Backdrop

The maternal and child health scenario in Andhra Pradesh and Telangana calls for an urgent need of action. The Maternal Mortality Rate (MMR) of AP and Telangana is 92 which is high compared to other states such as Kerala (61), Maharashtra (68) and Tamil Nadu (79) (SRS 2013). Maternal mortality is largely preventable and mothers who received financial assistance under Janani Suraksha Yojana (JSY) for births delivered in an institution were only a pitiful figure of 10.2% in both AP and Telangana (NFHS-4). AP and Telangana states have the 5th highest number of new born deaths in country and infant and child mortality rates are less compared to the national urban average but are much higher compared to Kerala, Tamil Nadu and Maharashtra.

The findings of the studies in Nepal, Bangladesh, Chhattisgarh, Bihar, reveal that SHGs in rural areas played a major role in implementing Behavioural Change Communication strategies and brought significant changes in socio-cultural factors, maternal child health seeking behaviours and reduced the incidence of IMR and MMR. Urban poor women tend to have adverse maternal and child health outcomes when compared to those of rural women. But very few studies were conducted in urban areas to assess the effectiveness of urban SHGs in improving the MNCH outcomes among poor.

Nutrition plays an important role in altering the IMR and MMR and improving MNCH outcomes especially among the poor communities living in slums. It is a known fact that an undernourished mother inevitably gives birth to an undernourished baby, perpetuating an intergenerational cycle of under nutrition. Undernourished girls have a greater likelihood of becoming undernourished mothers who in turn have a greater chance of giving birth to low birth weight babies, perpetuating an intergenerational cycle. This cycle can be compounded further in young mothers, especially adolescent girls who begin childbearing before they have grown and developed enough. When mothers take only short intervals between pregnancies and have many children, this can exacerbate nutrition deficits, which are then passed on to their children. Sadly a large proportion of India’s adolescents 56% of girls are anaemic which would adversely affect the growth, resistance to infections, cognitive development and work productivity.

Addressing malnutrition in India requires a life cycle approach that focuses on adolescent nutrition, delaying the age of marriage and first pregnancy, maternal nutrition to reduce low birth weight (including micronutrient supplementation), infant and young child feeding practices (including, early and exclusive breastfeeding), community management of acute malnutrition and adolescent nutrition and safety net to address gender barriers. The appropriate interventions are crucial to enhance the knowledge and behaviour change among the adolescents and women for achieving improved nutritional and reproductive health outcomes.

Mahila Abhivruddhi Society, Andhra Pradesh (APMAS) in partnership with IQVIA and with the support from Bill and Melinda Gates Foundation (BMGF) initiated the evaluation, learning and action research project with the following goal and objectives.

GOAL: Addressing gender barriers for improved nutrition outcomes in pregnant and lactating women and children below two years through SHG platforms in urban SHGs

Objectives:

1. Address gender barriers surrounding the nutritional status of pregnant, lactating women and children below two years leveraging the existing SHG platform in urban slums.
2. Promote dietary diversification among the pregnant and lactating women (PLW) by engaging with PLW and the influencers in the family.
3. Promote early initiation of breast feeding and exclusive breastfeeding by creating awareness among the mothers and family members.
4. Promote appropriate complementary feeding practices for children below two years with the focus on dietary diversification.


Project Location: 15 slums each in Ongole & Tirupati towns in AP & GHMC, Hyderabad, Telangana.
Project Period: August 2016 to December 2019.
Project Outreach: Pregnant and lactating women and children below two years.

Project Phases:

The action research project has three distinct phases to ensure scientific design of the project, systematic implementation by documenting lessons learnt and research based evidence for wider dissemination of the results.

Journey so far

A series of meetings were held between APMAS, Research Partner and BMGF on building conceptual clarity of the action research project and developed a road map for the formative phase. Field visits were made to different location in the states of Andhra Pradesh and Telangana and held discussions with SHGs and their federations as well the officials from MEPMA, GHMC, Municipal authorities and WCD. The major activities carried out and outcomes achieved so far are given below:

Formative Phase

• Recruitment of team members by APMAS and exposure to Project Parivarthan in Bihar.
• Selected three locations as project areas (Tirupathi, Ongole in AP and GHMC in Telangana) based on the town development index developed for the purpose.
• Built rapport with the major stakeholders both from Government and NGOs.
• Selected slums for the explorative studies using the composite index constructed with some of the development indicators in GHMC and Tirupathi.
• Conducted literature review and two explorative studies to develop a deeper understanding of urban poor women’s nutrition outcomes; gender, social, economic, and other barriers at household, community, and service-access levels; and the gaps in health service provision and demand system.
• Formed Advisory Committee with experts from health, research, evaluation & gender.
• Shared the literature review and the findings of the two studies in the wider consultative forum, advisory committee meeting and community consultation and guidance received for the phased implementation and designing intervention strategies.
• Collected IEC materials and modules on nutrition and gender from different organisations and customized as per the project needs.

