Category Archives: Calcutta Kids Blog

AIF Fellow impressions 2012-13 (1 of 2)

Posted on October 23, 2012 by Calcutta Kids| Leave a comment

I am so impressed and inspired by the motivation you see at Calcutta Kids. Every health worker I have been able to spend time with during my first month here is doing a wholehearted job to be a good resource to the organization and more importantly to the community they are serving. Thanks to our mentor Danya Sarkar, who helped us feel settled down, Pranav and I have been able to explore the community and learn all the various functions of the organization. As we make our visits into the field with the health workers, the community has noticed and recognizes us as new members of Calcutta Kids. We realized this as we looked a little lost while trying to find our way to the community center and two women immediately gave us directions before we even asked them!

The mission of Calcutta Kids can be understood through the manner in which the health workers communicate with the women of the community. Every child is important and can be given adequate care by simply monitoring them. If a child’s weight has not increased during the monthly Growth, Monitoring and Promotion Program, the health worker visits the mother in the following week and counsels her. The health workers express how they are really sad when they see no positive growth in the child. They encourage each mother to take more care of the baby, give her simple tips on how to create a healthy diet and also praise her when she has done a good job. Thus, the health workers have built a great relationship with the mothers of the community. The mothers are always happy to see the didis and welcome them into their houses. They also offer tea or lunch and ask us to spend time with them. When the health worker completes filling up her form and questionnaire, the women thank her for coming and tell her that they felt happy they got to chat with them. The women also trust the health workers as much as they trust a doctor. Even when the health workers are merely on their walk from one house visit to another, many women stop them with their babies and talk about how their child still has a cold or might have developed a skin infection.

Meeting for pregnant women lead by Laxmi Gupta

Meeting for pregnant women led by Laxmi Gupta

The success stories from Calcutta Kids are commendable and its establishment in Fakir Bagan is very apparent in the number of people who visit the clinic everyday or the manner in which we are received in each house. However, there is still work to be done. Although the women recognize the messages delivered by the health workers, many women still do not seem to be adopting a change in their habits. They usually quote too much housework and stress in their lives as reasons for not being able to follow the health workers advice. Even when they come to the community meetings, they listen to the messages or watch the videos but whether they are following the key points is something yet to be assessed. This is a project I plan to work on during my time at Calcutta Kids. I will be working out behavior change communication strategies using different methods of delivering messages to the community. I will be working with the health workers and the beneficiaries to find out why they are not able to follow simple, yet key health practices. Through the health counseling sessions, community meetings and discussions groups I hope to understand the needs of the women, analyze existing techniques of delivering health messages and find ways to improve them. Eventually, I hope to create a sustainable structure to monitor and evaluate changes in health behavior as put forth by the health workers.- Sriya Srikrishnan (AIF William J. Clinton Fellow 2012-2013)

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The CK-AIF Partnership

Posted on October 15, 2012 by Calcutta Kids| Leave a comment

The partnership with the America India Foundation’s Clinton Fellowship Program has become an integral part of Calcutta Kids and a rich addition to our operations. In a field which has become infamous for its infighting and noncooperation, this partnership represents the best in international development cooperation. Here are two organizations which have their own distinct objectives, but share a common goal—to create positive social change in India. And together we have been doing just that…creating positive social change through eager young people committed to helping India bring about change that will help empower traditionally disadvantaged populations and, in turn, bring about sustainable poverty alleviation.

Since its inception, Calcutta Kids has enjoyed the chance to mentor and provide valuable learning opportunities for the next generation of western development workers through our internship positions. We’ve had dozens of young people from the United States and Europe work with Calcutta Kids to learn about and participate in our mission to improve the health status of pregnant women and children in slum areas of Kolkata. These internships have proven overwhelmingly positive for both the interns and for Calcutta Kids. At the same time, we’re aware that doing it right requires a lot of work on our part to identify the right interns, link them up with needed tasks that will utilize their skills, and then organize logistical support for them.

2012-2013 AIF Fellow, Pranav Reddy

Last year we began partnering with AIF’s Clinton Fellowship Program. And it was a terrific year indeed. AIF carefully selects Fellows who are not only eager to learn, but who also show considerable potential to benefit the small organizations with which AIF partners. AIF also organizes funding for the fellows, and facilitates housing for them. Taking care of these logistics allows Calcutta Kids the time to focus on the Fellow and the task, and to figure out the best means of linking the two. Last year, AIF sent us Margy Elliott who had recently finished her MPH at Columbia University. Margy spent ten months with us, quickly became part of the Calcutta Kids family, and, in the process, solidified our relationship with AIF.
Margy took on an array of professional tasks at Calcutta Kids—and in each served as a healthy bridge between the community health workers and the main office administration. She also developed our beautiful website and conducted a SWOT analysis which has provided invaluable insights, and, in turn, has resulted in significant morale boosting among the Calcutta Kids team.

