compared to the first round, the model considered round as an independent variable. The other independent variables entered into the model were the age of the women, caste of the women, below poverty line (BPL) category, residential status of the women and district. The continuum of maternal and neonatal care was defined as the women who received at least three ANC visits in a health facility, who delivered in a health facility, who stayed in the facility for at least 48 hours and who received PNC visit by ASHA at home. All the statistical analyses were conducted using Stata version 12.0 (StataCorp LP, College Station, TX, USA).

Ethics approval and permissions

The ethical approval to analyze and publish the monitoring data were sought by the institutional ethics review board of St. John's Research Institute, Bengaluru. The subjects who participated in the study were explained about the purpose of the study; oral consent sought before the actual data collection by the field investigators. The project also sought appropriate permissions from the government of Karnataka to implement the interventions and the monitoring assessments.


   Results Top


[Table 1] presents the distribution of recently delivered women between different rounds of CBTS. Since the purpose of CBTS was predominantly to monitor the project, only few background characteristics of the women were collected. Overall, no difference was observed in the distribution of women according to age, caste/tribe and district across various rounds of CBTS. However, the difference in the distribution of women according to possession of BPL card was observed in the subsequent rounds as compared to the first round. It was also found that the percentage of women who were visitors, increased from 73% in round-1 to 83% in round-5. The proportion of women who were visited by ASHA more than three times also gradually increased in the study districts.
Table 1: Percentage distribution of recently delivered mothers according to selected characteristics in different rounds of community behavior tracking survey

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Trends in selected maternal and neonatal care indicators for recently delivered women across CBTS rounds are provided in [Table 2]. Three or more ANC visits to a health facility increased from 73% in Round-1 to 92% in Round-5. It was also found that more women delivered in an institution and stayed 48 or more hours in the health facility after the delivery across various CBTS rounds. PNC visit by ASHA in the home within 1 month of delivery did not show any improvement across various rounds of CBTS. However, a gradual increment in the continuum of maternal and neonatal care over the time period was identified in the study area. Initiation of breastfeeding within 1 hours of delivery improved over the time period. The test for trends across various rounds of CBTS showed a significant difference over time for all the outcome variables studied, except for PNC visit by ASHA within 1 month of delivery.
Table 2: Trends in selected maternal and neonatal care indicators for births during the 2 months before the survey

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Continuum of maternal and neonatal care had significantly improved between CBTS rounds [Table 3]. Non-scheduled caste and non-scheduled tribe women were likely to have a higher coverage for care across than scheduled caste or scheduled tribe women. The continuum of care was found to be significantly higher among women who were visited by the ASHA more than three times during the pregnancy.
Table 3: Logistic regression results of women who received continuum of care

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Since the early initiation of breastfeeding provides benefits for both the baby and the mother, the World Health Organization recommended that breastfeeding be initiated within 1 hour of birth.[16] A significant improvement in the initiation of breastfeeding within 1 hour after delivery was observed between various rounds of CBTS [Table 4]. The odds of initiating breastfeeding within 1 hour after delivery was lower among women who were non-scheduled castes and non-scheduled tribes, however, the effect was not significant. As observed for other two indicators, more than three visits by ASHA during the pregnancy were associated with improvements in the initiation of breastfeeding within 1 hour.
Table 4: Logistic regression results of women who breastfed the child within 1 h of delivery

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   Discussion Top


The purpose of the study was to assess the effect of a package of interventions in Karnataka on improving the utilization of maternal and neonatal services in Koppal and Bagalkot districts. There has been apprehension that traditional study designs, such as cluster randomized designs, are not always feasible at a time when many programs are being scaled up in virtually every district.[17] As such, we adopted an observational study based on the analysis of data used for continuous monitoring of the project.

