Background and Community Context

Overview

The Maternal and Young Child Health Initiative (MYCHI) started in late 2005 to improve health knowledge and increase access to healthcare for pregnant women and young children living in the Fakir Bagan slum of Howrah, West Bengal.

There are four main objectives of MYCHI:

      • Reduce maternal morbidity and mortality
      • Reduce child morbidity and mortality
      • Improve birth weights
      • Ensure that children aged 0-3 years grow normally

To meet these four goals, Calcutta Kids’ MYCHI delivers preventive health measures at key points in the life cycle, notably pregnancy (intrauterine growth) and postpartum for a woman, and the critical developmental period of the first three years of life of a child. Calcutta Kids’ MYCHI is designed to assist and empower urban poor mothers to obtain optimal prenatal and post natal health for themselves and their children through intensive counseling, information dissemination, and access to health services.

Our Objectives

Reduce Maternal Mortality & Morbidity: Though India has seen a dramatic reduction in maternal mortality rate (MMR) by 59% from 1990 to 2008, the country still has the highest number of women dying from childbirth in the world. India’s MMR was 570 in 1990 and is now 230 (most recent statistic, 2008). Even though the progress is notable, the annual rate of decline is half of what is needed to achieve the MDG 5 target, reducing MMR by 75% from 1990 to 2015. Pregnant women still die from five major direct causes: postpartum hemorrhage, infections, high blood pressure, unsafe abortion, and obstructed labor. Maternal mortality is higher in rural areas and among poorer and less educated communities.1

Reduce Child Mortality & Morbidity: More than two million children under the age of five die each year in India of preventable causes. The child mortality rate dropped from 116 deaths per 1,000 children under age 5 in 1990 to 69 in 2008, but it is still a long way from the national target of 39 (which is the 75% reduction called for in the MDG 4 target). Three causes account for the majority of neonatal deaths in India: prematurity and low birth weight, neonatal infections, and birth asphyxia and birth trauma. Pneumonia and diarrheal diseases account for 50 percent of under-five deaths. Fifty percent of total under-five mortality is ascribed to malnutrition. Under nutrition and micronutrient deficiencies contribute to disease burden and premature mortality among young children. Children with multiple anthropometric failures are at a greater risk of morbidity, and are more likely to come from poorer households.2

Reduce Low Birth Weight: Twenty eight percent of babies in India are born with low birth weights (less than 2.5 kilograms)—a figure that has barely changed in 25 years. Low birth weight is a major cause of neonatal death. Low birth weight babies can face serious short and long-term health consequences. Immediate problems include: underdeveloped lungs and breathing problems, immature liver, anemia, inability to maintain body temperature, inability to feed properly, and risk of infection. Depending on the cause of low birth weight, long-term effects can include physical impairments which may impact brain growth and development, and social and cognitive delays. ‘Reducing the incidence of low birth weight has substantial economic benefits, such as increased labor productivity later in life and decreased costs associated with child illness or death.3

Ensure that Children Age 0-3 Grow Normally: 42.5% of children in India are underweight, and 48% of children are stunted. This means that almost half the under-five population is not growing properly and will not reach their full potential in adulthood. Multiple micronutrient deficiencies, primarily iron deficiency anemia (IDA), which is highly prevalent (69.5% in under-five children) in India also have serious effects on child growth.4

Urban Slum Context: “Hidden Cities”

The urban slum context is unique, and addressing the health needs of the urban poor is complex. In India (and most developing countries), health policy and practice have traditionally focused on the rural poor. Rural areas now have a systematic government health care structure (established by the National Rural Health Mission – NRHM), while urban areas are not yet covered by a systematic policy and structure for health services.

The National Urban Health Mission (NUHM) has been in development since 2002, but has yet to be fully implemented. In the interim, the Indian government’s Reproductive and Child Health program (RCH) and various schemes for maternal and child health have been rolled out, but with limited reach in the most vulnerable urban populations—the urban slums.