In September of this year, AIF sent us two new fellows—Pranav Reddy and Sriya Srikrishnan—both of whom are quickly becoming part of the Calcutta Kids team and family. Still early on in the fellowship, Pranav and Sriya are getting to know the organization with the idea of identifying limiting factors and means by which they might best be addressed. Sriya is spending a substantial amount of time in the field with our community health workers and participating in our community meetings. She also is working to increase the effectiveness of our behavioral change communication efforts. And she is examining means by which Calcutta Kids might establish a more meaningful and sustainable collaboration with government programs. Pranav, meanwhile, is carefully examining Calcutta Kids data and looking for cost-effective means of expanding our coverage area—one of the organization’s major goals for the coming year. He has a particular interest in examining the inner-workings of an Indian NGO, and then helping to mainstream administrative tasks.

2012-2013 AIF fellow, Sriya Srikrishnan

As was the case with Margy last year, we are expecting valuable results from the work Pranav and Sriya are doing. They’re off to a great start!

All of us at Calcutta Kids are grateful to those individuals who have helped to make this partnership with AIF possible. We look forward to the next 9 months with Sriya and Pranav, and then to many more years with such bright and eager AIF Fellows.—Noah Levinson

(A similar blog written by the same author was submitted to AIF to be posted on their website.)

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CK Starts Routine Deworming

Posted on September 10, 2012 by Calcutta Kids| Leave a comment

We introduced an exciting new component to our young child health initiative that we hope will help improve the health status of children in Fakir Bagan.  During our Growth Monitoring and Promotion (GMP) camp this week, Calcutta Kids carried out routine deworming of preschool age children. We have been discussing this idea for several months now after our data analysis showed a high prevalence of worm infestation in a group of malnourished children enrolled in our nutrition pilot program (YChiNG). At the time, we dewormed the children in the YChiNG program, but realized that there were many more children in our catchment area who could benefit from deworming.

Nasreen helping a father give deworming medicine

We were motivated in part by a Government of India mass deworming campaign in New Delhi earlier this year, which included deworming not only school-age children in government schools, but also pre-school age children in ICDS/Anganwadi (government health) centers. During last month’s GMP in Fakir Bagan, we conducted a survey with mothers of children 1-3 years old, asking them to report if their child had an incidence of intestinal worms in the past 6 months. A resounding 43% of mothers answered yes, which reflected a clear need for an intervention.

Intestinal worms, which are pervasive in India, can have devastating effects on a child’s physical and mental growth. In low-income urban areas like Fakir Bagan, where sanitation and hygiene are poor and many children walk around without shoes for protection, the most common type of intestinal worms are soil transmitted helminthes. Once in the body, these parasitic worms feed on host tissues, including blood, leading to a loss of iron and protein. They also hinder the absorption of nutrients. The result is diarrhea, anemia, and malnutrition, all which have a detrimental impact on child health, growth, and development. To counter the negative effects of worms, the WHO recommends periodic drug treatment (deworming) of all children living in endemic areas. (1) Studies have shown that routine deworming of children can have significant positive outcomes on nutrition, growth, and cognitive performance.

A child excited about the new deworming medicine

School-age children are thought to have a high burden of worm infestation. Fortunately, they are easy to reach for deworming because schools serve as pre-established distribution networks. The evidence shows that routine deworming makes a difference. One landmark study showed that deworming can reduce school absenteeism by 25%. Furthermore, children who are regularly dewormed earn over 20% more as adults and work 12% more hours, while those infected are 13% less likely to be literate. (2) Global campaigns now target pre-school age children, who are tougher to reach but also a vulnerable group in terms of exposure to worms. Studies conducted in Indian slums show that there is substantial weight gain in young children (pre-school age) who are dewormed regularly. (3)

Apart from the mass campaign in Delhi this year, which followed mass campaigns in Bihar and Andhra Pradesh a few years back, deworming campaigns have not been widely organized in India. Given that deworming is extremely cost-effective at only a few cents per pill, and provides both short-term and long-term physical and cognitive benefits to a child, India could see great benefits by ramping up state deworming campaigns, which can be effectively carried out through government schools and ICDS/Anganwadi health centers. The WHO includes intestinal worms among “the 17 neglected tropical diseases” which WHO Director General Margaret Chan described as “diseases that are largely silent, as the people affected or at risk have no political voice.”. The WHO launched its “neglected tropical diseases” campaign to raise awareness among policy makers and donors, in hopes of stimulating more action, like deworming campaigns. For Calcutta Kids, this new deworming initiative marks a proactive step to address the “neglected disease” that is most prevalent in our community.