Lack of attention to demand creation at the community level and strategies to promote changes in care-seeking and behavior were suggested to be important factors for the failure to deliver effective MNCH interventions at scale.[18] The findings of the study revealed that the interventions implemented through the project had the potential to increase community engagement and demand creation through ASHA as observed by improvements in the utilization of MNCH care services. The intervention with ASHAs focused extensively on improving their outreach planning, quality of home visits, and communication skills through the use of the simplified pictorial tools which had possibly led to improved knowledge and behaviors of the community members and hence the improved utilization. Similar results were indicated by recent community-based studies that have shown strong linkage between community-based interventions and MNCH outcomes.[6],[8],[19],[20]

While indicators had improved at an aggregate level in the study setting, specific population groups such as schedule caste/tribal populations still lag behind compared to others for most of the indicators. Evidence also indicated that these groups were at a higher risk for neonatal morbidity and mortality.[14] In Northern Karnataka, most of these groups resided in small hamlets outside of the main villages, frequently migrating to places that offer better employment opportunities and hence dropped out of the care continuum. It was also observed that the caste and gender-related challenges faced by ASHAs could also influence reach and coverage of these population groups.[21] The availability of data related to coverage of high-risk populations at regular intervals could be of great help for program managers to plan and track progress made in coverage of these high-risk groups.

The stay of women for more than 48 hours after delivery and initiating breastfeeding within the 1 hour of delivery had only marginally improved between the rounds indicating that they continued to remain a challenge in the region. Studies had indicated both cultural issues as well as health systems challenges affect the coverage of these services.[22] In spite of these challenges, ASHAs seemed to have had some success as the study showed an association between the ASHA visits and 48 hours stay (data not shown).

The study had certain strengths and limitations. The study was undertaken in high priority district settings trying to measure the effects of interventions at a large operational scale which was of considerable interest to the program managers and policy makers within India. Since, our study was an observational study we were not able to attribute the change in the MNCH care outcome indicators to the project interventions. However, we believe that within a short span of 2 years the gradual change observed in the study districts could not have been possible without the activities carried out in the project; the project documentation on the process involved in implementing the community-based interventions reinforced this fact.[21] We noticed significant changes in the distribution of women according to holding of BPL card between Round-1 and other study rounds. In the first round of CBTS, the interviewers were instructed to consider the BPL certificate from the village panchayat office and not to consider ration card for identifying women from the BPL household. However, in the subsequent rounds of survey, the interviewers considered ration card for identifying women from the BPL household. The data of Department of Food, Civil Supplies, and Consumer Affairs, Government of Karnataka accessed through online indicated that around 54% and 64% of the households in Bagalkot and Koppal districts have BPL cards.[23] Hence, it may be possible that the data from Round-1 CBTS underestimated the women with BPL cards. However, multivariate analysis did not suggest any variation in the MNCH outcomes according to status of BPL card holding.

One of the important implications of the CBTS was that it provided real-time data and reduced the time gap between data collection, analysis and dissemination of the findings to the program managers. It also provided data disaggregated by caste, age, and other demographic factors, which was crucial to track progress in addressing inequities. In general, the program managers in the public health domain rely on large-scale household surveys, namely National Family Health Survey and District Level Household Survey, for planning MNCH programs.[14],[15] However, these large-scale surveys are infrequent (occur in 4–5 years); the availability of results is delayed and hence not helpful for programmatic planning and action. In this regard, a concurrent data monitoring systems such as CBTSs which offers population level data on critical MNCH care indicators can be critical for district and regional level program managers for planning and implementation.


   Conclusion Top


The study showed that community-based interventions implemented in the northern Karnataka contributed to changes in certain critical maternal and neonatal care outcomes. The focused streamlining and simplifying the work of the frontline workers, particularly the ASHAs had led to the success. The study also highlighted the slow progress made in coverage of high-risk population groups and certain critical services; the possible reasons being related to the health systems and community systems which unless tackled sufficiently may not complement the ASHA work to achieve the results as much as desired. Finally, the CBTS proved to be an effective concurrent monitoring methodology that gave population level MNCH data on a frequent basis to aid program planning and implementation at district and regional level. These lessons possibly can have implications for other high priority district settings in the country.

Acknowledgment

The authors would like to thank all study participants in the districts of Koppal and Bagalkot. We also acknowledge the contribution made by the project staff namely Ms. Prathibha Rai, Dr. Suresh Chitrapu, Mr. Somashekar Hawaldar, Dr. Troy L Cunnigham, Dr. Swaroop and Mr. Ajay Gaikwad and other regional and district level staffs who were closely involved in implementing the interventions. We acknowledge the support and cooperation of National Health Mission and State Health Society of Government of Karnataka in implementing the interventions and the assessments.

Financial support and sponsorship

Bill and Melinda Gates Foundation. The views expressed herein are those of the authors and do not reflect the official policy or position of the Bill and Melinda Gates Foundation.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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