Why should we pay attention to the health of urban poor communities? In the last few decades, the rapid growth of urban population has increased the percentage of urban poor in India from 15% (in the 1960s) to 25% (in the 1990s.)5 The urban growth rate over the past decade was 3% while the slum growth rate was double, at 5-6%.6 One out of four poor persons in the country is now an urban resident, and poverty is no longer only a rural phenomenon (Urban Health Resource Center). This rapid urbanization has rendered inadequate primary health care facilities further deficient while cost and other factors make secondary/tertiary care and private facilities out of reach for most poor urban residents. The urban poor encounter a distinct set of health problems, compounded by lack of safe water, poor sanitation and drainage systems, inadequate housing, and access to health services. Low income urban families are most at risk for adverse health outcomes, particularly mothers and children. Statistics show that health indicators of the urban poor are substantially worse than higher income urban groups and comparable to the rural population in India.

Urban poor maternal health statistics:7 Only 54.3% of mothers had at least 3 ANC visits (vs. 83.3% of urban non-poor mothers); only 18.5% of mothers consumed IFA for 90 days or more (vs. 41.8% of urban non-poor mothers); and only 44% had facility delivery in even though clinics/hospitals are in close proximity (vs. 88.5% of urban non-poor mothers).

Urban poor child health statistics:8 Only 39.9% of urban poor children under five years old are completely immunized. Less than half (44.7%) of urban poor children 0-5 months old are exclusively breastfed. Just 56.2% of children 6-9 months are receiving semi-solid or solid food along with breast milk, during the optimum time when complimentary foods should be introduced to prevent growth faltering. Seventy-one percent of urban poor children under-five have anemia, which has a critical impact on child growth, physical and cognitive development.

Health indicators are similar for the urban poor and rural populations. However, there is an alarming difference in basic health service coverage for mothers and children: Only 53.3% of the urban poor children under age six live in enumeration areas covered by an AWC (Aanganwadi Center), while 91.6% of their counterparts in rural India are covered by an AWC. According to the Department of Family Welfare, the presence of an AWC in a slum has been associated with decreased child malnutrition and lower infant mortality rate (IMR). This means that urban poor women and children have much less access to essential health services that could significantly improve their health outcomes.

With increasing urban migration and increased growth of urban poor populations, health challenges in urban slums will only increase in the years ahead, unless more focused, integrated strategies are initiated to mitigate the health and nutrition problems of the urban poor.

Why Fakir Bagan?

Fakir Bagan slum is situated in Howrah, the sister city to Kolkata, on the western side of the Hooghly River. The slum of predominantly migrant families from Bihar, Jharkhand, and Uttar Pradesh has developed along the railroad tracks on public land. It is therefore an unauthorized settlement, making its residents vulnerable to displacement and ineligible for a number of government-provided services. When Calcutta Kids conducted a baseline survey of Fakir Bagan in 2006, the area consisted of tali bari (unfinished clay tile homes) and tent-like homes whose residents were sweepers, domestic workers, laborers, and rickshaw pullers by trade. Although the government had already launched its ICDS and AWC programs, they had not yet reached Fakir Bagan and the residents did not have access to any local government health services. Health indicators for the population were dismal. Of the women surveyed: over 30% of those who had been pregnant within the past 3 years reported having had a child who died; 14% had not received any antenatal care; 34% did not receive iron-folic acid tablets during pregnancy; 40% of women reported that they did not get more rest then usual during their last pregnancy. Approximately 67% of mothers had an institutional delivery in a private or government hospital (higher than for the urban poor in India at 44%), but still highlighted the necessity to ensure that all women in Fakir Bagan are able to deliver in a health facility. Only 8% of mothers initiated breastfeeding immediately after birth while only 28% fed colostrum to their newborn infants. Complimentary foods were being started at 9 months on average, three months older than the optimum recommended age.9 Such problematic practices and service delivery shortcomings were likely to lead to negative health outcomes for both mothers and their young children. These findings strongly supported the urgent need for improved access to health care, health and nutrition counseling, and effective community-based health initiatives.

Over the years, Fakir Bagan has changed in a number of ways. The population itself is changing with an influx of wealthier developers constructing multistory buildings which are being rented out not only by the poor residents but also slightly higher income groups. The topography has changed, too; the single-story tali bari and tent-like structures are now interspersed with unfinished, precarious-looking apartment buildings. The government has now established three AWCs, but services are scant. Even the critical growth monitoring and promotion components do not seem to catch the most vulnerable children. A few NGOs on the periphery of Fakir Bagan are also providing some services such as TB treatment, rations and mobile clinic support that residents can access.