The first round of deworming this week marked the beginning of our commitment to ensure routine deworming every 6 months to each preschool aged child in Fakir Bagan. We reached each of the 311 children between 1-3 years old, but missed some children who had traveled to the village with their families, but they should be covered in future rounds. Between rounds, we will immediately treat any children who present with worms. Parents at the camp were positive about the deworming intervention. The results were telling. In the words of one father, “My child was feeling sick and her stomach was swollen from worms. I am happy that she is now getting medicine to make her better.” – Danya Sarkar

1. http://www.who.int/elena/titles/deworming/en/
2. http://www.dewormtheworld.org/why-deworm/the-evidence-for-school-based-deworming
3. Effects of Deworming on Malnourished Preschool Children in India: An Open-Labelled, Cluster-Randomized Trial. Shally Awasthi, Richard Peto, Vinod K. Pande, Robert H. Fletcher, Simon Read, Donald A. P. Bundy. PLOS Neglected Tropical Diseases, April 2008, Volume 2, Issue 4

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We Will Miss You Ma

Posted on August 23, 2012 by Calcutta Kids| 2 Comments

On 9th August 2012, Mrs. Shwasti Chaudhuri, a founding board member of Calcutta Kids Trust, passed away. An unsung hero in almost every road she travelled, Mrs. Chaudhuri played a key background role in the establishment and ongoing success of Calcutta Kids. I wish to use this week’s blog to write about this extraordinary woman and the impact she had on my life.

In 2002, during a 9 month stay in Kolkata, I was introduced to Santanu and Shwasti Chaudhuri by dear friends of Calcutta Kids, Charlie and Cordie Puttkammer. Santanu was a retired business man and a former board member of Shaw Wallace; Shwasti had a small handmade paper factory and managed their beautiful home—one of the last standing British bungalows on Ballygunge Circular Road.

The Chaudhuris and I became enamored with each other. They were very supportive of the work I was then doing with the Ashalayam Mobile Health Clinic, but they realized quickly that the road I was headed down – non-stop work with the neediest kids in the slums – was a dangerous one—one that might very well lead to burnout. The Chaudhuris, worldly people who knew how hard life in Kolkata could be for foreigners, had seen others push too hard and then give up in desperation. And they made it their mission not to let this happen. They ‘adopted’ me and on a weekly basis would invite me to join them for dinner at one of the old British clubs of Kolkata—the Bengal Club, the Calcutta Club, the Saturday Club, or their home which is almost as big and fancy as a dinner club.

Noah and “Ma” distributing sweaters to destitute children in the winter of 2004 in honor of Fred Rogers.

The generosity showered upon me by the Chaudhuris was overwhelming, and along with marvelous conversations and delicious food and the best soufflé I’d ever tasted, I was introduced to and welcomed into a new Kolkata—a Kolkata far different than that of Mother Teresa’s work and the street children with whom I worked every day. If it was possible to fall deeper in love with Kolkata than I already had, it happened through the Chaudhuris.

My relationship with the Chaudhuris became that of a surrogate son. I soon began calling Mr. Chaudhuri “Baba” and Mrs. Chaudhuri, “Ma”. In 2003, when I returned to Kolkata for another long period of time, Ma and Baba invited me to live with them, and I continued to live there whenever I was in Kolkata until 2008.

While living with the Chaudhuris, Ma and I would regularly have long conversations. Ma would listen to me talk about my successes and failures working with the poor of Kolkata; she would listen to my frustrations; she would give guidance, but more often, she would just listen or re-direct my thinking if I was badly off the mark. Ma never told me what to do unless I specifically asked. She told me that the only way I was going to survive in Kolkata is if I made mistakes and learned from them. Ma was a great listener and someone I could always bounce ideas off.

When I was sick from dysentery or viral fever, Ma nursed me. When the Chaudhuris son Kaushik returned from America to live with them (I had been staying in Kaushik’s bedroom) Ma gave me her room so that I could stay close to the family; when I was far away from home and I lost two grandparents in just one month, Ma dried my tears. My own dear mother, Louise, was very close to Ma and they often holidayed together in the hills.