Implementation Phase

• In the context of NFHS4 data and based on the outcomes of formative explorative studies of the action research project, the focus was narrowed down on nutrition outcomes and an intervention framework was prepared focusing on pregnant and lactating women and children below two years.
• Established Project Offices in all three locations and recruited the field team.
• Based on findings of the formative research, consultations and internal discussions, the theory of change and pathways for the implementation phase were finalised.
• Selected slums for the explorative studies using the composite index constructed with some of the development indicators in GHMC and Tirupathi.
• Line listing was done and based on the findings the treatment and control slums were finalised.
• Developed CB & SBCC plans, Theory of Change, baseline tools & indicators and evaluation design.
• The implementation phase of the project was officially launched in September 2018 by conducting project launch workshops in all the 3 locations by involving the officials from MEPMA, UCD, Health department, ICDS and also leaders from Slum Level Federations/Town level federations. The launch workshops provided better understanding of the project among the stakeholders and the coordination become smooth for the field team.
• A detailed implementation plan was prepared and roles and responsibilities of the HO/Field teams were clearly defined. The main activities include home visits, BCC sessions with target communities/spouses, SHG Meetings, SLF meetings (Regular and special), visit to Anganwadi centers, local and national events. The implementation phase has been initiated in the first week of August along with the celebration of Breastfeeding week.
• SLF leaders were facilitated to collaborate with ICDS, MEPMA and Health Departments to celebrate breastfeeding week in the first week of August and Nutrition week in September. The team had organised quizzes, rallies, food demonstrations with low cost locally available foods, well baby shows and exhibitions. A pamphlet was specially designed and distributed in the slums. HO team attended a meeting organised by WCD Telangana on celebration of Nutrition month under Poshan Abhiyan.
• BCC materials of three Flip Books (1. Flip book on care during pregnancy and lactating; 2. Flip book on feeding practices for children 0-6 months and 3. Flip book on feeding practices for children 7-24 months). The following BCC materials are under development:
1. Poster and pamphlet on the role of husbands/fathers during pregnancy and lactating.
2. Poster and pamphlet on key messages to pregnant and lactating women.
3. Poster and pamphlet on anemia.
4. Booklet for adolescent girls.
5. Blast messages.
6. Short videos.
7. Pamphlet and flexi on diet diversity.

• The following Capacity Building activities were held during the implementation phase
1. ToTs on gender, nutrition, mentoring.
2. Training to Mentors and Health facilitators on gender, maternal & child nutrition and health.
3. Refresher training in all three locations on counseling techniques, behavior change communication, adult learning principles and participatory learning and action cycles. These trainings are very useful for effective outreach.
4. Training on usage of tablets, data collection using ODK application.
5. Refresher trainings on the ODK application.
6. Exposure visit for the SLF/SHG leaders and field teams from Ongole and GHMC to Sri Padmavathi Mahila Samakhya (SPMS) with the purpose to create a vision among the participants to work for various needs of their members. After the visit 3 SLFs have been reactivated. Learnings have been shared in all the groups.
7. A curriculum has been developed for 12 months and capacities of SLF/SHG leaders have been built in special meetings on monthly basis through PLA sessions.

• MIS tools were developed, pilot tested and uploaded on ODK application. Field teams were trained on the finalized four formats. Real time customized data collection has been initiated by the field teams using the tablets.
• Stakeholder meetings were conducted in all the 3 project locations. In Ongole and Tirupati these meetings were conducted under the leadership of Project Directors of MEPMA. Progress, challenges and gaps in the field have been discussed. The officials are also met by both the filed team and HO team and apprised on the progress of the project.
• The baseline report is finalised and the midline tools are under preparation. The policy briefs are also under preparation by the learning partner, IQVIA.
• The advisory committee was reconstituted and the second meeting of advisory committee was held in the 3rd week of January 2019. A new Theory of Change (ToC) was developed based on the suggestions given by the members. BCC materials were revised by incorporating the feedback given by the advisory committee members.


Constraints and Challenges

  • Dearth of qualified and staff with passion for action research project
  • Alignment of project strategies in line with NULM framework and MEPMA priorities
  • Getting the partners and stakeholders on board in a given specified time
  • Migration of certain target communities affecting outreach
  • The SHGs and SLFs are weak in certain places

Way Forward

Theory of Change is revisited to focus on dietary diversity with gender as a cross cutting theme. Midline survey will be conducted through qualitative assessment in the months of February and March 2019. Policy briefs on identified issues will be prepared by IQVIA. The capacities of the SLF/SHG leaders will be built on gender and dietary diversity.

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