Calcutta Kids targeted interventions have had substantial success since work began in 2006. Health indicators have improved in Fakir Bagan, but there is still more to be done to ensure optimum health for all pregnant women, mothers, and young children. (Click to read more on Benefits and Success> Despite a slight demographic shift and growing government, NGO and private health practice presence, Fakir Bagan remains a vulnerable slum in terms of location, basic services, occupational hazards, access to health services, education, and gender status. Residents face the burden of a poor drainage system and rampant flooding during the rainy season, becoming exposed to a host of diarrheal and water-borne diseases. Multistory buildings in this setting cannot be equated with better or safer accommodation: residents of flats still face the same problems (lack of ventilation, overcrowding, and poor hygiene) as their tali bari neighbors. Although there is easy availability to health services, these services may be unacceptable and unaffordable to the population, particularly women and young children. In recent years, more mothers have begun working outside the home to increase family income, and it is the children who bear the consequences in terms of lack of care and proper feeding. Calcutta Kids continues to fill an important gap in the lives of women and children in Fakir Bagan.

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Footnotes

1. Though India has seen a dramatic reduction in maternal mortality rate (MMR) in the by 59% from 1990 to 2008, the country still has the highest number of women dying from childbirth in the world. India’s MMR was 570 in 1990 and is now 254 . Even though the progress is notable, the annual rate of decline is half of what is needed to achieve the MDG 5 target, reducing MMR by 75% from 1990 to 2015.—UNICEF

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2. More than two million children under the age of five die each year in India of preventable causes. The child mortality rate dropped from 115 deaths per 1,000 children under age 5 in 1990 to 63 deaths per 1,000 children under five in 2010, but it is still a long way from the national target of 39 for every 1,000 births (75% reduction to achieve the MDG 4 target). – UNICEF

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3. 28% of babies in India are born with low birth weights (less than 2.5 kilograms)— UNICEF. ‘Reducing the incidence of low birth weight has substantial economic benefits, such as increased labor productivity later in life and decreased costs associated with child illness or death.’- Reducing the Incidence of Low Birth Weight in Low-Income Countries Has Substantial Economic Benefits. World Bank Res Obs (Spring 2006) 21(1): 25-48.

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4. 42.5% of children in India are underweight, and 48% of children are stunted; iron deficiency anemia (IDA), which is highly prevalent (69.5% in under-five children) in India- NFHS 3

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5. In the last few decades, the rapid growth of urban population has increased the percentage of urban poor in India from 15% (in the 1960s) to 25% (in the 1990s.)- Dutta Gaurav, Poverty in India and Indian States. FCND Discussion Paper N47. International Food Policy Institute, Washington DC. 1998.

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6. The urban growth rate over the past decade was 3% while the slum growth rate was double, at 5-6%.*- All Slums are Not Equal: Child Health Conditions Among the Urban Poor- Siddharth Agarwal, Shivani Taneja, Indian Pediatrics, Volume 42-March 17, 2005

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7. Urban poor maternal health and urban poor child health statistics: NFHS 3 (disaggregated data)

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8. Only 53.3% of the urban poor children under age six live in enumeration areas covered by an AWC (Aanganwadi Center), while 91.6% of their counterparts in rural India are covered by an AWC. – NFHS 3

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9. Of the women surveyed: over 30% of those who had been pregnant within the past 3 years reported having had a child who died; 14% had not received any antenatal care; 34% did not receive iron-folic acid tablets during pregnancy; 40% of women reported that they did not get more rest then usual during their last pregnancy. Approximately 67% of mothers had an institutional delivery in a private or government hospital (higher than for the urban poor in India at 44%), but still highlighted the necessity to ensure that all women in Fakir Bagan are able to delivery in a health facility. Only 8% initiated breastfeeding immediately after birth while only 28% fed colostrum to their newborn infants.- Analysis of Baseline Data 2005 report (Calcutta Kids)

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