In 2005 when Calcutta Kids opened an office in Kolkata, Ma and Baba formed the Calcutta Kids Trust with an initial sizable donation. Ma and Baba were supportive of the Trust, but in a hands-off way. They knew that Calcutta Kids was my baby and they gave it and me the freedom we needed to grow. They often warned about potential problems; they often gave their opinions on ideas I would have, but they let me guide the Trust with their support. Board meetings were always held at their home and Ma would make sure that the trustees were well fed with singharas, an array of sandesh, pakoras and Darjeeling tea.

It’s because of Ma and Baba that I was able to survive as long as I have in Kolkata; it’s because of their love and support and friendship; it’s because they welcomed me into their home; it’s because they gave me the comfort I needed to juxtapose with my troubling days; it’s because they protected me while allowing me to make the mistakes which would eventually make Calcutta Kids what it is today.

In many ways, my life is what it is today because of Ma and Baba. Without Ma and Baba I certainly wouldn’t have survived this long in Kolkata and Calcutta Kids would likely not exist. And without my being in Kolkata, I never would have met Evangeline—my life partner.

This photo was taken at Noah and Evangeline’s wedding in India on January 14th 2012. Evangeline is sitting on Baba’s lap, and Noah is standing between his mother Louise, and his Ma, Shwasti.

Even after moving out of their home, I remained a son of the house. Ma and I spoke on the phone nearly every day. And oh how I will miss that daily phone call. But even more than the phone calls I will miss the one-on-one conversations we had over tea lounging on the bed; I’ll miss Ma’s infectious smile; and I’ll miss her scolding me for chewing on toothpicks and pulling hairs from my head when I am anxious.

Before Ma died, she told her family that I was like a son to her. The Chaudhuri family gave me the honor of carrying Ma’s body from the house to the hearse, and they asked me to participate in the Hindu rituals which a son performs for his mother. I’m deeply grateful to the family for giving me that honor.

Calcutta Kids will be forever in debt to Ma for all her love and support and to honor Ma’s life, we will continue to provide the best possible care to the pregnant women and children of Fakir Bagan.–Noah Levinson

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The Story of Puja Yadav

Posted on August 14, 2012 by Calcutta Kids| 1 Comment

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

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Milena Commits Another $50K to CK

Posted on August 8, 2012 by Calcutta Kids| Leave a comment

During my first summer in Kolkata in 2000 while working at Mother Teresa’s Home for the Dying Destitutes I met Milena Kotys, a social worker from New Jersey. Milena has remained a dear personal friend and is also a close friend to Calcutta Kids. In 2007, Milena’s father Wasyl passed away and a year later to honor her father, Milena started the Kotys Memorial Fund—a permanent endowment in the name of Calcutta Kids to fund our weekly health camp. In 2008, the weekly health camp cost around $5,000 per year to run. And safe investment returns in India are around 10% so Milena set a goal to raise $50,000.

Three years later, at a Kotys Memorial Fund fundraiser hosted by Ginny and Ravi Akhoury, I shared the following toast with Milena:

“Milena: Congratulations! You have done it. You’ve delivered on your promise to raise $50,000 for the Calcutta Kids endowment in honor of your dad. Fundraising is not easy and you should be incredibly proud. I feel so fortunate to have had you as a partner in raising funds for Calcutta Kids—and even though the goal has been met and your commitment has been fulfilled—I hope your assistance will continue. It’s been beautiful watching you through this process as every solicitation you send out; every phone call you make; every event you plan is done with such love, such intentionality; because you treat each of these acts as a tribute of love to your dad. I’m sure Wasyl is among us right now with a big smile on his face—the smile surely represents pride in what you have accomplished; and gratitude for the way you and your family have chosen to honor his life. On behalf of the many women and children in Fakir Bagan who receive free life-saving services because of your work.”

Between the establishment of the Fund and 2011, the weekly health camp turned into an outpatient daily clinic with a full time female doctor. The costs therefore increased, but the interest from the Kotys Memorial Fund has substantially helped in covering the operating expenses of the clinic.

Milena is currently in Kolkata for a few weeks and she’s been spending a lot of time at Calcutta Kids. Yesterday, she shared some observations with us about the clinic which I have paraphrased below:

Milena Kotys with members of the Calcutta Kids team (August 2012).

“The weekly health camp has been turned into a high quality primary health clinic open five days a week. It makes me so happy that more patients can be seen more frequently. The weekly health camp was in a dingy room in the slum and now it’s in a clean, spacious, well-organized space with privacy for all patients; food and drinks are provided as well as all necessary medicines and yet there is still no charge to the patients and their families. There is even a security guard who keeps the clinic safe and welcomes the patients. Doctor Mukherjee is lovely and the staff is professional and kind. And the data system is just awesome. It’s wonderful to see the digital growth charts marking the progress of each child.”

Milena also sang the praises of the community health workers knowing that none of the work we do is possible without them.

Pleased with what Calcutta Kids has been able to do with the money she raised in honor of her father, Milena announced that over the next few years, she will raise another $50,000 for the Calcutta Kids endowment—again in honor of her father Wasyl.

All of us at Calcutta Kids are deeply moved by Milena’s generosity, and grateful for her commitment to the mothers and children we hold so dear. Thanks Milena. –Noah Levinson

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C-Section Blog Series (4 of 4)

Posted on July 28, 2012 by Calcutta Kids| Leave a comment

The third part of our C-section blog series focused on the circumstances leading up to Calcutta Kids’ decision to stop partnering with private clinics for facility based deliveries, and instead (a) offer a Delivery Savings Scheme (DSS) which would provide financial assistance for beneficiaries to deliver wherever they prefer; and (b) up the ante on birth preparedness through a new home counseling curriculum. This week’s blog describes that curriculum, provides data on beneficiaries’ usage rates of the delivery savings scheme, and calls attention to the fact that more community involvement is necessary for the delivery savings program to succeed.

Throughout the pregnancies of our beneficiaries, our CHWs visit their homes at least once a month. During the last few months of pregnancy, the visits have become more standardized and focus on the following themes:

  • Danger signs. What to watch out for—especially pain in the lower abdomen, heavy white discharge or bloody discharge. In such cases, pregnant women are advised to go immediately to the facility with which they are registered, and to call their Area in Charge for support
  • What not to worry about: Many women become worried if the gestational age of their child crosses 37 weeks. The CHW’s counsel the women not to worry about this until around 40 weeks at which time they should visit their facility.
  • Preparation: The family is counseled to assure the availability of transportation to the facility regardless of the time of day or night, and to ensure that money is set aside for transport. They are also told what documentation to have ready to take with them to the facility.
  • To C or not to C: Pregnant women and their families are provided with knowledge about C-sections. They are informed of the recognized and accepted indications for C-sections; the potential risks for the mother after a C-section delivery; the potential risks for the mother during her next pregnancy; the immediate risks for the baby during a C-section delivery; and the potential long term risks for a C-section-delivered child.

The CK staff has gone through an intensive training focusing on these themes. (You can see these materials in the resources section of our website or you can click here for the Labor and Delivery Educational Session and here for the C-Section Education Session.)  They also have received refresher training on the labor and delivery process, fetal development, and complications that can occur during labor. And they are equipped with flip charts and other materials to facilitate their home-based counseling with pregnant women.

Delivery Savings Scheme Data:

  • Scheme began in July 2011
  • Since inception, 68 CK pregnant women out of 162 pregnant women in households registered with CK, have enrolled in DSS
  • Of those 68, 45 remain pregnant
    • Of the 45 who delivered, 2 had miscarriages; 29 had normal deliveries, and 14 had c-sections.
    • Of the 45 who delivered, 24 took place in private facilities and 19 took place in public facilities.
  • Currently (July 2012) there are 55 pregnant women involved with Calcutta Kids and 21 are participating in the DSS.

With a DSS user rate of around 40%, the scheme is not working as well as we would like. And the DSS is not working as a replacement for the services being provided earlier through private facilities.

Next week, Calcutta Kids will be holding a number of focus group discussions to try and figure out why it is that more pregnant women are not taking advantage of this scheme. The discussions will be held separately with those who have used the DSS and those who have not. We look forward to sharing what we learn from these discussions in a future blog.

From this data, however, some questions arise: Does this experience coupled with the micro insurance experience indicate that families (a) don’t have surplus cash on hand or (b) aren’t willing to use surplus cash for such a purpose or (c) that the men in the family are not willing to set such money aside for this or (d) there a is basic fear (based on the reality that there is a lot of huckstering that goes on in the slum) that they might never see their money again?

Clearly we have more work to do in facilitating a good option for safe facility-based delivery among our beneficiaries. We are confident that we will be able to find a solution which benefits our beneficiaries while at the same time protecting them—and also Calcutta Kids. -Sumana Ghosh, Danya Sarkar and Noah Levinson

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C-Section Blog Series (3 of 4)

Posted on July 20, 2012 by Calcutta Kids| Leave a comment

In 2007, a young man visited Calcutta Kids from abroad. He was interested in exploring why Calcutta Kids at that time was working with the private health sector rather than the government sector. Instead of explaining the deplorable state of government hospitals and going into the gory details of government bureaucracy, I asked the young man if he might like to join me in visiting a nearby government hospital. He agreed and we hopped into a cycle rickshaw and headed for the hospital.

Fifteen minutes later, we stepped out of the rickshaw, walked into the hospital, and were greeted by a line of stretchers carrying corpses waiting to be picked up by the morgue. We stood there for a few moments trying to get our bearings. When we moved forward, our guest tripped over a large rat that was scurrying across the floor. The young man told me that he now understood why we worked with private hospitals and clinics.

For the most part, our experiences with private clinics and hospitals over the years have been positive ones. Our beneficiaries prefer the private sector as does most of the population of India. And, given the fact that Calcutta Kids was covering the cost of this private hospitalization partially or fully, the beneficiaries were overwhelmingly pleased with this arrangement.

Over the years, however, our understanding of both the private and public health sector in India has evolved, and as we recruited more medical staff on our team, we began to seriously question our exclusive partnership with the private sector.

Part of the evolution in our thinking resulted from a better understanding of C-sections in our area. The rising cost of C-sections our beneficiaries are paying combined with our understanding of the dangers of unnecessary C-sections frightened the Calcutta Kids team and we began to examine our options carefully.

We realized that we were facing two major issues: the first a potential major operational threat to Calcutta Kids; the second an ethical dilemma: Because we have had relationships with particular clinics and were paying the fees for deliveries at these clinics, we were in essence accrediting them; beneficiaries who trusted us throughout their pregnancies were trusting the facilities with which we partnered. This meant, in turn, that if something at these clinics were to go wrong, we would be blamed. Such a situation could create major problems for Calcutta Kids. The ethical dilemma was that since we were paying for the deliveries at these clinics which practiced excessive use of C-sections, we were partially responsible for any deleterious effects of an unnecessary C-section on a mother or child. Was it possible that while we believed we were providing the best possible care for pregnant women and children, we might be exposing them to unnecessary risk?

Below is a brief synopsis of our discussions.

  • We could speak with the private sector clinics, encourage them to follow WHO protocols on the appropriate conditions for C-sections, and then request medical reports for each C-section financed by Calcutta Kids. This option was tried without success. After all, C-sections are increasingly the norm, and the clinics did not want to follow a protocol inflicted upon them by an NGO.
  • We could open our own maternity clinic, although at an exorbitant cost. This was never really an option. Our focus is on nutrition, BCC, and preventive care and that is where it should remain.
  • We could encourage our patients to advocate themselves for normal deliveries unless a C-section is clearly warranted. This we also do but with limited success. Rarely will a poor uneducated family go against the advice of a doctor.
  • We could stop paying for C-sections altogether. But what about those rare cases where C-sections are indeed necessary and families cannot afford them?
  • We could partner exclusively with the government hospitals. But this goes against the preference of our beneficiaries.

Finding none of these options satisfactory, and recognizing the danger to our beneficiaries and to Calcutta Kids, we ended up terminating our formal partnerships with the private sector. What we put in its place is a delivery savings scheme—a financial incentive to ensure a facility-based delivery. The delivery savings scheme enables women to save money in a safe place and to receive a matched amount from Calcutta Kids of up to 2,000 rupees. The beneficiaries then can choose to spend this money at a private clinic (Rs.4000 will likely cover a normal delivery, but not the full cost of a C-section) or they can go to a government hospital where the delivery will be free and use this savings for postnatal care.

Along with the delivery savings scheme, we’ve begun a program of intensive counseling for pregnant women to help assure that they understand all that they need to know about deliveries and can make an educated decision about whether to have a C-section if the doctor recommends one.

The last blog post in this four part series will speak about Calcutta Kids’ experience with the delivery savings scheme as well as the curriculum mentioned above. –Noah Levinson

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C-Section Blog Series (2 of 4)

Posted on July 12, 2012 by Calcutta Kids| Leave a comment

The rise of C-section rates in many parts of the world has triggered a global debate on the use of C-sections, the ideal rate of C-section, and appropriateness of high rates in certain countries. In 1985 the World Health Organization (WHO) recommended a C-section rate of not more than 10-15%. In 2010, they withdrew that guideline and replaced it with a more general statement that, “There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them.” The WHO’s decision to not focus on a universal, evidence-based optimum rate makes sense in light of the difficulties of doing so but, without a specified rate, there is no easy benchmark by which to monitor and interpret the use and potential overuse of c-section deliveries.

When clinically indicated for complications during pregnancy or labor, C-sections greatly improve obstetric outcomes, which in turn improve maternal and child health outcomes. In many developing countries, women have inadequate access to emergency obstetric care leading to preventable maternal and perinatal morbidity and mortality. In such settings, it is essential to strengthen health systems and infrastructure to ensure that C-section services are provided when they are medically indicated and could save lives.

In populations with excessively high C-section rates, on the other hand, there is growing concern about the health and economic consequences when C-sections are performed for reasons other than medical necessity. A C-section is a major surgical intervention that should be carefully considered in light of associated risks that can increase maternal and perinatal morbidities, which include bleeding, infection, blood clots, and increased need for ICU care. C-sections can also have long-term consequences on child health, including increased risk of developing allergies and asthma. (1) Maternal mortality for women undergoing C-sections is four to ten times higher than for vaginal birth. A multi-country study carried out in Latin America indicated that an increase in rates of caesarean delivery is associated with increased use of antibiotics postpartum, greater severe maternal morbidity and mortality, and higher fetal and neonatal morbidity. (2) Another multi-country study carried out in Asia in 2007-8 showed that there was an increased risk of maternal mortality and severe morbidity in women who undergo C-section with no medical indication. (3) Furthermore, in low-income countries with an unmet need for C-section (where women who need C-sections are not receiving them due to inadequate access to obstetric care), the issue of resource drain is important: If C-sections are restricted to only clinical indications and not performed unnecessarily, resources would not be sapped from other sections of the health system.

http://cartoonistsatish.blogspot.in/2009/07/muhurat-c-section.html

Currently, the global C-section rate is about 15%, but there are huge variations in C-section rates across countries and regions in the world. A consistent increase has been seen in the rate of C-section deliveries in most developed countries and in many developing countries including India. Globally, China has the highest rate at an alarming 46% of births being C-section (3); Brazil follows behind at 37% (4). In the United States the rate has been steadily increasing in the past decade and is now at 30%, while in Scandinavian countries it hovers around 20%. In Asia, after China, Vietnam and Thailand have the highest rates with 36% and 34%, respectively. The lowest rate in Asia is Cambodia, with 15%. (3) Although India’s rate is not disturbingly high in the global context, its rate has spiked from 2.2% in 1992-3 to 18% today. Within India, the states of Kerala, Goa, and Andhra Pradesh have the highest rates. In West Bengal the rate rose from 3.3% in 1992-3 to 19% in 2009-10. (5)

There is also a large divide between urban and rural areas, and between public and private facilities. West Bengal as a whole has a C-section rate of 19%; the city of Kolkata’s rate is 33.5% while rural Malda District’s is 2.2%. In Kolkata as in most large Indian cities, the C-section rates in private hospitals are much higher (50% and up) than in public hospitals, which average about 12%. (6) This emerging trend is a classic example of inequalities in access to C-sections in developing countries: It means that in poor, rural areas where there is less access to emergency obstetric care, women who medically need C-sections may not be getting them, while women living in urban areas and going to private hospitals are getting C-sections that may be performed unnecessarily, causing unwarranted risk to the mother and baby.

The trend in rising C-section rates in India and other parts of the world is driven by many reasons factors including, but not limited to:

  • Increase in facility-based deliveries and improved access to emergency obstetric care; improved surgical and anesthetic techniques
  • Doctors’ preference for the procedure due to ease, timing, and financial   incentive compared to vaginal delivery
  • Women’s preference for the procedure to avoid long labor and delivery
  • Over medicalization of childbirth process
  • Lack of information on natural birth options for women
  • Perception of safety of the procedure; casual attitudes about surgery and limited awareness about realities of surgery
  • Increase in heavier women and older women giving birth
  • Increase in multiples (twins, triplets, etc) due to fertility drugs and IVF

How do rising C-section rates affect Calcutta Kids?

Our beneficiaries at Calcutta Kids are very much affected by C-section trends in West Bengal, as their deliveries are taking place in government and private hospitals in Howrah. In the past five years, we have witnessed increasing rates of C-section for women who are participating in our program. In a preliminary analysis of data, our C-section delivery rate has increased from 10% in 2007 to 30.4% in 2012. There may be many contributing factors, including an increase in facility-based deliveries from 67% in 2005 to 90% in 2012. However, we are conducting further analysis to assess these trends and explore the reasons behind them.

Calcutta Kids is not involved in the childbirth process for our beneficiaries and we cannot directly affect any decisions made once a woman has been admitted to the facility, so we do not have any control over C-section rates among our beneficiaries. However, we can take advantage of opportunities during pregnancy to raise awareness about birth preparedness and help a woman understand what she can expect at the facility, including what decisions will be made once the birth process has begun.

Next week’s blog post will cover Calcutta Kids’ experience with facility deliveries and C-sections , followed by a blog post on our work with health workers and pregnant women on birth preparedness and facility delivery. -Danya Sarkar

Citations:

  1. Mode of Delivery Is Associated With Asthma and Allergy Occurrences in Children. Muhammad T.Salam, MBBS, MS, Helene G. Margolis, PhD, Rob McConnell, MD, James A. McGregor, MD, Edward Avol, MS, Frank D. Gilliland, MD, PhD. Annals of Epidemiology, Volume 16, Issue 5, May 2006; 341–346.
  2. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. José Villar, Eliette Valladares, Daniel Wojdyla, Nelly Zavaleta, Guillermo Carroli, Alejandro Velazco, Archana Shah, Liana Campodónico, Vicente Bataglia, Anibal Faundes, Ana Langer, Alberto Narváez, Allan Donner, Mariana Romero, Sofi a Reynoso, Karla Simônia de Pádua, Daniel Giordano, Marius Kublickas, Arnaldo Acosta, for the WHO 2005 global survey on maternal and perinatal health research group. Lancet 2006; 367: 1819–29.
  3. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Pisake Lumbiganon, Malinee Laopaiboon, A Metin Gülmezoglu, João Paulo Souza, Surasak Taneepanichskul, Pang Ruyan,Deepika Eranjanie Attygalle, Naveen Shrestha, Rintaro Mori, Nguyen Duc Hinh, Hoang Thi Bang, Tung Rathavy, Kang Chuyun, Kannitha Cheang, Mario Festin, Venus Udomprasertgul, Maria Julieta V Germar, Gao Yanqiu, Malabika Roy, Guillermo Carroli, Katherine Ba-Thike, Ekaterina Filatova, José Villar, for the World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Lancet 2010; 375: 490–99.
  4. The Role of Nonclinical Factors in Cesarean Section Rates in Brazil. Kristine Hopkins and Ernesto Amaral. Population Research Center, University of Texas at Austin.
  5. Levels and Trends in Caesarean Births: Cause for Concern? Sancheeta Ghosh, K S James. Economic & Political Weekly January 30, 2010 vol xlv no 5.
  6. Telegraph article: To C or not to C?

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C-Section Blog Series (1 of 4)

Posted on July 4, 2012 by Calcutta Kids| Leave a comment

For the month of July, Calcutta Kids’ weekly blog will be on the topic of C-section deliveries, and the challenges of working in maternal and child health during a time when C-sections are becoming the norm.

According to a December 2011 article  in the Telegraph, West Bengal “has more Caesarean section deliveries in private hospitals than anywhere else in the country”, and Kolkata has the highest rate at 33.5%. C-sections are convenient for doctors and lucrative for facilities, so doctors are beginning to schedule deliveries regardless of a medical need. Some of the best private hospitals in Kolkata have even removed labor rooms altogether, and only offer the C-section option.

C-section deliveries can lead to serious complications such as hemorrhage, lingering abdominal pain, hernia, blood clots, and long-term effects including a required hysterectomy and even death. C-sections can also impact the child, and can lead to increased incidence of asthma and allergies, as well as possible neurological disorders. In addition, C-sections are expensive and recovery time is often greater than for a vaginal birth. As a public health organization, Calcutta Kids encourages best practices for maternal and child health. This includes safe prenatal care; a vaginal, facility-based delivery (wherever possible); access to comprehensive emergency obstetric and newborn care; exclusive breastfeeding for the first six months after birth, and critical health messages given to the new mother and family.

Through this series, readers can learn more about C-section rates in India and West Bengal, decisions made at the facility level, and our difficulty in having an impact in the delivery room. We will also share what Calcutta Kids is trying to do to empower women through birth preparedness, and welcome your comments and suggestions on ways we can address these challenges. -Margy Elliott

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